The success of tracheal autotransplantation depends mainly on vascular integrity. The degree of blood supply in tracheal autotransplantation in puppies was studied according to the grafted site and extent of peritracheal sheath dissection. We divided 3 groups accordingly. In group I (N=7), cervical 7 ring tracheal autografts were removed and were orthotopically transplanted without tracheal sheath dissection. In group II (N=9), thoracic 7 ring tracheal autotransplantation was undertaken with proximal and distal dissection of the 4 ring peritracheal sheath. In group III (N=15), thoracic 7 ring tracheal autotransplantation was performed with the tracheal sheath preserved. Each graft was wrapped with an omental pedicle flap. Long term survival rates (>100days) were as follows : group I, 0% ; group II, 11.1% ; group III, 46.7%. Fatal tracheal complication rates, excluding death due to intestinal complications and exhaustion were as follows : group I, 100% ; group II, 80% ; group III, 33.3%. The difference between group I and III was statistically significant (P<0.05). There was no statistically significant difference between groups II and III, but group III tended to have a lower rate than group II. These results indicate that the preservation of the peritracheal sheath and improvement of the stability of the graft with an omental pedicle flap is an important factor for success in tracheal grafting in puppies.

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We evaluated the bronchoscopic findings and the clinical courses of so-called low-grade malignant tumor which originated in major airway. These consisted of 10 cases of central type carcinoid, 5 adenoid cystic carcinomas and 3 mixed tumors. Endoscopical findings showed the polypoid type of carcinoid had a pale or red color, but did not find submucosal invasion. Adenoid cystic carcinoma occurred in major bronchi more frequently than the other tumors, and showed longitudinal and submucosal invasion with vascular engorgement. Three out of 5 patients had a poor outcome. In mixed tumor there were no typical bronchoscopic findings. Three cases of adenoid cystic carcinoma and 1 mixed tumor had stage III or IV invasive tumors, and all 4 died of primary cancer. The survival time of resectable cases veraged 60 months (6&acd;153months). The five year survival rates for the three types (carcinoid, adenoid cystic carcinoma and mixed tumor) were 67%, 30% and 67%, respectively. Therefore, the early diagnosis is important even for low-grade malignant tumors.

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The heat probe method is usually used with endoscopic treatment for gastrointestinal bleeding. The authors studied the effects of heat coagulation on tracheal tissues and tried clinically to halt bronchial bleeding and to dilate bronchial stenosis caused by tumors. Effects were evaluated histologically in normal tracheal tissues from 4 autopsied human cases and 3 mongrel dogs. The depth of injury produced by heat probe coagulation with 30-90 J heat extended no deeper than the fibrocartilage palates. On preliminary experiments with dogs, the injured tracheal tissues were repaired with fibrosis within 4 weeks of heat treatment. The heat probe method thus was considered safe if the heat power is 90 J or less at any one point. Clinically, 4 lung cancer patients with hemoptysis due to bronchial bleeding from carcinoma were treated with the heat probe, and 3 patients with bronchial stenosis due to intrabronchial tumors were treated to dilate airways. In conclusion, the heat probe method is a promising bronchoscopic treatment for visible tracheo-bronchial bleeding and tumorous lesions.

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A 27-year-old woman was admitted because her chest X ray film showed a tumor-like shadow adjacent to the right hilus. Bronchoscopy, bronchography and CT scan revealed two bronchogenic cysts connecting with a bifurcated supernumerary bronchus arising from the right main bronchus. Serum CA 19-9 was elevated but became normal after surgical resection of the cysts. Pathological findings of the resected specimen showed a bronchus with cartilage and two bronchogenic cysts the walls of which were lined by cilliated cylindrical epithelium.

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Six cases of roentgenographically occult lung cancer were treated with photodynamic therapy (PDT) combined with radiation therapy (RT). Four cases were endoscopically evaluated as early hilar type squamous cell carcinoma and 2 were clinically early hilar type squamous cell carcinoma. Disappearance of tumors was seen following only PDT in 3 of 6 patients, and remarkable reduction of tumors was proved in the other three patients. In all cases, complete disappearance of tumors was proved after radiation therapy and no case had local recurrence within the observation period (4 to 87 months). Combination of PDT and RT seemed to be very effective methods for the local control of ROLC, but three patients died of intrathoracic metastasis or second primary lung cancer. Therapy for these cases still remains unclear.

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Upper lobectomy and R2 lymph nodes dissection were performed following chemotherapy (CDDP+VDS+MMC) on a 43-year-old patient with adenocarcinoma of the lung. The carcinoma was determine to be pT2N0M0. The surgical stump of the right upper lobe bronchus was wrapped with pericardial fat tissue. Necrotizing bronchitis was evident from the orifice of the right upper bronchus to B^6 by fiberbronchoscopic examination 10 days after the surgery. Bronchial pleural fistulae were not seen at that time. The lesions improved within 60 days after the surgery. Although necrotizing bronchitis is very rarely seen after lobectomy, surgeons should be aware that extensive bronchial lymph node dissection is required for malignancy resection, and that bronchial lymph node dissection is one method for preventing necrotizing broncitis. The wrapping in this case served to prevent necrotizing bronchitis though extensive dissection was required.

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A 73-year-old female was admitted in November 1991 because of high fever and productive cough. She had received antituberculous drugs for pulmonary tuberculosis for three years. Sputum smears and cultures were positive for acid-fast bacilli, but were negative for fungi and other pathologic bacteria. Chest X-ray on admission showed a cavity with a fungus ball in the right apex. Chest CT scan showed that the ball moved when the patient shifted position. Bronchofiberscopy showed a large communication between the cavity and right B^1. The fungus ball was visible through the communication. Endobronchial infusion of saline solution into the cavity was performed and the fungus ball was broken up mechanically. Cultures of biopsy specimens grew A. fumigatus. Antifungal drugs were not administered, but complete lysis of the aspergilloma developed during 3 months after bronchofiberscopic examination. A. fumigatus precipitin was initially present, but disappered 17 months later. It seemed that transbronchial infusion of saline solution and mechanical disruption of the fungus ball were effective for the treatment of pulmonary aspergilloma.

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We present one case of bronchial aneurysm without any underlying lung disease. A 77-year-old man was admitted to our hospital with a complaint of totalling acute repeated hemoptysis more than 200ml. Chest-X-ray film on admission showed an infiltrative shadow in the left lower lung field. However, there was no other symptom. Bronchoscopic examination, performed immediately, revealed the bleeding to be from left B^4. Bronchial arteriography revealed a circular aneurysm approximately 4 mm in diameter. The aneurysm was found in the area of left S^4, and was thought to be the cause of hemoptysis. Bronchial aneurysm is very rare as the cause of hemoptysis. In Japan, only 20 bronchial aneurysm cases have been reported. Since hemoptysis without other systemic abnormality is very rare, special care must be taken and bronchial arteriography using gel sponge cubes should be performed.

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A 15-year-old female with mucoepidermoid carcinoma of the right upper lobe bronchus successfully treated by the right sleeve upper lobectomy is reported. She was admitted becourse of hemoptysis. Chest X-ray revealed to apparent abnormality. However, on CT bulla in rS^6 and a tumor shadow in the right upper lobe were observed. Bronchofiberscopy revealed a protruding tumor with a smooth yellowish surface at the orifice of the right upper lobe bronchus. Biopsy suggested adenoma. She underwent right sleeve upper lobectomy. Histologically the tumor was composed of epidermoid cells and mucin producing cells, therefore a pathological diagnosis of mucoepidermoid carcinoma was made. The tumor extended in the bronchial wall, but did not invade the lung parenchyma. The patient's condition is satisfactory 2 year and 10 monthes after the operation.

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Six patients were treated with transbronchial polypectomy using electrosurgery. Of the six, 1 had tracheal stenosis due to tracheal cancer, 1 had a tracheal papilloma, 3 had bronchial stenosis due to lung cancer, and 1 had bronchial obstruction due to neurinoma. We failed to diminish the tracheal stenosis in one patient, but were successful in resecting the tracheal papilloma and in decreasing bronchial stenosis or obstruction in the other 5 patients. With transbronchial polypectomy using electrosurgery, most cases with polyps or stenosis due to polyps show rapid improvement. The procedure does not produce the amount of smoke seen in YAG laser treatment. If it is diffcult to strangulate the tumor in a supine position, a lateral or prone position may be more suitable.

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A 49-year-old female with recurrent esophageal leiomyosarcoma invading the carina complained of severe dyspnea. Bronchoscopy revealed remarkable stenosis of bilateral main bronchi due to the recurrent tumor. Therefore endoscopic Nd-YAG laser therapy was immediately performed to improve dyspnea. Bronchoscopy after the Nd-YAG laser treatment revealed a long stenosis from the orifice of the right main bronchus to the distal end of the truncus intermedius and a localized stenosis of the orifice of the left main bronchus. A silicone stent with silicone rings around the outside, 12mm in length and 9mm in external diameter, was inserted into the orifice of the left main bronchus with a flexible bronchofiberscope under local anesthesia. Good fixation and sufficient patency was obtained. This stent was useful for improving the quality of the patient's life.

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A 35-year-old man was admitted with chest pain, hemosputum, and multiple nodules with cavity formation on chest roentgenogram. Lung biopsy revealed necrotizing granuloma with multinucleated giant cells and necrotizing arteritis. Anti-neutrophil cytoplasmic antibody (C-ANCA, normal range ≦10 ELISA units) showed high values in serum 96 ELISA units (28.2 ELISA units・dl/g by albumin correction), pleural effusion 87 ELISA units, and BALF 9.2 ELISA units (699 ELISA units・dl/g by albumin correction). After commencing treatment by prednisolone and cyclophosphamide, the clinical findings, CRP and chest roentgenogram improved. However C-ANCA in serum and BALF still showed high values. Soon recurrence developed with hemosputum and nasal bleeding, CRP elevation and deterioration of abnormal shadows on chest X-ray film. The clinical course of this case suggests that C-ANCA is useful as an index of activity, there are few reports on C-ANCA in BALF and pleural effusion, therefore its clinical significance should be investigated further.

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A 39-year-old male was admitted on June 1990 for further examination of an abnormal chest shadow. He was a cigarette smoker but had no respiratory symptoms. Chest X-ray on admission showed a well-defined mass shadow in the left lower lung field. Chest CT scan showed a mass 1.5cm in size and mild increased density limited to the subpleural zones in the postero-inferior areas of both lungs. Open lung biopsy revealed that the tumor was pulmonary hamartoma. Microscopic findings of the specimen from left S^<10> showed mild thickening of the alveolar septa and evenly dispersed macrophages throughout alveolar ducts and bronchioles. Transbronchial lung biopsy specimens from right S^9 also showed DIP-like pathologic changes. As DIP-like pathologic changes were seen not only around hamartoma in the left lung, but also in the right lung, it seemed that the DIP-like pathologic changes in this case were not related to pulmonary hamartoma. BAL findings of both lungs revealed that there was an increase in total cell counts, but no increase in the percentage of lymphocytes and eosinophils. He had continued smoking after discharge and was followed up for 3 years without treatment with corticosteroid. Chest CT scan in 1993 showed a mild increase in density in the subpleural zones as compared with 1990. This case resembled respiratory bronchiolitis in terms of the clinical features, but resembled DIP in its pathologic features. The relation between respiratory bronchiolitis and DIP was discussed.

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The patient was a 67-year-old female with subarachnoid hemorrhage. After the operation, oral food intake was difficult because of drowsiness. Broad-spectrum antibiotics for various infections were used in the postoperative period. The patient developed a bleeding tendency after the operation. On the 29th post-operative day hemoptysis and cyanosis occurred. Chest X-ray film showed a diffuse alveolar pattern in both lung fields. Bronchofiberscopic examination revealed blood in the trachea and bronchi. We diagnosed this case as pulmonary hemorrhage and cause was suspected to be hemorrhagic diathesis associated with broad-spectrum antibiotics administration. After treatment with a vitamin K preparation, pulmonary bleeding subsided and prothrombin time normalized. Although pulmonary hemorrhage caused by antibiotics is rare, it can take a serious course once it does occur. Therefore, it is necessary to carefully consider the use of antibiotics in such patients with bleeding tendencies.

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Kirschner's wires are widely used for fixation of bone fractures, with cause serious complications only very rarely. A rare case of K-wire migration through the trachea is reported. A 28-year-old male was admitted to our hospital with complaints of cough and bloody sputum. Chest X-ray film showed a metallic needle approximately 5cm. in length in the upper mediastinum above the sternum. There was no evidence of pneumothorax, pleural effusion or mediastinal emphysema. Chest CT scan revealed a metallic needle passing completely through the trachea. Bronchoscopic examination revealed a metallic needle passing through the upper trachea from the right posterolateral 3rd cartilage to the left anterolateral 5th cartilage. Migration of a K-wire into the trachea was diagnosed, because of his history of right clavicular-osteosynthesis 6 months previously. Two months after osteosynthesis using 3 K-wires, two of the wires were extracted and 4 weeks roentgenological examination revealed a broken K-wire. The distal half of the K-wire was extracted. 2 days after admission, operation was performed with a collar skin incision under local anesthesia. Separating the trachea and the left sternothyroid muscle the surface of the metallic needle was seen covered with thin fibrous tissue and granulation. The metallic needle was extracted without tracheotomy. Intubation with a cuffed endotracheal tube was performed after needle extraction because air leaks could be seen at both puncture sites in the trachea. The tracheal puncture sites were not sutured. Drainage was performed at both sides of the trachea and the wound was closed. The patient was discharged no the 12th day after operation without complications. In this patient, there were no symptoms during the interval of 3 months between extraction of half of the remaining needle and the subsequent examination demonstrating the needle in the trachea. Shoulder joint mobility is extensive therefore if a broken K-wire is found after claviclar osteosynthesis on X-ray examination, surgical operation should be performed soon to extract it because of the possibility of migration.

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A case of long-standing bronchial foreign body which caused granulomatous changes in the bronchus and bronchiectasis after expectoration of the foreign body was reported. A 47-year-old man, who aspirated the tip of a mechanical pencil when he was about 1 year old, was admitted complaining of recurrent pneumonia. He was diagnosed as localised bronchiectasis of the left lower lobe bronchus. 7 years later, he was admitted with chest pain and dyspnea. Bronchography revealed obstruction of left B^<1+2> and lingular bronchus in addition to the left lower lobe bronchus. As the left lung was thought to be very poorly ventilated and recurrent pneumonia would occur, left pneumonectomy was done.

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A rare case of bronchial actinomycosis associated with bronchial foreign body (chicken bone) was reported, and a review of the literature was made. A 56-year-old woman visited our hospital because of bloody sputum. Respiratory sounds were diminshed. Chest X-ray film revealed no remarkable abnormal changes but chest tomography showed stenosis and calcification of the truncus intermedius. Bronchofiberscopy showed a foreign body in granulation of the truncus intermedius and transbronchial biopsy of the granulation was made. Biopsy specimens showed sulfur granules, then bronchial actinomycosis was diagnosed and she was treated by penicillin. After treatment, the granulation disappeared and the foreign body (chicken bone) was removed easily. The patient was discharged with no complications and no recurrent signs were found. Bronchial actinomycosis associated with foreign body is a rare disease and only one case has been reported in Japan. Patients with tracheo-bronchial foreign body should be treated keeping the possibility of bronchial actinomycosis in mind.

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