High frequency ventilation (HFV) is an advantageous method during tracheo-bronchoplastic surgery, because it can provide adequate ventilation and oxygenation with minimal obstruction of the surgical field. Experimental studies were performed in dogs to decide the optimal conditions of HFV for tracheo-bronchoplastic surgery. The results were applied to 11 cases of tracheal & bronchial plastic surgery. For HFV, or HFO-jet ventilator (Mera Co., Tokyo) was employed. For insufflation, a 3.0 mm-sized catheter with a 2.4 mm internal diameter was used. The results were as follows : In the dog model, sleeve right upper lobectomy and right sleeve pneumonectomy were done under various HFV settings. (1) In cases of sleeve lobectomy, application of HFV to the affected side can improve intraoperative oxygenation. A driving gas pressure (DGP) of 0.5-1.0kg/cm^2 and a frequency (F) of 6-10 Hz were found to be the optimal setting for sleeve lobectomy. (2) In cases of sleeve pneumonectomy, adequate ventilation and oxygenation were achieved with only HFV of the opposite lung. The optimal setting of HFV for sleeve pneumonectomy was a DGP of 1.0-2.0 kg/cm^2 and F of 6-10 Hz. Eleven cases of tracheo-bronchoplasty were performed using HFV (4 cases of right sleeve pneumonectomy, 2 cases of sleeve lobectomy, 1 carinal reconstruction and 4 tracheal resections). From the arterial blood gas analyses, it was verified that the HFV provided continuous and adequate ventilation and oxygenation during the period of airway reconstruction.

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This paper indicates some enhanced endoscopic images of bronchi obtained by a digital color image processing system. This system consists of fiberscope, computer, TV-camera, frame memory and color CRT display. For an easier detection of hilar type early lung cancer, blood vessels and irregularities on the surface are emphasized by the newly developed digital method.

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Pre-operative bronchoscopy was performed on 43 patients with advanced esophageal carcinoma. Bronchoscopic findings could be classified into four types by the grade of tracheobronchial involvement. In type I [-], no abnormalities were discernible. In type II [±], either protrusion of tracheobronchial wall with normal mucosa or abnormal findings such as thickening of longitudinal folds, irregularity and/or redness of the mucosa, and engorgement of mucosal blood vessels was present. In type III [+], there was evidence of both protrusion of tracheobronchial wall and abnormal findings of the mucosa. In type IV [++], tracheobronchial obstraction or stenosis caused by the polypoid tumor of esophageal carcinoma was observed. Type IV [++] was found in 5 patients (12%) out of 43, III [+] in 12(28%), II [±] in 13(30%) and I [-] in 13(30%). The sites of abnormal bronchoscopic findings were from the lower portion of the trachea to the left main bronchus in 77 percent of 30 petients. 73 percent of the abnormal 37 lesions was caused by direct invasion of the primary esophageal tumor and 23 percent was caused by lymphnode metastases of esophageal carcinoma. Five patients of type IV [++] underwnent radiotherapy. Out of the 12 patients with type III [+], 4 had radiotherapy, 5 exploration or bypass operations and 3 resection. Out of the 13 with type II [±], resection was performed on 8 patients (62%), exploration or bypass operations on 4 and radiotherapy on 1. Resection was performed on 9(70%) out of the 13 with type I [-]. In conclusion, pre-operative bronchoscopy seems to be very important in assessing the sites and the grade of tracheobronchial involvement and resectability of advanced esophageal carcinoma.

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Deformation of the residual bronchus after lobectomy is observed most predominantly in case of left upper lobectomy. To know the actual frequency and degree of the deformation of the residual bronchus after left upper lobectomy, 19 patients were observed bronchofiberscopically three weeks to 21 year after left upper lobectomy. The cause of the deformation of the residual bronchus was investigated pathologically, comparing with endoscopical findings, in one patient, whose residual left lung was removed accidentally five years after the left upper lobectomy. The endoscopically observed deformations of the residual bronchus after left upper lobectomy were (1) bend of the left main bronchus to upward, (2) clockwise torsion of the left main bronchus around the longitudinal axis at an angle of 60-90°, (3) protrusions of the bronchial wall, and (4) bronchial stenosis due to the protrusions. The deformations of the left main bronchus were observed in all of the 19 patients. Following the torsion of the main bronchus, forward movement of the stump of the upper lobe bronchus was observed also in all patients. Protrusion of the bronchial wall was seen in 18 out of 19 patients. Site of the development of the protrusion was in the orifice of the left lower lobe bronchus in 16 patients, in the distal portion of the main bronchus in 1, and in the basal segmental bronchus in 1. Bronchial stenosis, produced by the protrusion, was seen most frequently in the orifice of the basal segmental bronchus, in 15 out of 18 patients with development of the protrusion ; in the orifice of the lower lobe bronchus in 2, in whom the belonging segmental bronchi were not stenosed ; and in the main bronchus in 1, in whom the stenosis was localized only in the site of protrusion. The pathological investigation of the resected lung revealed that the protrusion of the bronchial wall, which was proved bronchofiberscopically before operation, was composed of folded bronchial cartilages covered with the mucous epithelium. This fact is suggesting that the protrusion of the residual bronchus after the left upper lobectomy is developed by folding of the bronchial wall due to a sharp bend of the bronchus, caused by movement and reexpansion of the residual lung. By analysis of the relation between the closing method of the bronchial stump of the left upper lobe and deformation, it became clear that development of protrusion was less in case that was suture line was crossing the longitudinal axis of the residual bronchus, than in case that was parallel to the axis. Therefore, it is concluded that development of the protrusion of the residual bronchial wall after the left upper lobectomy can be prevented by the method of closure of the bronchial stump.

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Intrabronchial hemorrhage induced by transbronchial lung biopsy (TBLB) is a serious complication. In 192 cases of TBLB, 6.3 percent of cases were complicated with moderate or massive intrabronchial hemorrhage. We employed the bronchial wede method by balloon catheter and infusion of thrombin solution in seven cases, and succeeded in halting the bleeding. Pathological examination of TBLB specimens showed 500 μ of bronchial artery and 1, 000 μ of pulmonary artery involved in the specimens. This proposed method can prevent massive bronchial hemorrhage as a complication of TBLB.

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Fiberoptic bronchoscopic findings of lung cancer are macro-pathologically divided into two major categories, i.e. the primarily mucosal type and the primarily submucosal type. The primarily submucosal type tumor can be observed bronchoscopically, in cases in which a peripheral type lung cancer has proliferated to invade more medial bronchi. The author has divided primarily submucosal type tumors further into 5 subtypes according to the bronchoscopic features and the results of pathological analysis : "normal folds", "interrupted surface undulation", "accentuated irregular folds", "subepithelial invasion" and "extramural type compression". The visual findings of "interrupted surface undulation" and "accentuated irregular folds" correspond to the intramural type of the macropathological classification, while "subepithelial invasion" corresponds to the subepithelial type and "extramural compression" to the extramural type. A detailed endoscopic analysis of the exact type of growth permits a correct understanding of the nature and type of development of the lesion. These bronchoscopic findings of submucosal type tumor, except "normal folds", significantly suggest that the regional lymph nodes are already involved. Moreover, the order of bronchi in which abnormal findings are observed, correlates with the clinical stage and operability. When these findings of primarily submucosal type tumor are observed at more medial sites than the lobar bronchus, the clinical stage of the patient can be estimated as III or IV. However, when these lesions exist at sites more peripheral than the segmental bronchus, the clinical stage is presumably II or III. Primarily submucosal type tumors observed in the truncus intermedius or the lobar bronchus are sometimes operable, and sometimes inoperable. On the other hand, the primarily submucosal type tumor at sites more peripheral than the segmental bronchus can be estimated as operable. Such detailed analysis of bronchoscopic findings of primarily submucosal lung cancer provides significant clinical information.

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Over the 6 years we have treated 136 patients with endoscopic Nd-YAG laser for various airway diseases. In this studies, we have examined the results and also the reasons for non-effective cases (19 cases) out of 64 lung cancer cases. Among these non-effective cases, there were 2 procedures. for emergency widening, 12 procedures for palliative widening of airway, 4 for curative vaporization of tumor and 1 for hemostasis. Considering the reasons for non-effectiveness, underestimation of the extent of cancer invasion was recognized as the single most impotant factor.

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The patient, a 39-year-old male had been undergoing hemo-dialyis for chronic renal failure, and on 31 December, 1984 hemoptysis occurred during the dialysis, which then stopped for a while, but after his return home a little bleeding occurred again. He tried not to cough, as far as possible. 2-3 days later breathing became gradually difficult and a slight fever also appeared. On 6 January a chest X-ray revealed atelectasis of the left lower lobe, and on 9 January bronchofiberscopy was performed. A thrombus was found in the left main bronchus about 1 cm distal to the carina of the trachea that completely obstructed the left main bronchus. Even with the use of biopsy forceps, a brush for cytology, etc. only small pieces could be removed. On 11 January YAG LASER irradiation was performed on the thrombus under bronchofiberscopy. Owing to LASER irradiation the thrombus retracted, and air started to flow into the distal part of the bronchus which had been completely obstructed. Further, the part of the thrombus irradiated by LASER, coagulated and became so hard that it could be seized with biopsy forceps, and the thrombus was removed slowly. The thrombus filled the left main bronchus to the subsegmental bronchi as a lump, but it could be removed nearly completely, and the patient was completely cured.

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A 55 year-old woman with congenital tracheo-esophageal fistula was admitted with a history of chronic productive cough since infancy. The chest X-ray showed mottled and reticular shadows in the lower half of both lung fields. Bronchoscopy revealed a tracheo-esophageal fistula, which was found in midway between the glottis and carina. Right thoracotomy was performed. At the level of the third thoracic vertebra, a fistula 3cm in diameter between the anterior wall of the esophagus and the posterior tracheal wall was found and divided. There was total absence of inflammatory reaction in surrounding tissues. The openings in the two structures were closed with interrupted sutures and covered with the surrounding tissues. Her postoperative course was uneventful and her cough completely disappeared. Congenital tracheo-esophageal fistula in adults is a rare entity. In this report, the clinical course of this case is presented and the diagnosis and treatment of this entity is discussed.

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Four cases of tracheobronchopathia osteochondroplastica were reported. Case 1 was a 74 year-old man with chief complaints of cough and hemoptysis. Fiberoptic bronchoscopy revealed multiple irregular nodular lesions in the trachea and in main bronchi. Case 2 was a 56 year-old man without any complaints but had abnormal findings on his chest roentgenogram. Fiberoptic bronchoscopy showed multiple nodular lesions in the trachea, main bronchi, orifices of the right upper and middle lobe bronchi and in the orifice of left B^8. Case 3 was a 48 year-old man with a chief complaint of chest pain. Fiberoptic bronchoscopy revealed multiple small nodular endotracheal lesions. Microscopic examination of biopsied specimens in 3 cases revealed bone and cartilage tissues under the submucosa and marked squamous metaplasia in the epithelium. Case 4 was a 60 year-old woman with chief complaints of cough and dyspnea. Bronchoscopy revealed multiple hard and white nodules in the tracheal wall and at the carina. Adenocarcinoma was recognized in the left lower bronchi. The bronchoscopic features of tracheobronchopathia osteochondroplastica are very specific and caracteristic, but histological diagnoses from biopsied specimens are needed. We suggest that case 3 and 4 might be in the earlier stage and case 1 in the late stage of tracheobronchopathia osteochonoroplastica.

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A case of endobronchial hamartoma in an anomalously branching bronchus is described. The patient, a 49 year-old male, complained of cough and sputum. He underwent thoracotomy on a diagnosis of bronchial tumor at another institution but adhesion reportedly prevented resection. However the tumor grew larger subsequently and the patient was transferred to the Department of Surgery of Tokyo Medical College. Chest-ray film revealed a nodule in the righ hilum. Bronchofiberscopic examination showed the tumor to be located in the truncus intermedius and endobronchial hamartoma was diagnosed by transbronchial biopsy. Surgery revealed that the right B^<1+2> and B^3 branched at different points from the right main bronchus and the tumor extended from B^<3b> up to the right main bronchus and truncus intermedius. Right S^3 segmentectomy was performed. Microscopically, the tumor was covered with columnal epithelium and was composed of chondromatous tissue, fatty tissue and connective tissue. We believe that this is the first report in the world of an endobronchial hamartoma developing in an anomalously branching bronchus.

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It is important to detect widening of the bronchial bifurcation by bronchoscopy for localization of early control type lung cancer. The authors studied the relation between bronchoscopic findings and histological findings in areas of widening of the bronchial bifurcation. Among seventeen cases with thickening bronchial bifurcation, all of which showed pathological findings histologically, 4 were invasive carcinoma (3 squamous cell carcinoma and one adenocarcinoma), one was malignant lymphoma, 2 were carcinoma in situ (both squamous cell carcinoma), 4 were atypical squamous metaplasia, 5 were metaplasia without atypia and one was basal cell hyperplasia. Bronchoscopically, in invasive carcinoma the mucosal surface showed more marked irregularity and swelling than carcinoma in situ and atypical metaplasia. On the other hand, no differences were found in bronchial mucosal color, irregularity and swelling between carcinoma in situ and atypical squamous metaplasia. Therefore it was bronchoscopically hard to distinguish carcinoma in situ from atypical squamous metaplasia.

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This is a report of an unusual case of multiple recurring papillomas that originally involved the larynx of a 45 year-old male and later the trachea. He visited our hospital because of expectoration of tissue fragments and bloody sputum. At bronchoscopy, multiple, fragile, pink-grayish, papillary tumors were found in the trachea. Biopsy revealed the tumors to be squamous cell papillomas. Since the patient had a history of a laryngeal papilloma when he was 35 years old the tracheal papillomas were interpreted as lower respiratory tract involvement of the previous laryngeal papilloma. During endoscopic Nd-YAG laser treatment, a new papilloma was recognized on the left vocal cord. Furthermore, four months after the treatment, multiple recurrence in the trachea was recognized. In the case of respiratory tract papilloma the possibility of a previous history of laryngeal papilloma should be considered, as well as whether the lesion is solitary or multiple. Treatment should to be into account the propensity for local recurrence and malignant degeneration of papillomatosis, with or without laryngeal papillomas.

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Two cases of relapsing polychondritis were reported. Both of them were 59 year-old males. Their initial symptoms were related to laryngotracheal involvement (stridor and irritable cough). Bronchoscopic findings were as follows : (1) edematous swelling of tracheobronchial cartilages, (2) marked general stenosis of the bronchial orifices, (3) disappearance of tracheobronchial cartilage. Because the main cause of death in relapsing polychondritis is airway obstruction, repeated bronchoscopic examination is useful to evaluate the severity and prognosis of the disease.

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We experienced three cases of broncholithiasis all of which probably had different etiologies. Case 1 was a 48 year-old male presenting with bloody sputum. For the previous 8 years he had pneumonia each year. His chest roentgenogram showed an atelectasis of the right middle lobe and multiple calcifications in bilateral lung hilar area. Bronchofiberscopy revealed a broncholith at the orifice of the right middle bronchus. It was suggested that the broncholith was derived from an intralobar calcified lymphnode. Case No.2 was a 39 year-old female presenting with abnormal findings on chest roentgenogram, showing destroyed left lung and severe stenosis of the left main bronchus. Bronchofiberscopy revealed a broncholith at the orifice of the left main bronchus which showed pin-hole stenosis. It was suggested that the broncholith was caused by mucus retention. Third case is 70 year-old male visited our hospital with hemosputum. However it was no particular findings in his chest roentgenogram. Bronchofiberscopy revealed the broncholith on the tracheal ring 10 cm above carina. This broncholith seemed to be derived from calcification of tracheal cartilage. We were able to pick up the broncholith in case 1 and 2, but couldn't in case 3. In component of broncholith, it was different between case 1 and 2.

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We reported three cases of sarcoidosis associated with prominent endobronchial nodules, and analyzed endoscopic findings in our 130 cases of sarcoidosis. Case 1 was a 57 year. old female complained of blurred vision. Fiberoptic bronchoscope revealed remarkable multiple nodules mainly scattered around the carina to the bilateral main bronchus. Histologically, bronchial biopsies of the nodules showed noncaseating epithelloid cell granulomas. Durig the steroid therapy, prednisolone 40 mg orally for the ocular lesion, disappearance of most nodules was observed and after cessation of the steroid administration, recurrence of the nodular lesions was confirmed. Other 2 cases, a 24-year old female with systemic lymphadenopathy and a 24-year old male with eye symptom, also showed multiple nodules bronchoscopically and epithelioid granulomas were confirmed histologically in the biopsy specimens. We performed 213 times of fiberoptic bronchoscope in 130 cases of sarcoidosis. Endoscopic finding of hypervascularity was observed in 75.1% and nodular lesions in 14.1%. In 31 patients undergone bronchial biopsy, histological confirmation of sarcoidosis was obtained 8 out of 19 patients with nodular lesions (42.1%) and 4 out of 12 patients without nodular lesions (33.3%). It is true that positivity of the bronchial biopsy is lower than that of transbronchial biopsy. However, considering about the complication of TBLB, bronchial biopsy can be another safe modality for the diagnosis of sarcoidosis. We may conclude that bronchial biopsy should be the first step procedure for the histological diagnosis of sarcoidosis.

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Tracheobronchial anomalies are not infrequent. A total of 85 tracheobronchial anomalies were detected in 71 patients based on a review of bronchographies of 13, 222 cases from Jan. 1959 to Dec. 1984. Theincidence of tracheobronchial anomalies was 0.64% of all cases. Displaced bronchi was seven times as frequent as supernumerary bronchi. A total of 75% traceobronchial anomalles were in the right upper lobe. Tracheal bronchus was the most frequent, its incidence being 30% of all cases. A rare case of a double right tracheal bronchus supplying the entire right upper lobe (B^1, B^<2+3>) was found in a 57 year-old female with an atrial septal defect. 5 cases were complicated with cervical rib, absence of rib, atrial septal defect etc. These anomalies were considered to have occurred synchronously with the development of the airway.

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A 52 year-old male was admitted with recurrence of pneumonia over a period of ten years, with coughing and hemoptysis. Chest X-ray revealed right lower lobe atelectasis and bronchoscopic examination confirmed complete obstruction of the right lower lobe bronchus by a smooth and rounded endobronchial mass. Right middle and lower lobectomy was performed. The tumor was diagnosed histologically as bronchial mucous gland adenoma. He is apparently disease for two years after surgery with no X-ray and clinical evidence of recurrence. A case of bronchial mucous gland adenoma which is very rare and truly benign was reported.

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