Background and Objective. To survey the current state of the use and complications of respiratory endoscopy, the Japan Society for Respiratory Endoscopy performed a nationwide, postal questionnaire survey. Methods. The survey form was mailed to all 538 facilities certified by the society. The subjects were patients who underwent respiratory endoscopy in 2010. The numbers of procedures, complications, and deaths were investigated by lesion and procedure using the enclosed inventory. Results. The inventory was collected from 483 facilities (89.8%). The number of diagnostic flexible bronchoscopy procedures was 103,978, and 4 patients died (0.004%). The complication rate by lesion ranged from 0.51% to 2.06%, with the highest rate in patients with diffuse lesions. The complication rate by procedure ranged from 0.17% to 1.93%, with the highest rate in patients who underwent forceps biopsy. The complication rate after forceps biopsy of solitary peripheral pulmonary lesions was 1.79% (haemorrhage: 0.73%, pneumothorax: 0.63%), and that after endobronchial ultrasound-guided transbronchial needle aspiration (EBUST-BNA) of hilar and/or mediastinal lymph node lesions was 0.46%. Therapeutic bronchoscopy was performed in 3,020 cases; one patient died of expandable metallic stent insertion-induced haemorrhage (0.03%). By procedure, the complication rate after foreign body removal was the highest (2.20%). Medical pleuroscopy was performed in 1,563 cases. The highest complication rate occurred after biopsy using no electrocautery (1.86%). A total of 228 (47.2%) facilities experienced breakage of bronchoscopes and/or devices. Conclusions. Respiratory endoscopy was safely performed, but education concerning complications caused by new techniques is necessary.

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Background. Endobronchial ultrasonography with a guide sheath (EBUS-GS) is a method of identifying the locations of lesions on EBUS images in three dimensions and a positioning guide sheath, thereby making it possible to repeatedly perform bronchial brushing and transbronchial lung biopsy at the same site. In recent years, the effectiveness of EBUS-GS has been reported, but there are few studies on the effectiveness of the introduction of EBUS-GS. Objective. We assessed the diagnostic effectiveness of EBUS-GS by comparing the results with those before its introduction. Subjects and Methods. The subjects of the study were 103 patients with pulmonary peripheral lesions who underwent EBUS-GS (EBUS-GS (E) group), and they were compared with a historical control group of 102 patients who underwent fluoroscopy-guided bronchoscopic examination (Control (C) group). An ultrasound probe and a guide sheath were used in combination in the E group. Virtual bronchoscopic navigation and rapid cytology were not used in either group. Results. There were no significant differences between the two groups in age, sex, lesion size, or procedure time. The diagnostic yield of lesions less than 20 mm in size was 88.6% in the E group and 30.8% in the C group. Moreover, the diagnostic yield in lesions sized 20 mm or more was 91.2% in the E group and 52.6% in the C group. There was a significant difference between E and C group (p<0.0001). In cases in which an internal echo was measured by EBUS, the diagnostic sensitivity was 98.4% and diagnostic accuracy was 98.6%, whereas in cases in which only an adjacent echo was measured by EBUS, diagnostic sensitivity was 80.0% and diagnostic accuracy was 85.7%. Conclusion. EBUS-GS revealed that diagnosis by bronchoscopy under conventional fluoroscopy for a pulmonary peripheral lesion would become easier when using it together with EBUS-GS.

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Background. Malignant pleural mesothelioma (MPM) is a rapidly progressive malignancy with a median survival of 10 to 12 months. Mesothelioma usually shows a poor response to chemotherapy; complete response (CR) is rare. Case. A 74-year-old female patient presented with pleural effusion. She had worked as a baker for 30 years and had a history of asbestos exposure from the oven. She had experienced right chest pain since December 2005, and a chest X-ray revealed a right pleural effusion. Subsequently, she was referred to our hospital in February 2006. Thoracoscopic examination under local anesthesia with biopsies demonstrated multiple parietal pleura-based nodules and confirmed epithelioid malignant mesothelioma. She received 4 cycles of cisplatin + irinotecan + doxorubicin with radiologic CR which was maintained until October 2010. The patient is currently alive and has a good performance status (PS), although she shows signs of relapse. Conclusion. CR to chemotherapy is rare but could be possible for MPM with a number of good prognostic factors. This patient had (1) epithelioid subtype, (2) stage 1 disease on first presentation, (3) good PS, (4) female, (5) no thrombocytosis, (6) normal white blood cell count. Thoracoscopy under local anesthesia is a useful for diagnosis of early stage of MPM.

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Background. Tracheal injury by blunt trauma is comparatively rare, but the mortality is high. Therefore, it is important to diagnose the condition rapidly and decide on the treatment plan correctly. If tracheal trauma is suspected, it is important to detect the injured part of trachea by radiography and bronchoscopy. We report a case in which the injured part of the trachea could be detected non-invasively by virtual bronchoscopy. Case. A 60-year-old man fell and bruised anterior region of his neck. From his clinical findings and CT scan, we suspected cervical tracheal injury. We performed virtual bronchoscopy based on a CT scan taken on admission, and diagnosed type Ia tracheal trauma. We carried out conservative treatment with intubation for 1 week, and confirmed cure of the injured part of trachea without an operation. Conclusion. Virtual bronchoscopy provided accurate information for diagnosis and treatment of tracheal trauma and was useful for non-invasive decision-making.

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Background. Postoperative bronchopleural fistula is often difficult to manage. While a variety of therapeutic approaches have been reported, treatment for bronchopleural fistula still remains controversial. Case. A 73-year-old man developed a bronchopleural fistula during treatment for pyothorax after right lower lobectomy. Bronchofiberscopy confirmed a small air leakage at the anastomosis site in the right lower bronchus. N-butyl-2-cyanoacrylate was successfully applied through the bronchofiberscope to close the fistula. The patient is currently free from relapse of the bronchial fistula 8 months after this endoscopic intervention. Conclusion. Endoscopic single application of N-butyl-2-cyanoacrylate seems to be a simple and effective treatment option for the closure of bronchopleural fistula with a small air leakage.

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Background. Bronchial foreign bodies can cause the bronchiectasis. However, a long interval (35 years) from the absorption of a foreign body at age of 5 years old was implicated in the present case. Case. A 40-year-old woman with wet cough and low grade fever was given a diagnosis of bronchiectasis. She was admitted to our hospital in May 2008 because of exacerbation of symptoms. She had right precordial crackles. Computed tomography (CT) showed bronchiectatic changes confined to the right upper lobe. Bronchoscopy revealed stenosis of the right main bronchus, orifice of the right upper lobe bronchus, and right truncus intermedius. The patient underwent right upper lobectomy and tracheobronchoplasty. When the right upper lobe was resected, a plastic body (12 mm in size) was found. Her bronchiectasis was considered caused by bronchial obstruction due to this foreign body. Her symptoms disappeared and her pulmonary function was improved after the surgical treatment. Detailed history taking revealed an episode of a foreign body (a plastic flower) aspiration at age 5. The plastic foreign body was difficult to detect by chest X-ray and CT. Conclusion. This case suggested that an intrabronchial foreign body can cause long-term obstruction of bronchus resulting in atypical bronchiectasis.

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Background. Sarcoid-like reactions in mediastinal lymph nodes, which mimic recurrence, are rarely seen following surgical cancer resection. Cases. Case 1: A 64-year-old man who underwent a wedge resection of the right lower lobe as limited surgery for lung adenocarcinoma was noted to have mediastinal lymphadenopathy on chest computerized tomography (CT) 3 years after the operation, which was suspected to be recurrence. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) revealed non-caseating granulomas diagnosed as a sarcoid-like reaction. Case 2: A 79-year-old woman who underwent a left upper lobectomy for lung adenocarcinoma showed an enlarged pre-carinal lymph node on chest CT 32 months postoperatively. EBUS-TBNA confirmed a sarcoid-like reaction in that node. Conclusion. When mediastinal lymphadenopathy is seen following surgery for lung cancer, a pathologic confirmation is desirable to rule out a sarcoid-like reaction, even though it is a rare entity.

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Case. A 70-year-old man had been continuously receiving interferon and ribavirin for the treatment of chronic hepatitis type C since November 2009. In addition, a thoracic aortic aneurysm was being monitored with high resolution-computed tomography (CT) on a 6-monthly basis. CT in July 2010 revealed a round nodule, 17 mm in diameter, with an irregular margin in the right middle lobe of the lung. CT one month later revealed the nodule had increased in size. An adenocarcinoma was suspected, however, laboratory examinations showed no elevation of tumor markers or inflammatory parameters. A transbronchial biopsy by bronchoscopy and CT guided lung biopsy were performed, and the microscopic findings demonstrated the presence of polypoid granulation tissue in the air space. The nodule was diagnosed as a focal organizing pneumonia. Conclusion. In this case of focal organizing pneumonia, the clinical and radiographic findings lacked specificity and the disease was ultimately diagnosed by transbronchial biopsy. In its solitary form, it was difficult to distinguish focal organizing pneumonia from adenocarcinoma of the lung. Further cases need to be documented to help improve the differential diagnosis.

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Background. While median sternotomy is frequently used for tracheal sleeve resection, right posterolateral incision facilitates tracheal resection in some cases. Case. A 55-year-old woman had a cough for 2 years. A chest CT taken on an annual health check-up demonstrated a tumor in the upper intrathoracic trachea. Bronchoscopic examination showed that her trachea consisted of 16 rings of tracheal cartilage in total and that she had a polypoid intratracheal tumor, 2 cm in size, from the 8th to 10th ring from the cricoid cartilage. The biopsy showed adenoid cystic carcinoma. Because the CT indicated invasion of the tumor to the esophagus, we selected right posterolateral thoracotomy to facilitate dissection between the back wall of the trachea and the esophagus. As a clear operative field was obtained by 4th intercostal space with right posterolateral incision, dissection of the tumor from the esophagus and 4 rings of the tracheal resection was successfully performed. The postoperative course was uneventful. Although the negative surgical margin both of the tracheal stump and esophagus were obtained microscopically, additional irradiation (50 Gy) was performed to the tumor bed because the tumor infiltrated close to the esophageal surgical margin. The patient is alive and without any complication at 9 months after the operation. Conclusion. Right posterolateral thoracotomy is a useful approach for sleeve resection of upper thoracic tracheal cancer which is suspected to invade the esophagus.

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Background. Lung aspergilloma often causes of lung bleeding, which results from inflammation of the lungs. Generally bronchial artery embolization (BAE) is first tried for the treatment of massive hemorrhage due to lung aspergilloma, and if there were refractory to treatments, operation is considered. However, in some cases, these procedures are impossible because of poor physical condition or the treatment environment. Recently, cases in which endobronchial Watanabe spigots (EWS) have been attempted to be used to halt lung bleeding transbronchially are increasing. Case. A 62-year-old man was admitted on an urgent basis to our hospital for hemoptysis lasting for 2 months. He had an old scar with a cavity that derived from tuberculosis in his right upper chest, and this area was suspected to be the bleeding site. After admission, because his breathing problems were exacerbated, causing respiratory failure, we treated him using an artificial ventilator. Because bronchial artery embolism was difficult to perform, EWS was used for hemoptysis. Although temporary arrest of the hemorrhage was successful, complete hemoptysis was not possible. Conclusion. We propose that because blocking the bronchus with an EWS for hemoptysis is a comparative indication, we should change the procedure to BAE if it is not effective.

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Background. Relapsing polychondritis (RPC) is a relatively uncommon disease and its diagnosis in the early stage can be difficult. It is reported that it takes about 2.9 years to establish diagnosis from the onset of the disease. Case. A 44-year-old man presented with fever and cough. Findings of biopsy-obtained tissue of tracheal cartilage in the neck and ^<18>F-fluorodeoxyglucose positron emission tomography examination finally led to a diagnosis of RPC localized to the tracheobronchial region. We were able to initiate treatment about a month after the onset, which is early compared to the common course of RPC. Corticosteroid therapy provided symptomatic improvement and marked improvement of tracheobronchial mucosal edema by bronchoscopy. Nevertheless his respiratory obstruction was not improved to the desired extent. Corticosteroid monotherapy failed to obtain remission of disease, therefore an immunosuppressive agent was required in combination. Due to later marginal exacerbation in the therapeutic course his respiratory function gradually deteriorated. Conclusion. Despite the early identification and treatment of RPC, permanent obstructive pulmonary dysfunction could occur in many RPC patients. In the management of RPC, we emphasize the need for very strict control of disease to maintain the patient's respiratory function.

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