Purpose. Evaluation of the usefulness of endobronchial ultrasonography (EBUS)for the diagnosis of peripheral lung lesions as a guide for TBLB, and improvement of diagnostic accuracy, and reduction for the discomfort of the procedure. Patients and Method. ln 50 cases examined between January and December 2001, a 20 MHz radial type probe (Olympus,Tokyo)was inserted via the instrumentation channel of the bronchoscope and advanced to the peripheral lesion to obtain the EBUS image. Subsequently the probe was removed and biopsy was performed under fluoroscopic control. The EBUS image and clinical diagnostic effectiveness were investigated. Furthermore, the sensitivity of transbronchial diagnosis for lung cancer and the specificity of the ability to exclude lung cancer by this transbronchial method were investigated by comparison with 42 control cases examined only by fluoroscopy before the introduction of EBUS. Results. In 38 cases (76%) EBUS showed the peripheral lesion (33 from inside the affected bronchus (group A), and 5 from the adjacent bronchus (group B)). The clinical diagnoses were lung cancer in 24 cases, benign disease in 25 cases and 1 case remained unknown. The sensitivity of transbronchial diagnosis for lung cancer was 17/24 cases (70.8%) which was similar to that of the control cases 16/23 cases (69.6%). However, restricting evaluation to only group A, the sensitivity was 15/15 cases (100%), which was better (p = 0.06) than the sensitivity of the group of the cotrol cases in which the position of the cytology brush was estimated to be correct by fluoroscopy only (group a). Concerning the specificity of exclusion of lung cancer by the transbronchial method, there was no overall difference between EBUS cases: 25/33 cases (75.8%) and control cases: 19/26 cases (73.1%). However, group A of EBUS (18/18 cases, 100%) was statistically significantly better (p = 0.02) than the control group a (16/20 cases, 80.0%). Conclusions. EBUS clearly imaged the peripheral lung lesion in 76% of cases, indicating the correct location for the biopsy procedure. Especially when the US probe was introduced inside the affected bronchus, the sensitivity of transbronchial diagnosis of lung cancer and the specificity of exclusion of lung cancer were better than in the procedure using only fluoros copy.

View full abstract

Background. Multidetector-row computed tomography (MDCT) allows the high resolution multiplanar reconstruction (MPR) of images taken in the coronal, sagittal and axial planes. Purpose. To evaluate the branching patterns of the A^3a pulmonary artery in the right upper lobe from MPR images, and to assess the MDCT protocol and analysis method. Methods. The 32 cases studied comprised 30 patients with known or suspected disease of the lung parenchyma and 2 healthy volunteers. An MDCT scanner, Aquilion (Toshiba, Tokyo, Japan), was used for pulmonary imaging. Coronal and sagittal images were reconstructed from the axial scans at 2-mm intervals. The arterial variations of A^3ai and A^3aii, arising from either the superior trunk or the ascending artery (a branch of the inferior trunk) were evaluated. Results. A^3ai was found to originate from the superior trunk in 31 subjects (96.9%) and from the ascending artery in one subject (3.1%), whereas A3aii originated from the superior trunk in 12 subjects (62.5%) and from the ascending artery in 12 (37.5%) . Conclusion. High resolution MPR images can provide a means of assessing the arterial branching patterm at the level of the sub-segmental pulmonary artery.

View full abstract

Background. Bronchial artery embolization (BAE) is well known as conservative therapy for hemoptysis. Objectives. Bronchial arteriography was performed in 20 patients from May 1998 to June 2001 in our hospital. We retrospectively investigated the background, symptoms, clinical findings, and outcome in 13 patients with hemoptysis who underwent BAE. Methods. We embolized bronchial and nonbronchial systemic arteries by superselective embolization employing a coaxial microcatheter system. We used gelatin sponge and metallic coils as occlusive material. Results. Most of the underlying diseases were acid-fast bacilli related. Immediate cessation of hemoptysis was achieved in 10 of 13 atients, but not in 3 patients who subsequently underwent surgery. At long-term follow-up (3 to 18 months, average 9.7 months) no patient underwent BAE again and there were no significant complications. Conclusion. BAE for control of hemoptysis is a safe, minimally invasive, conservative therapeutic method that has not only immediate, but also long-term effects.

View full abstract

Purpose. We evaluated the indications of thoracoscopic treatment in the management of acute bacterial empyema. Materials and Methods. We reviewed 41 cases of acute bacterial empyema in our hospital between 1998 and 2002. We divided the patients with acute bacterial empyema into two groups, 1) medical treatment group (MT group, n = 13), who received antibiotic therapy and closed-tube thoracostomy alone, 2) thoracoscopic treatment group (TT group, n = 28), who underwent thoracoscopic surgery with debridement, pleurectomy, and decortication. Results. There was no significant difference in the initial clinical characteristics, the total duration of pleural fluid drainage, the total duration of antibiotic therapy, and the hospitalization periods between the two groups. In the MT group, body temperature and serum concentration of C-reactive protein (CRP) improved three days after closed-tube thoracostomy alone. In the TT group, body temperature, peripheral blood leukocytes, and serum CRP levels did not improve after closed-tube thoracostomy, which was performed for treatment before thoracoscopy. The clinical findings in the TT group improved after thoracoscopic surgery. The average duration of antibiotic therapy after thoracoscopic treatment in the TT group was 7 days. The mean duration of hospital stay after thoracoscopic treatment in the TT group was 19 days. In the MT group, the duration of antibiotic therapy was 21 days, and the duration of hospital stay was 29 days. Conclusion. These results suggested that thoracoscopic treatment seems to be a promising procedure in the management of acute bacterial empyema, especially in those patients who show no response to closed-chest catheter drainage within three days.

View full abstract

Background. Stenting is a standard strategy for tracheobronchial stenosis. When there is a long stenosis, airway bstruction may be caused by bleeding or endobronchial edema, a sometimes-fatal complication of stenting. Purpose. To maintain oxygenation during stenting by a percutaneous cardiopulmonary support system (POPS). Methods. We induced PCPS under local anesthesia and then performed general anesthesia. The stents were then inserted orally. Results and Conclusion. We treated three cases of tracheobronchial stenosis by this method, using a different type of stent for each patient. Oxygenation was well-maintained in all patients under PCPS, and the stents were safely implanted.

View full abstract

Purpose. We report two cases of lung cancer with carinal invasion and atelectasis of one lung. The indications of intra-bronchial therapy are also discussed. Case 1. A 67-year-old man had a polypoid tumor (small cell lung cancer, intermediate type) in the left main bronchus invading the carina with left lung atelectasis. The tumor was resected by intra-bronchial electrocautery, followed by radiation therapy. Recurrence was not observed 3 months later. Case 2. A 73-year-old man had an adenocarcinoma invading the carina and both main bronchi with left lung atelectasis and bilateral pneumonia. Although we chose radiation therapy because of the high intraoperative risk of stenting, the stenosis of the right main bronchus progressed despite radiation therapy. Therefore we performed intrabronchial stenting for the right main bronchus, but the patient died one week later. Conclusion. Atelectasis of one lung due to lung cancer sometimes improves by irradiation or chemotherapy. However, the situation of patients with lung cancer invading the carina with atelectasis of one lung is different from that of simple atelectasis of one lung, because those patients have a high possibility stenosis of the contralateral main bronchus occuring during treatment. In those cases, prompt resolution of the lung atelectasis by intrabronchial treatment is essential, even if there is considerable intraoperative risk.

View full abstract

Introduction. Endobronchial ultrasonography (EBUS) was useful in providing information to avoid life-threatening complications of endobronchial intervention. Case 1. A 45-year-old man underwent left sleeve pneumonectomy for lung cancer. He suffered from dyspnea 6 months postoperatively. Bronchoscopy revealed a pin-hole-like stenosis in the tracheo-bronchial anastomosis. Computed tomography revealed that the right pulmonary artery was in contact with the anastomosis. Laser treatment could not be completely carried out for fear of injury to the artery. EBUS showed the pulmonary artery to be on the right-anterior side of the stenosis. Based on this finding, laser therapy focusing on the opposite side was carried out without any serious complication. Case 2. A 75-year-old man underwent left sleeve lower lobectomy for lung cancer. After four months, he suffered from dyspnea on exertion. Bronchoscopy revealed stenosis of the bronchial anastomosis, and EBUS showed that there was 5 mm or more distance between the anastomosis and surrounding vessels. Based on this finding, laser therapy was performed around the stenosis. Conclusions. Endobronchial intervention is not always safe, due to possible complications such as massive hemorrhage or ediastinal emphysema. In the assessment of bronchial and extrabronchial wall structure, EBUS has recently been introduced. Two patients were successfully treated by endobronchial intervention without any complication based on the helpful findings of EBUS. This procedure is useful in preventing serious complications in endobronchial intervention.

View full abstract

Background. Pleural manifestations are rare in sarcoidosis, occurring in about < 1-11% of previous series. They include pleural effusions, pleural thickening, and spontaneous pneumothorax. We report a case of pleural sarcoidosis, and its thoracoscopic findings. Case. A 56-year-old woman was referred to our hospital because of bilateral hilar lymph node swelling, diffuse interstitial infiltrate in the right middle-lower lung field, and right pleural effusion on chest X-ray film taken in a medical examination. T-lymphocyte subsets in pleural fluid and BAL showed increase in the CD4: CD8 ratio. Bronchoscopy showed telangiectasia and a small nodule with granulation tissues. We made a diagnosis of lung sarcoidosis, and observed the case without medication because of the absence of symptoms. The pleural effusions increased comparatively quickly. Because pleural manifestations are rare in sarcoidosis, we decided to perform thoracoscopic examination for definitive diagnosis of pleural effusion. Thoracoscopy showed multiple whitish granulations and telangiectasia on the parietal and visceral serous membrane, and biopsy of these granulations showed sarcoid tissue. Conclusion. Thoracoscopic findings may be useful for diagnosing pleural involvement of sarcoidosis.

View full abstract