Objective: Bronchopleural fistula after pulmonary resection is one of the most serious complications in thoracic surgery. The purpose of this study was to evaluate The efficacy of wrapping of The bronchial stump or anastomosis with a pedicled intercostal muscle flap to avoid this particular problem. Methods: Between January 1996 and December 2000, 365 patients with primary lung cancer underwent pulmonary resection. In 59 patients at high risk for bronchopleural fistula development, prophylactic wrapping of the bronchial stump or anastomosis with a pedicled intercostal muscle flap was performed. The risk factors were as follows: 1. presence of diabetes mellitus, 2. chronic renal failure, 3. previous chemotherapy or radiotherapy, 4. steroid administration, 5. pneumonectomy, sleeve lobectomy, or right middle and lower lobectomy, 6. others. In the remaining 306 patients with no risk factors, none of the bronchial stumps or anastomoses were reinforced. Results: There were 43 men and 16 women. Age ranged from 44 to 82 years(mean 64.8). There were 27 adenocarcinomas, 27 squamous cell carcinomas, 4 small cell carcinomas, and 1 large cell carcinoma. Thirteen patients died late after operation, mainly due to recurrence of carcinoma. There have been no fistulas in the bronchial stumps or anastomoses wrapped with a pedicled intercostal muscle flap(incidence, 0%). In 306 patients with no risk factors, 11 patients developed bronchopleural fistula(incidence, 3.6%)Conclusion: Wrapping of the bronchial stump or anastomosis with a pedicled intercostal muscle flap is a useful, easy and quick technique to avoid bronchopleural fistula after pulmonary resection.

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Background: We developed a method of bronchial embolization using silicone(BEUS)in 1989. BEUS appears to provide a surer and longer bronchial blockade than conventional bronchial embolization methods. We further developed the Endobronchial Watanabe Spigot(EWS)as a silicone bronchial filler. Puropose: Clinical trials were carried out in cases of intractable pneumothorax and peripheral bronchial fistula etc.to evaluate the clinical usefulness and safety of EWS. Methods: BEUS with EWS was performed in 37 cases(35 institutes). Results: They consisted of 24 cases of intractable pneumothorax, 7 cases of pyothorax with bronchial fistula, 4 cases of pulmonary fistula, 1 case of bronchial fistula and 1 case of bronchobiriary fistula. Affected bronchi were determined by balloon catheter test or by other findings in 30/37(81.1%)cases. BEUS with EWS was performed in 32 cases and the air leakage was stopped in 12/32(37.5%)cases and was reduced in 14/32(43.7%)cases. After their improvement of respiraory status, the thoracic drainage tube was removed in 19/31(61.3%)cases. Pneumonia, dyspnea and atelectasis occurred as complications in 2/32(6.3%)cases as a complication of BEUS with EWS, but they were not so severe. Conclusions: BEUS with EWS is a useful method for intractable pneumothorax and bronchopleural fistula.

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Background: Accurate diagnosis of the staging of lung cancer is needed for appropriate therapy. However clinical diagnosis by CT scanning is sometimes not accurate. Purpose: We examined the merit of thoracoscopic staging. Methods: Fifty-eight patients with non-small cell lung cancer(NSCLC)were referred to the Haibara General Hospital in recent years. Under general anesthesia, thoracoscopic examination was performed preoperatively and the staging was determined thoracoscopically. Then we compared the clinical staging with the thoracoscopic, surgical, and pathological staging. Results: There were six clinical T3 patients who were diagnosed with chest wall invasion on CT scanning. However two of the six patients did not have chest wall invasion thoracoscopically, and were proved to be pathologic T2. On The other hand, there was one patient who was considered to have no chest wall invasion on CT, but turned out to have invasion by thoracoscopic examinaion(t-T3). Radiologically occult pleural effusion was present in 13 patients(22%). On pleural effusion cytology, two patients were positive(ClassV), and eleven were negative(Class I). The percentage of the patients correctly staged for T status by CT, thoracoscopy, and surgery were 76%, 86%, and 95%, respectively. The percentages of correctly staged N status were 76%, 78%, and 95%, and The percentages for TNM status were 60%, 71%, and 88%, respectively. Thoracoscopic examination was very useful for the diagnosis of T status, such as chest wall invasion or pleural effusion. However the accurate size of the tumors or the extension of lymph node metastasis was not occurably diagnosed. Conclusions: Thoracoscopic examination sometimes gives us some useful information for the thoracotomy approach. Thoracoscopic examinations should be performed preoperatively.

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Transbronchial needle aspiration(TBNA)technique has been considered as a valuable and low-risk procedure for diagnosing mediastinal malignancies in recent years. However it has not yet been used routinely in day-to-day practice in Japan. To evaluate the usefulness and safety of TBNA using a histological needle via a flexible bronchoscope, we performed the TBNA technique to diagnose mediastinal malignant lesions in 15 cases suspected of lung cancer or other thoracic malignancies in which the lesion was covered with normal epithelium and had no mucosal invasion. These cases included 13 cases of primary lung cancer and 2 cases of malignant lymphoma. A definitive diagnosis with TBNA technique was obtained in 11 of 15 cases, and the rate of diagnostic accuracy was 73.3%. No significant complication was observed except for a small amount of bleeding in one case and fever elevation after examination in another case. We suggest that TBNA is an extremely valuable diagnostic procedure of choice in patients with mediastinal or hilar lymph node malignancies.

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We studied the BALF findings in 11 HIV-infected patients with Pneumocystis carinii pneumonia(PCP). Blood examinations revealed that mean counts of CD4 positive T cells were 45/μl and that serum LDH and CRP values had increased. In BALF findings we recognized mean total cell counts had not increased greatly. The findings of BALF revealed an increase in the percentage of the lymphocytes and decrease of the CD4/8 ratio. There was no significant difference in the BALF findings of non-smokers and smokers with PCP. We compared KL-6 concentration of BALF of HIV-infected patients with and without PCP. KL-6 concentration was significantly higher in patients with PCP than without PCP. We recognized a significant relationship between BALF KL-6 concentration and serum LDH value.

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We encountered a 71-year-old woman with post-intubation tracheal stenosis. She complained of dyspnea 6 weeks after extubation of an endotracheal tube through which she had received ventilation support for respiratory failure for 15 days. Bronchofiberscopy revealed a pinhole-like tracheal stenosis and a tracheostomy was made distal to the stenosis. After weaning from the respirator, she underwent resection of the stenotic tracheal lesion including the tracheal stoma and reconstruction with end-to-end anastomosis. She recovered without any complication.

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A 52-year-old man complained of fever, dyspnea and chest discomfort. He had undergone trimodality therapy for malignant pleural mesothelioma, which consisted of left extrapleural pneumonectomy followed by chemoradiotherapy, 19 months before. Bronchofiberscopy revealed a foreign body, white cottony material, at the bronchial stump. It was excised endoscopically and proved to be a hemostat, made of oxycellulose, from which Haemophilus was cultured. The patient recovered and dischrged after the removal. Since the oxycellulose was used after the bronchial stump was closed, it is thought to have been excreted from the thoracic cavity to the bronchus.

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A 66-year-old man was admitted with haemoptysis. Chest CT and bronchoscopy revealed a hard polypoid tumor with and irregular surface obstructing the orfice of right B^4. Biopsy specimens showed moderate dysplasia of the bronchial epithelium and inflammatory change with fibrosis. The tumor was resected using an endoscopic electrosurgical snare, as the tumor was considered to be benign. Histological examination confirmed the tumor to be chondromatous hamartoma. Bronchoscopy two months after the treatment showed no evidence of recurrence. We consider that the endoscopic electrosurgical snaring is a useful and minimally invasive technique for the treatment of endobronchial hamartoma.

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A 69-year-old man was admitted with a chief complaint of wheezing on effort. Chest computed tomography on admission revealed and endobronchial lesion in the left mainstem bronchus. Flexible bronchoscopy showed a smooth and yellowish pedunculated polypoid tumor arising 2 rings of cartilage distal from the carina in the left main bronchus. It almost occluded the lumen of the bronchus and moved in the lumen like a pendulum with respiration. Biopsy of the lesion suggested squamous cell papilloma. Endoscopic resection was performed with a high-frequency electrosurgical snare. The histology of the resected specimen confirmed the lesion to be an endobronchial lipoma. Endobronchial lipomas are extremely rare benign tumors that cause bronchial obstruction, leading to extensive distal parenchymal damage. The endoscopic electrosurgical snaring technique for endobronchial tumor is a safe and effective method that allows preservation of pulmonary function.

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A 58-year-old man presented with diffuse malignant pleural mesothelioma. The disease was complicated by acute respiratory distress syndrome(ARDS)and respiratory failure after right extrapleural pneumonectomy. A bronchial stump fistula and empyema developed concurrently during respiratory control with a respirator. Respiratory failure worsened and required respiratory control over a long period of time, during which two operations were performed: one for resuturing the bronchial stump and covering it with a latissimus dorsi muscle flap by reopening the chest, and the other for fenestration of the chest wall. For the purpose of isolation of the remaining left lung from the empyema cavity, respiration was controlled with a double-lumen endotracheal tube under tracheotomy for differential lung ventilation to obtain weaning. After weaning from mechanical respiration, the right bronchial limb of a Dumon Y-shaped silicon stent was cut and the stump was closed with a silicon membrane to obstruct the bronchial fistula. Temporary implantation of this stent led to obstruction of the bronchial fistula, enabling the patient to be discharged. This result has shown that the silicon airway stent primarily used for securing the constricted airway lumen can also be used to obstruct a bronchial fistula.

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We employed 3-dimensional computed tomography(3D-CT)to evaluate bronchial lesions in a patient with bronchial tuberculosis. Bronchial tuberculosis was diagnosed in 75-year-old woman by bronchoscopy and was successfully treated. 3D-CT clearly visualized the improvement of the bronchial lesions following treatment. Based on this experience, 3D-CT was found to be an excellent alternative to bronchoscopy for the evaluation of bronchial lesions with minimum stress for the patients and much less risk of exposure to infectious material by the medical staff.

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