[Results of surgery for pT4 lung cancer]

During 1977 and 1991, 54 patients with lung cancer underwent surgery at Niigata University Hospital and were diagnosed with pathological T4. The survival rate of these pT4 patients was 32.5% at 3 years and 24.4% at 5 years. There was no significant difference between the survival rates of those with squamous cell carcinoma and those with adenocarcinoma. 5-year survival rate of 20 patients with N0 disease and 23 patients with N2 disease was 43.0% and 13.0%, respectively (p < 0.05). 5-year survival rate of 21 patients with organ invasion alone, 21 with dissemination or malignant effusion alone, and 12 with organ invasion plus dissemination or malignant effusion was 22.5%, 28.6% and 0%, respectively; there was no significant differences between these rates. Seven patients survived over 5 years; however, there were no obvious common factors. An aggressive surgical approach is indicated for T4 lung cancer, not only in patients with N0 disease but also in those with organ invasion alone or small amounts of malignant effusion alone.

Preoperative use of erythropoietin for cardiovascular operations in anemia

Erythropoietin was used in 10 patients undergoing elective cardiovascular operations who were compromised with anemia. Initially, their blood hemoglobin levels were less than 10 g/dL (range, 7.5 to 9.9 g/dL). Erythropoietin (600 to 700 units/kg per week) was administered intravenously or subcutaneously for about 2 to 12 weeks. Blood hemoglobin levels increased in each patient (11.0 to 14.5 g/dL) until the day operation, and during this course autologous blood donations (400 to 1,200 mL) were obtained from 8 patients. As a result, homologous blood transfusions were needed in only 1 patient in whom erythropoietin treatment was interrupted for other reasons. All these patients were discharged without event, and no adverse effects due to erythropoietin were found. Although the causes of anemia were not specified in some of these patients, it was noteworthy that erythropoietin was effective even in a patient with hypoplastic bone marrow. Subcutaneous use was assumed to be especially favorable in managing anemic patients, in whom preoperative erythropoietin treatment could be continued for up to 82 days. We conclude that erythropoietin would be beneficial for the anemic population to secure homologous-blood-free operations.

[A concomitant operation of aorto-coronary bypass graft and lung cancer: report of a case]

A case of a 66-year-old man with ischemic heart disease and lung cancer is reported. Chest roentgenogram revealed an irregular 2.8 x 2.0 cm mass in the right upper lobe. Coronary angiography showed 75-90% stenosis of the left anterior descending artery, and these lesions was suspected to cause perioperative myocardial infarction. A concomitant operation of aorto-coronary bypass graft and right upper lobectomy was performed through median sternotomy. A concomitant operation must be considered to be definitive and ideally preferable in selected cases.

[A case who developed mechanical pulsus alternans after Bentall's operation for annuloaortic ectasia]

Left ventricular pulsus alternans developed immediately after Bentall's operation in a 37-year-old patient with Marfan's syndrome accompanied by severe left heart failure due to annuloaortic ectasia. Echocardiographic examination suggested that this symptom was caused by alternating contractility based on left ventricular myocardial failure. Left heart failure disappeared early after operation, but pulsus alternans persisted until 7 months after operation, when EDVI decreased from 225 ml/m2 to 113 ml/m2.

[Invasive thymoma involving the liver: a case report of transdiaphragmatic extension]

A 38-year-old woman had an invasive thymoma which disseminated into the thoracic cavity and infiltrated the lateral liver surface. Such transdiaphragmatic extension by an invasive thymoma is rare, however, routine abdominal CT should be performed in invasive thymoma cases to avoid underestimating the extent of disease.

[Surgical management of desmoid tumors of the chest wall: a case report and review of literature]

A 45-year-old man without special predispositions showed a chest wall tumor with tenderness. A needle biopsy revealed a desmoid tumor which had invaded the muscles. A wide resection from the second to fifth rib was carried out and 4 years have passed without recurrence. A resection, at least 3 cm away from the lesion, is necessary for desmoid tumors which seem to have clear margins.

[Surgical management of multiple rib fractures: a case report of rib stapler]

A 66-year-old woman with multiple rib fractures was successfully treated with the use of Rib Staplers (Judet's struts made of titanium). Rib Staplers are effective for the stabilization of fractured ribs even if fracture lines are oblique.

[Experimental study of patch reconstruction of tracheal defects with Marlex mesh]

Animal experiments of the patch reconstruction of tracheal defects using Marlex mesh were performed on 41 mongrel and beagle dogs. They were consisted of four groups. In group I, cervical tracheal defects were reconstructed with simple Marlex mesh patches. In group II, cervical tracheal defects were reconstructed with Marlex mesh patches which were reinforced by three polyacetal-resin half rings. In group III, thoracic tracheal defects were reconstructed with Marlex mesh patches which were reinforced by half rings, and were covered with omental pedicle flaps. In group IV, a pedicled rectus abdominis muscle flap was prepared, and the inner side of Marlex mesh was covered by anterior sheath of the rectus abdominis and the external surface of the mesh was reinforced by rings and rectus muscle. Accordingly, in this group, thoracic tracheal defects were reconstructed by this combined Marlex mesh and pedicled muscle flap. In group I, Marlex mesh patches protruded into the tracheal lumen a large number of cases. On the contrary, in group II, in which meshes were reinforced by half rings, no protrusion of Marlex mesh patches was recognized. But granulation and abscess formation was observed in a large number of this group. In group III (omentopexy group), in spite of few granulation and abscess formation, complete epithelialization were obtained in only three of twelve dogs. In group IV (muscle flap group), few granulation and abscess formation was observed, and complete epithelialization were obtained in seven of twelve dogs. In conclusion, 1: Reinforcement of Marlex mesh by polyacetal-resin half rings was effective to maintain the tracheal lumen. 2: Using of omental pedicle flap or rectus abdominis muscle flap was effective to prevent the abscess and granulation formation. 3: Use of rectus abdominis muscle flap resulted in good epithelialization. 4: The inner surface of patches was covered with the flattened epithelium 2-3 months after surgery, and then covered with ciliated cells almost completely except central area of patches 6-12 months after surgery. The reconstruction of tracheal defect with combined Marlex mesh and rectus abdominis muscle flap may be ready for clinical use, however further investigation is necessary to develop tubular reconstruction of trachea in future.

[Surgery of vascular rings associated with complex intracardiac anomaly]

Two rare cases with surgically treated vascular ring associated with complex congenital cardiac anomaly are reported. Each case showed vascular ring due to right aortic arch, right descending aorta, aberrant left subclavian artery and left ductus arteriosus. Case 1 was a 2-year-old boy associated with ligamentum arteriosum and total anomalous pulmonary venous connection (TAPVC), and presented dyspnea and dysphagia. Case 2 was a 3-year-old girl associated with patent ductus arteriosus (PDA) and tetralogy of Fallot (TOF). In case 1, the two-staged operation was performed because of the necessity of mechanical ventilation and of recurrent respiratory infection. Division of the ligamentum, dissection of bronchus and esophagus was performed at the first operation through left thoracotomy, and the intracardiac repair of TAPVC was done three months later. In case 2, PDA division and the intracardiac repair of TOF was done simultaneously through median sternotomy because of the mild symptom of vascular ring and technical feasibility. Each case was successfully treated and became completely asymptomatic.

[Surgical treatment of advanced (p-stage III.IV) lung cancer less than 2.0 cm in size]

We treated surgically 567 patients with primary lung cancer from June 1975 to December 1989. There were nine patients with advanced (p-stage III.IV) lung cancer less than 2.0 cm in size. The five year survival rate was 50.8%. The histological diagnosis was adenocarcinoma in 6, squamous cell carcinoma in 3. A curative resection was performed in seven of nine patients. Six patients had one level metastasis of mediastinal lymph node. Three patients in whom relative curative resection was performed at surgery later developed regional recurrence. However, distant metastasis was not evident in all but one of nine patients. In conclusion surgical resection is considered to be significant in patients with advanced (p-stage III.IV) lung cancer less than 2.0 cm in size.

[Significance of fiberoptic bronchoscopy after pulmonary resection of lung cancer for early detection in second lung cancer]

By the end of 1988, seventy five cases after pulmonary resection for lung cancer and one case after pulmonary resection for basal cell hyperplasia were examined with fiberoptic bronchoscopy as postoperative follow up. Endobronchial tumor was detected in 14 cases. In seven cases, endobronchial tumor was located at site far from the surgical bronchial anastomosis. These tumors were suspected as second lung cancer as long as examined by fiberoptic bronchoscopy. Histological type of all of these was squamous cell carcinoma. Re-operations were performed in five cases and two of them were early lung cancer. In 6 cases (13.6%) among 44 cases examined with fiberoptic bronchoscopy after pulmonary resection for central type squamous cell carcinoma, second lung cancer was detected. In the case of central type squamous cell carcinoma, usually the tumor appears to be of same histological type and at same location. Among those cases those who smoke heavily should be separated as high risk group. If this group is followed with fiberoptic bronchoscopy or sputum cytological examination, it is more possible to detect second lung cancer at an early stage.

[Successful resection and reconstruction of the left atrium, right atrium and atrial septum under extracorporeal circulation in a patient with invasive pulmonary carcinoma]

A 69-year-old man was admitted to our hospital with a complaint of cough and hemoptysis. His chest X-ray showed an obstruction of the right intermediate bronchus and resultant atelectasis of the middle and lower lobes. Cytological examination by bronchoscopy showed squamous cell carcinoma. Although the cancer involvement of the left atrium could not be clearly defined by preoperative chest CT scan, the cancer invasion to the left atrial wall was recognized intraoperatively. Right pneumonectomy along with resection and patch reconstruction of the left atrium, right atrium and atrial septum was performed under extracorporeal circulation. Postoperative hemodynamic state was stable, and echocardiography showed normal volume of the left atrium. Histological examination of the resected specimen showed moderately differentiated squamous cell carcinoma with the involvement of the left and right atrial wall. The resected margins of the left and right atria were free of malignancy. Although he had been clinically in good condition and free from any sign of cancer recurrence, he died of aspiration pneumonia five months after the surgery.

[A case report of lung cancer with chest wall invasion arising from a bulla wall]

A 45-year-old man with a history of pulmonary bullae complained of back pain and chest pain while playing golf. His plain chest X-ray film revealed pulmonary bullae and an 8 cm tumorous mass. Although bronchoscopic biopsy was unsuccessful, adenocarcinoma was confirmed by transcutaneous lung biopsy. Because chest wall invasion was found by CT scanning, right upper lobectomy with chest wall resection and dissection of hilar and mediastinal lymph nodes was performed (p-T3N0M0, stage IIIA, relative curative resection). The postoperative course was uneventful and no sign of recurrence is evident eight months later. It was strongly suggested by histopathological study that the chest wall invasion of poorly differentiated adenocarcinoma arose from the bulla wall. Formerly, only two non-curatively resected cases with chest wall invasion of lung cancer arising from a bulla have been reported in Japanese literature.

[Pulmonary complication after resection of lung cancer--difficulty in expectoration and cough dynamics]

From January 1975 to December 1986, 415 patients were operated for primary lung cancer. Postoperative pulmonary complications were observed in 83 patients and among them 48 patients (57.8%) suffered from difficulty in expectoration. Postoperative expectoration mostly depends on the ability of coughing. To evaluate cough dynamics, expiratory flow-rate and volume at voluntary maximal cough were measured. The more expiratory flow rate and volume a cough has, the more effective it is for expectoration. In those patients with decreased FEV1.0, or respiratory muscle weakness because of emaciation and aging, or severe pain in the wound, the cough dynamics was decreased. By cleaning retained secretions in the respiratory tract, postoperative pulmonary complications would be prevented. However in cases where the decrease in postoperative cough dynamics is predictable, application of limited resection should be considered as well.

[Combined valvular and coronary artery surgery]

Combined valvular and coronary surgery were performed on 9 patients between 1973 and 1986. Valve replacements were consist of 5 AVR (including 1 translocated AVR and 1 Bentall operation), 2 MVR and 2 double valve replacement. Coronary surgery were of 6 aorto-coronary bypass using great saphenous veins, 1 innominate artery-coronary bypass using a Dacron prosthesis, 1 punch-out of coronary ostium and 1 dilatation of the left coronary ostium with a vein patch. Retrograde infusion of cardioplegic solution from the coronary sinus were done in patients with coronary ostial stenoses. One emergency case with acute cardiac failure died immediately after operation, and one with double valve and one with mitral valve replacement died of hepatic failure and multiple organ failure respectively within 1 year after surgery. Combined valvular and coronary surgery are necessary for patients with both diseases. Although the results of double valve replacement were not satisfactory, they would be improved using intra-aortic balloon pump and ventricular assist devices actively.

[A case of congenital diaphragmatic hernia due to left central tendon defect in pregnancy]

A twenty-seven-year-old 25 weeks gestation female was admitted with recurrent symptoms of nausea, vomiting and epigastric pain. She was diagnosed as left diaphragmatic hernia by chest X-ray film, CT and esophago-gastrography. During operation, a left central tendon defect was observed, and was 3.5 cm in diameter. The margin of the defect was smooth and round. It was associated with diaphragmatic eventration. The small intestine and transverse colon were herniated into the left thoracic cavity. The central tendon defect was closed with direct mattress sutures and was reinforced by overlap-technique of the diaphragm. To our knowledge, this type of defect has not been described previously in Japan. Diaphragmatic hernia in pregnancy is very rare, and presents abdominal pain, vomiting and dyspnea. Usually the diagnosis is achieved by chest X-ray film. However, esophago-gastrography should be added, if the diagnosis could not be confirmed by chest X-ray film. Conservative management is reported to bring high mortality, therefore, prompt surgical repair is advisable.

[Clinical trial of forphenicinol for the lung infection with Mycobacterium avium, Mycobacterium intracellulare complex]

Clinical evaluation of forphenicinol, a low molecular weight immunomodulator, in patients with Mycobacterium avium, Mycobacterium intracellulare complex pulmonary infections has been conducted in a multicenter trial participated by 9 institutions in Kyushu during a period of 12 months from July 1982 to August 1983. Forphenicinol was administered for 6 months without changing the regimen of antituberculous drugs used previously. The following results were obtained. 1. Ten out of 33 eligible patients were evaluated as showing good responses; In 5 of them, elimination of M. avium, M. intracellulare complex from sputum was observed. In the other 5 patients, number of bacilli excreted was decreased significantly after treatment. 2. All of the cases with good responses were those which were simultaneously administered with antituberculous drugs. 3. Patients with thick-walled cavities, following cured tuberculosis, which was superimposed with M. avium, M. intracellulare complex, were poorly responded to forphenicinol. 4. Side effects were observed in 3 out of 41 patients; 1 case each with fever, abdominal distension and anorexia. No abnormalities in laboratory test values were observed.

Field desorption mass spectrometric analysis of organic compound residues in the environment. I--Organochlorine insecticides

Field desorption mass spectrometry is applied to the positive identification of organochlorine insecticides and their related compounds residing in field soil environment. Additionally, standard field desorption mass spectra of these compounds are presented. Soil samples were collected in lettuce and spinach fields, and insecticides were extracted, cleaned up, and separated with thin-layer chromatography. Residue levels were measured by injecting the extract into a gas chromatography equipped with an electron capture detector. Residues of p,p'-DDT and dieldrin in field soil samples were clearly identified by field desorption mass spectrometry using the emitter dipping method. Moreover, mixed residues of these insecticides were simultaneously confirmed. However, residues of insecticides and their related compounds other than p,p'-DDT and dieldrin could not be characterized. All spectra of standard showed prominent [M].+, [M(35Cl(n-1), 37Cl)].+ and [M(35Cl(n-2, 37Cl2)].+ ions, and the [M(35Cl(n-1), 37Cl)].+ ion was the base peak in all spectra obtained.

Organochlorine insecticide residues in field soils of the Kitakyushu district--Japan 1970-74

Residues of organochlorine insecticides were monitored in field soils of the Kitakyushu District, Japan, from 1970 to 1974, before and after the insecticides were banned from agricultural fields. The arithmetic mean (AM) and geometric mean (GM) of BHC reached maximum levels in 1970 and 1971, then decreased rapidly during 1972 and 1974. Among BHC isomers, beta-BHC had highest mean levels and was therefore thought to be the most persistent of the isomers in field soils. Residues of aldrin, dieldrin, and endrin peaked in 1970 and/or 1971, and then decreased yearly. The percentage of sites which had aldrin contamination have decreased; those with dieldrin contamination have increased. Mean values of p,p'-DDE, p,p'-DDT, and sigmaDDT declined more slowly than did BHC and cyclodienes. Values of DDT and its related compounds were higher than were those of BHC, aldrin, dieldrin, and endrin. The residues of p,p'-DDE were most frequently detected of the DDT compounds.

Organochlorine insectide residues in vegetables of the Kitakyushu District, Japan--1971-74

The residue levels of organochlorine insecticides BHC, DDT, endrin, and dieldrin in the Kitakyushu District, Japan, were monitored from 1971 to 1974. Agricultural uses of these insecticides were banned in 1970. BHC isomers, alpha, beta, gamma, and delta-BHC were detected in all vegetable samples taken; beta-BHC residue appeared in the highest levels. The proportions of each BHC isomer in total BHC residues were much different from those in the technical product. Average residue levels of alpha, beta, gamma, and delta-BHC, dieldrin, endrin, and DDTR (p,p'-DDE+p,p'-TDE+o,p'-DDT) in 1971 were 0.007, 0.042, 0.010, 0.008, 0.021, 0.010, and 0.041 ppm in radishes, and 0.004, 0.007, 0.009, 0.003, 0.087, 0.031, and 0.009 ppm in cucumbers. Levels found in 1974 were 0.002, 0.003, less than 0.001, less than 0.001, 0.005, 0.006, and less than 0.001 ppm in radishes, and less than 0.001, 0.001, 0.001, less than 0.001, 0.008, 0.009, and undetectable in cucumbers. These residues were translocated form the insecticide-contaminated field soils to the vegetables through therir roots. Residue levels of dieldrin and endrin frequently exceeded the pesticide tolerance limits of Japan, but DDTR residues were only slightly above the specified levels.