In recent years endoscopy has been widely used for the diagnosis and treatment of numerous aerodigestive diseases. Because patients may be examined successively using the same endoscope, there is a possibility of transmitting microorganisms to the next patient in such endoscopic examinations. Hospitals, therefore, must address the issue of preventing contamination accompanied by endoscopy. Presently in Japan, hospital-acquired infections are increasing. This has become with a growing social interest. For an endoscopist, the most effective means of decreasing such infections is to prevent contamination accompanied by endoscopic examinations. It is necessary to have a contamination-prevention committee, to have a contamination-prevention surveillance system and to educate the medical staff about successful contamination prevention. In this paper we present general matters to be attended when dealing with hospital-acquired infection and contamination. We outline the prevention of specific infectious diseases caused by MRSA (methicillin resistant S. aureus), HBV (hepatitis B virus) and HIV (human immunodeficiency virus).

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Bronchoscopes are frequently used for diagnosis and therapy. Contaminated bronchos copes potentially induce not only nosocomial infection but also misdiagnosis. Therefore, cleaning and disinfection of bronchoscopes are very important. We experienced bacterial contamination of suction channel and automated endoscope reprocessing machine. Since we improved our sterilizing methods in 1987, we have seen no further contamination. In this paper, we report the procedures for the prevention of contamination of the bronchoscopes with general bacteria and MRSA. The procedures are as follows: (1) A forceps channel cap is removed and changed to gas sterilized new one. (2) A suction channel is cleaned with brush. (3) A bronchoscope is disinfected by immersion in alkali-diaminoethyl glycine (Tego-51) for 40 minutes. The Tego-51 has strong sterilizing effect against bacteria including MRSA and acid-fast bacteria. (4) An automated reprocessing machine is used not for disinfection, but only for rinsing bronchoscopes with filtered water and with air for drying. (5) All compartments of the automated machine are disinfected by irrigation with Tego-51 once a month. (6) After each procedure was accomplished, bronchoschope is sterilized in Ethilene oxide gas.

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The mycobacterial contamination of a bronchoscope has been a problem. At our institution, there was several cases of such contamination. Atypical mycobacterial contamination of tap water could not prevent by installation of 0.2μm filter system in the case of intermittent use of water. The highest contamination was found in the connection tube between filter systems. During the course of our trial to prevent atypical mycobacterial contamination, we recognized the importance of brushing. Using artificial sputum, we studied a simplified cleaning method for the bronchoscope. For the first step of cleaning a bronchoscope, we must physically wash it. For washing it, it is necessary to brush every part of the device 10 or more times. We test-produced a simplified cleaning device which uses 1.0kg/cm² water pressure and benzalkonium chloride. It can be semi-automatically washed and it is useful because it is labor-saving. Because of its structure, suction valves were easily contaminated. Therefore, it needs to be carefully brushed, cleaned, and sterilized. The endoscope automatic washer (Olympus EW-10) is not perfect. The concentration of glutaraldehyde in EW-10 system decreased from 2 to 1.1% during one week. It is necessary to take care in having the user clean it by himself.

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Routine method (Tearai method): Mechanical washing with soap and tap water and disinfection using 2% glutaraldehyde. Cleaning and disinfection after finishing endoscopy session: Following mechanical washing, soaking endoscopes in 2% glutaraldehyde for over 10 minutes, and rinsing with a tap water. Endoscope washing machine can be used. Endoscopy staffs are required to use gloves, gowns, caps, masks and eye-coverings and hepatitis B vaccination.

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[in Japanese]

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Antimicrobial activity of lidocaine solution was studied as a part of the serial transtracheobronchial microbiological culture study using the flexible fiberoptic bronchoscope (FS). Six clinical strains including, E. coli, K. pneumoniae, Ps. aeruginosa, S. marcescens, S. aureus and Str. hemolyticus were used for this study. The colony count of these microorganisms ranged from 10⁶ to 10¹⁰/ml.
The antimicrobial activity of lidocaine solution was at a concentration of 3, 000 μg/ml or more, and this inhibitory activity was proportional to the lidocaine density. And at a concentration of 8, 000 to 24, 000 μg/ml or more, it changed to bacteriocidal, so possibly a small amount, say one or two per cent lidocaine solution, should be used instead of the 4% lidocaine solution. As soon as the microbial specimens are taken, they should be cultivated as quickly as possible.
The dilution technique method (DTM) of lidocaine in the FS suction channel, with gradual injection of a 2 ml saline solution into the suction channel and removal of the solution in the suction channel were performed with a suction machine. This is one more important procedure. The procedure showed statistically significant differences (P<0.001) of lidocaine concentrations in the specimens before and the after DTM procedure were proven.

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In this paper, we reported a clinical statistics of 971 cases who have undergone laryngomicrosurgery in University of Tokyo Hospital during last 9 years. Vocal fold polyp, polypoid vocal fold, laryngeal cancer and vocal fold nodule are of higher incidence.
Most of vocal fold polyps were seen in patients of the third to fifth decade of their age. There is no apparent sex difference. Duration of symptoms is less than 1 year. It is suggested that smoking, vocal abuse and drinking habit seem to be causative factors.
Vocal fold nodules were frequently seen in female patients of the second decade. On the other hand, all male patients were under 10 years old. Almost all patients have habitual vocal abuse.
Patients with polypoid vocal fold were in the fifth decade of their age. There is no sex difference in incidence. Duration of symptoms was comparatively long. It is suggested that smoking, habitual vocal abuse and drinking are contributing factors to produce polypoid changes in the vocal fold.

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A statistical study was made on foreign bodies in the trachea and bronchi in 59 patients (male: female=40: 19) hospitalized in our clinic between 1976 and 1991. Forty-nine patients were under 2 years of age. Peanuts predominated (37 cases, 62.7%) in the kinds of foreign bodies. The foreign bodies were found in the right bronchus in 24 patients, in the left bronchus in 21 patients and in trachea in 8 patients.

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We previously reported that the atrial natriuretic polypeptide (ANP) caused a relaxant effect with the tissue cyclic GMP (c-GMP) levels on a guinea pig tracheal smooth muscle.
We studied plasma immunoreactive ANP and c-GMP concentrations in various situations in patients with respiratory diseases which were divided into 3 groups, patients with bronchial asthma (BA, n=16), patients with chronic pulmonary emphysema (CPE, n=10) and patients with pulmonary insufficiency induced by pulmonary tuberculosis (Tbc, n=44). One hundred and thirteen healthy subjects were also studied as a control group. This is the first report that these clinical markers have been measured at same time in the field of respiratory diseases.
In conclusion, 1) Plasma ANP was significantly higher in patients with BA (attack) (P<0.05) and Tbc (P<0.01) than in control. 2) Plasma c-GMP was significantly higher in patients with Tbc (P<0.01) than with BA (remission). 3) There was a significant correlation between plasma c-GMP and log ANP in patients with chronic respiratory disease (r=0.714, P<0.05, n=72). 4) Plasma ANP was significantly higher at attack than at remission (P<0.05).
These results indicate that effects of ANP in patients with respiratory disease may be, at least in part, mediated by c-GMP being in the place of cyclic AMP, and ANP induced by pulmonary hypertention may cause a relaxant effect on tracheal and vascular smooth muscle. Therefore, exogenous ANP may also be useful on the therapy of patients with bronchial asthma. such as intractable asthma.

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Movement of the membranous part of the posterior tracheal wall on respiration was investigated in the early and late postoperative periods in 5 patients undergoing one-stage radical operation for esophageal cancer (esophagectomy and reconstruction performed at one time), 4 patients undergoing two-stage radical operation for esophageal cancer, and 4 patients undergoing radical operation for right lung cancer. The movement of the posterior tracheal wall was represented by the percentage of the difference between the maximal and minimal values of the anteroposterior diameter of the trachea to the minimal value of the anteroposterior diameter of the trachea. In all cases, the anteroposterior diameter of the trachea was maximal at the end of inspiration and minimal at the end of expiration. Fluctuations of movement in quiet breathing in the early period after operation for esophageal cancer were 16±5% and 12±3% for one and two stage operation respectively. In forced respiration in the early period, they were 31±12% (one stage) and 17±3% (two stage). However, in the late period, they were 12±4% (one stage) and 8±2% (two stage) for quiet respiration, 16±7% (one stage) and 12±5% (two stage) for forced respiration. All fluctuation rates were significantly higher than after operation for lung cancer. In forced respiration, the fluctuation rate was significantly higher in the early period after operation for esophageal cancer than in the late period. It was suggested that the marked fluctuation of the membranous part of the trachea in the early period after operation could be caused by removal of the esophagus which might have a role as a supporting tissue.

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During last ten years from 1981 to 1990, 311 patients with carcinoma of the thoracic esophagus were treated surgically in Kurume University Hospital. Postoperatively, 149 patients (48%) suffered from recurrent laryngeal nerve paralysis and 80 patients (26%) developed aspiration pneumonia. The incidence of aspiration pneumonia increased from 21% during the first five years (1981-85) to 31% during the later five years (1986-90) (P<0.05). The incidence of recurrent laryngeal nerve paralysis showed little difference between the two periods, 45% during the first five years and 51% during the later five years. Mortality during hospitalization due to aspiration pneumonia markedly decreased from 7% (11/155) for the first period to 2% (3/156) for the later period (P<0.05). This was caused by introduction of new multimodal treatments including (1) antethoracic reconstruction of the esophagus with gastrostomy which fascilitated decompression, (2) swallow-training starting with semi-solid foods prior to peroral intake of normal foods, (3) immediate silicone injection into the paralytic vocal fold, when necessary, and (4) surgical intervention including cricopharyngeal myotomy, laryngeal suspension and laryngectomy for severe aspiration pneumonia.

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Two cases of spontaneous cervical emphysema are presented. These cases are considered to be spontaneous pneumomediastinum emphysema restricted to the neck. The etiology is related to the rupture of terminal alveoli and dissection of air along the pulmonary vasculature. The differential diagnosis and treatment of this rare condition are discussed.

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