Application of a new tactile sensor to thoracoscopic surgery: experimental and clinical study

BACKGROUND

We developed a new tactile sensor that could quantify the hardness of objects as changes in the resonance frequency of the sensor (delta f). We have applied it to thoracoscopic operations for the localization of small invisible nodules in the lung.

METHODS

When the sensor probe was moved over the lung surface, a delta f curve was depicted on the computer screen. When the sensor tip reached a point directly above a hard object, a sudden upward jump of the delta f curve was evoked. After experimental studies using pigs, the sensor was applied in 8 patients. More recently we produced a needle sensor to distinguish small nodules from bronchi that may evoke similar upward jumps of the delta f curve. Eight nodules and four bronchi in resected human lungs were probed directly using this sensor.

RESULTS

In all of the patients, the hardness of various thoracic structures could be quantified. A total of 10 nodules were found using the sensor and resected thoracoscopically. The needle sensor distinguished nodules from bronchi, as the mean delta f of the bronchial walls (-64 +/- 45.9 Hz) was significantly higher than that of nodules (-526 +/- 168 Hz, p < 0.001).

CONCLUSIONS

Thoracoscopic detection of small and invisible pulmonary nodules using our new tactile sensor is feasible.

[Bronchogenic carcinoma associated with right aortic arch and postaortic left brachiocephalic vein--report of a case]

61-year-old male was admitted to our hospital for surgical treatment of bronchogenic squamous cell carcinoma arising from left B8. The patient had right aortic arch with aberrant left subclavian artery and postaortic left brachiocephalic vein. Intraoperatively, left ligamentum arteriorsus forming vascular ring between the left subclavian artery and the pulmonary artery was found, however the ligamentum arteriorsus was not divided because no symptom of esophago-tracheal compression was observed. The left brachiocephalic vein was located between the ascending aorta and the arterial ligament. The lower lobe of the left lung was resected, and lymph nodes in the left side of the mediastinum were dissected easily because the aortic arch was positioned on the other side. Preoperative assessment of the type of branching and the course of arteries and veins is important for safe operation.

[New tactile sensor for thoracoscopic detection of intrapulmonary nodules]

We have developed a new tactile sensor which can be used for thoracoscopic detection of invisible intrapulmonary nodules. We applied this new device for consecutive ten cases to excise twelve intrapulmonary nodules thoracoscopically from August 1994 to January 1995. In this report, one of ten cases was presented. The patient was a forty-three-year-old female and admitted with an indeterminate nodule on chest X-ray and computed tomography. When the sensor probe quantifying the hardness of objects by the changes in resonance frequency of the sensor (delta f) passed above the nodule, a sudden jump was evoked in delta f curve on the computer screen. The nodule was resected thoracoscopically and proved pathologically to be adenocarcinoma. Thoracoscopic procedure was then converted to open thoracotomy and lobectomy with lymph node dissection was performed.

Long-term results of surgical treatment of intracardiac tumors. Effectiveness and limitation of surgical treatment

Twenty-five cases of intracardiac tumors were operated upon from 1975 through 1994. Twenty-four operative survivors were followed up. The follow-up period ranged from 2 months to 19 years with an average of 8 years. The histological diagnoses of the tumors were as follows: benign tumors 21 (myxoma 20, leiomyoma 1) and malignant tumors 4 (sarcoma 3, carcinoma 1). In 21 cases, tumors had cardiac origins, while there were four intracardiac tumors which had originated in other organs and extended transvenously to the intracardiac cavity (leiomyoma 1, sarcoma 2, carcinoma 1). The results of surgical treatment of intracardiac benign tumors were satisfactory, regardless of their origins and multiplicity, both in the short-term and in the long-term. On the other hand, the long term results for malignant intracardiac tumors were extremely poor, although their excision or resection had a beneficial effect on the hemodynamics in patients with congestive heart failure or cardiogenic shock.

[Solitary rectal carcinoma metastasis to the left hilar lymph nodes: a case report]

A 66-year-old woman was referred to this institution for treatment of hemoptysis, atelectasis of the left upper lobe, and marked hypoxia necessitating oxygen therapy. A low anterior resection of the rectum had been performed for rectal adenocarcinoma 6 years and 3 months before this admission, and was followed by another resection after a local recurrence 20 months later. Bronchoscopy revealed an endobronchial tumor obstructing the left upper lobe bronchus. Tissue from a transbronchial biopsy revealed metastatic rectal carcinoma of the endobronchial lumen. There was no evidence of local recurrence or metastasis to other organs. A left pneumonectomy and lymph node dissection were performed successfully. The postoperative course was uneventful, and the patient was discharged after marked improvement of the arterial blood gas results. The pathological diagnosis of a resected tissue specimen was metastatic adenocarcinoma of the left hilar lymph nodes with invasion of the left main bronchus and protrusion into the endobronchial lumen. The patient remained disease-free for 6 months. At that time, computed tomography of the chest disclosed small metastases in the right lung and chemotherapy was begun.

[Pulmonary hamartoangiomyomatosis (lymphangiomyomatosis) in tuberous sclerosis--a case in which clinical course had been modified by previous surgical intervention]

A 42-year-old woman was referred to this institution because of persistent air leak associated with left spontaneous pneumothorax. She had undergone a radical hysterectomy with bilateral oophorectomy and left nephrectomy one year previously. The renal tumor was identified as an angiomyolipoma. This, along with the characteristic dermal lesions led to the diagnosis of tuberous sclerosis. Preoperative thin-slice chest CT showed multiple thin-walled, round and cystic air spaces in the pulmonary parenchyma bilaterally, as well as the left pneumothorax. Through a left thoracotomy, suture ligation and laser ablation of the pulmonary bullae was done. Examination of the biopsy specimen of the lung showed hamartoangiomyomatosis with multiple bullae. The proliferating smooth muscle in the walls of the bullae was positively stained by HMB45 monoclonal antibody. The patient recovered uneventfully, and was doing well three years later without medications. The prior surgical castration may have prevented progression of the disease.

Metabolic fates of carbon skeletons of methionine, serine, and alanine in growing rats fed soybean protein diets

The effects of dietary soybean protein isolate intakes on the metabolic fates of L-[U-14C]methionine, L-[U-14C]serine, and L-[U-14C]-alanine were investigated in growing rats. In the growth experiment for 21 days, body weight gain reached a plateau at more than 20 protein calorie percent (PC%) in the diet, and the protein efficiency ratio attained maximum in the 10 PC% group. Carcass and liver lipid contents increased greatly in the lower levels of dietary soybean protein, which was associated with their decrease in moisture contents. In the isotope experiments, the incorporation of 14C into the body protein 12h after the injection of [14C]methionine was extremely high (more than 80% of the dose) in the 5 to 15 PC% groups, but decreased thereafter in the higher PC% groups. The expired 14CO2 production from [14C]methionine was depressed in the lower PC% groups, and thereafter it increased with increasing levels of dietary protein, showing a break point at around 20 PC%. The carbon skeleton of [14C]alanine was extensively oxidized to 14CO2, even in protein-depleted rats, while serine carbon was utilized for body protein synthesis rather than for energy production. These results indicate that methionine, which is a limiting amino acid of soybean protein for rats, is preferentially utilized for body protein synthesis especially in protein-depleted rats, and the metabolic responses of methionine, serine, and alanine are quite different from each other.

[Thoracoscopic treatment of intrathoracic diseases]

Recently developed thoracoscopic surgical equipment and related instruments have enabled us to perform two groups of advanced thoracoscopic surgical procedures. Group 1: procedures formerly performed by open thoracotomy, and group 2: procedures performed by thoracoscopic surgery only. Group 1 includes bullectomy for spontaneous pneumothorax, wedge resection for lung nodules, resection of benign tumors of the mediastium or chest wall, lung lobectomy, and resection of giant bullae. Because thoracoscopic surgery is minimally invasive, intrathoracic surgical procedures should be performed by thoracoscopic surgery if the results are the same. Group 2 consists of surgery in patients with poor pulmonary reserve and laser ablation of the bullous lung in advanced emphysema. Until recently, surgical intervention was not an option in the patients in groups 2 because of the invasiveness of open thoracotomy. Thoracoscopic surgery allows resection of tumors in early stage lung cancer in patients with poor pulmonary reserve. Severely emphysematous lungs can be ablated with a laser and shrunk, to normalize pulmonary compliance, residual volume and total lung capacity, and thus relieve symptoms.

[Thoracoscopic resection of schwannoma: a report of two cases]

We have performed thoracoscopic resection of schwannoma without intraspinal extension in two asymptomatic cases confirmed by chest roentgenogram and computed tomography: the case 1 with the tumor as large as 4.0 x 4.0 x 3.5 cm found in the paravertebral fifth Intercostal space, the case 2 with the tumor as large as 3.2 x 2.5 x 1.8 cm found on the first rib in contact with the supreme intercostal vein. In the operation of case 1, the dilated fifth intercostal vein in contact with the tumor which could not be controlled by Endo-Clip was doubly ligated by the use of Knot-Pusher. The tumor was successfully dissected from the chest wall and proved to arise from the fifth intercostal nerve. The tumor was brought into Endo-Pouch and extracted through one of the skin incisions which was minimally enlarged to accommodate the pouched lesion. In the operation of case 2, curved forceps facilitated the procedure because the tumor located near the apex of thorax. The tumor was found to originate from sympathetic nerve and removed through the minimally enlarged incision as case 1. We conclude as the following. The benign tumor found in the mediastinum or the chest wall is amenable to thoracoscopic treatment. In thoracoscopic procedure, as the operation under thoracotomy, we must acquire skills of standard operative technique, i.e., suture or ligation, because those skills are necessary when Endo-Clip or Endo-GIA cannot be used. The skin incision should be minimally enlarged finally when the specimen is extracted to minimize operative intervention.

Enhancing effect of zinc acetate on the binding of 1-nitropyrene to polydeoxyguanylic-polydeoxycytidylic acid in the hypoxanthine-xanthine oxidase system

The main aim of this research was to investigate whether conformational alteration of polydeoxyguanylic-polydeoxycytidylic acid (poly[dG-dC].poly[dG-dC]) by zinc acetate would have an effect on the binding of 1-nitropyrene(1-NP) to poly[dG-dC].poly[dG-dC]. The binding of 1-NP to poly[dG-dC].poly[dG-dC] in the hypoxanthine-xanthine oxidase system in vitro was increased by zinc acetate. This increase was abolished when EDTA was added to the preincubated mixture of poly[dG-dC].poly[dG-dC] and zinc ions. Neither the production of 1-aminopyrene and its expected intermediates, N-hydroxy-1-aminopyrene and 1-nitrosopyrene, nor the 1-NP remaining in the reaction mixture was altered by the addition of zinc acetate without poly[dG-dC].poly[dG-dC]. From these findings, it seems that the hypoxanthine-xanthine oxidase system is not activated by zinc acetate. On the other hand, under the same reaction conditions but the hypoxanthine-xanthine oxidase system and 1-NP, it has been reported that zinc ions or complexes transform the B-form of poly[dG-dC].poly[dG-dC] to the Z-form. Therefore, these findings indicate that the formation of the Z-form or intermediates from the B-form by zinc ions may promote the binding of 1-NP to poly[dG-dC].poly[dG-dC].

[Thoracoscopic partial resection of the lung by use of Nd-YAG laser and standard suturing technique]

The patient was a 62-year-old woman who was referred to our department for bilateral diffuse abnormal shadows along with a sigmoid colon cancer that had been resected one month previously. Thoracoscopic partial resection of the left S8 region was performed. Nd-YAG laser with a contact tip was used for the resection. Hemostasis at the bed of the resection was assured by applying a free laser beam to oozing and non-coagulated surface. Additionally, the resected end was closed by standard continuous double over-and-over sutures in order to minimize the air leakage. Endo-Bulldog clamp facilitated the operation, minimizing hemorrhage from the resected end. This device can clamp any part of the lung and save one percutaneous puncture site necessary for thoracoscopic procedures. Postoperative course was uneventful. Pathological diagnosis was reported as an alveolar cell carcinoma of the lung.

[A case of mediastinal neurinoma originated from the left vagal nerve]

A 46-year-old man was admitted to our hospital because of an abnormal shadow on the chest roentgenogram. The operation was performed through left posterolateral thoracotomy. A tumor mass, 4.5 x 2.5 x 2.5 cm in size, was found and its origin was the left main vagal nerve 0.5 cm distal the branching root of the recurrence nerve. The tumor and a part of the left vagal nerve was resected en bloc. Pathological study revealed tha the tumor was neurinoma of Antoni A+B. Postoperative course was uneventful. This is the 34th reported case in Japanese literature of neurinoma with its origin from the intrathoracic vagal nerve.

Postaortic left innominate vein: radiological assessment and pathogenesis

Postaortic left innominate vein (PALIV) is a rare venous anomaly and the findings on plain chest radiographs have not been well described. Plain chest radiographs, CT and MR of nine adults known to have PALIV were reviewed. They all showed a high aortic arch, including four with a right-sided aortic arch and one with a double aortic arch, in postero-anterior radiographs, and seven showed curved shadows in the left upper mediastinum. On all lateral chest radiographs (n = 5), the superior retrosternal region was opacified by the high aortic arch. CT or MR images confirmed the aortic arch and/or innominate artery to be in that part of the retrosternal space, normally occupied by the left innominate vein, in all cases. Association of a curved shadow in the superior mediastinum with a high aortic arch on plain chest radiographs is therefore suggestive of, though not diagnostic for, PALIV. This entity was well documented by CT or MR and the radiological findings were considered to imply that developmentally PALIV is secondary to a high position of the aortic arch.

[The immunosuppressive effects of FK506 on single lung allotransplantation in Japanese monkey (Macaca fuscata)]

Allotransplanted lung of Japanese monkey (Macaca fuscata) was studied in view of immunosuppressive effects of FK506. Left lung grafts were transplanted orthotopically. According to the postoperative treatment, recipients were divided into two groups. Group A (N = 7): FK506 0.5 mg/kg/day intramuscularly up to the 6th postoperative day (POD) and 0.15 mg/kg/day thereafter, and Group B (N = 7): No immunosuppressive drugs. Chest radiographs, hematoxylin-eosin staining and immunostaining of the grafted lungs were evaluated in point of the rejection. Recipients of Group A survived 7 to 182 days, and those of Group B survived 5 to 35 days. All of them except one in Group A were sacrificed. Chest radiographs of the recipients in Group A showed diffuse shadows of the grafted lungs between the 7th and the 14th POD, however, they gradually became clear afterwards. On the contrary, those of Group B showed that the infiltrative shadow of the grafted lungs was progressive and it became completely radiopaque between the 5th and the 7th POD. Perivascular lymphocytic infiltration of the grafted lungs of Group A was absent or mild. However, prominent perivascular lymphocytic infiltration was seen in the grafts of Group B on the 3rd POD, and the infiltration into the alveolar wall was seen between the 5th and the 7th POD. Necrosis of the grafts was seen after the 7th POD in Group B. CD8 positive cells were observed in the perivascular region of the grafts of Group B and they were increasing after the 2nd POD. Fewer CD8-positive cells were observed in that of Group A on the 5th POD, and they were not increasing. Postoperative serum level of FK was maintained at 1.06-1.81 ng/ml in Group A. Postoperative blood chemistry examination revealed neither hepatic nor renal impairment in Group A. Based upon the above findings, it was concluded that the sufficient immunosuppressive effects were achieved by FK506 in the allotransplanted lung of the Japanese monkey.

Enhancement by cyclosporin A of metastasis from hamster cheek pouch carcinoma

Daily intravenous administration of 50 mg/kg cyclosporin A (CsA), after excision of cheek pouch tumors induced with 9,10-dimethyl-1,2-benzanthracene (DMBA), enhanced the incidence of cervical lymph node metastasis to 93%, a significant increase over the rates observed for animals receiving a dosage of 25 mg/kg (43%), and for control animals receiving no CsA (40%). No significant effect was evident on the growth rates of the metastasized tumour cells in the lymph node.

Biologically active constituents of Magnolia salicifolia: inhibitors of induced histamine release from rat mast cells

The extracts of the flower buds of Magnolia salicifolia showed remarkable anti-allergy effects in passive cutaneous anaphylaxis (PCA) test. The bioactive constituents of this medicinal drug were isolated by monitoring their activities with an in vitro bioassay system measuring inhibitory effects on induced histamine release from rat mast cells. Of the ten isolated compounds magnosalicin is a new compound of neolignan structure. In addition to the isolated compounds samples of coumarins and lignans were evaluated their biological activities with the in vitro bioassay.

[Single lung allotransplantation of Japanese monkeys--an immunohistological appraisal of the acute rejection]

Eleven orthotopic single lung allotransplantations of Japanese monkeys (Macaca fuscata) were done without immunosuppression. In the 7 monkeys acute rejection was obvious on chest X-ray and hematoxyline-eosin (HE) staining of the biopsied specimen. On the chest X-ray film, progressive interstitial shadow of the grafts became apparent at the third postoperative day, and they turned out completely radiopaque at the 6th- or 7th postoperative day. The HE staining revealed prominent perivascular edema at the second postoperative day. Perivascular round cell infiltration appeared at the third day and the massive round cell infiltration was observed in the perivascular region, vascular wall and alveolar wall with the thickening of the alveolar wall. Immunostaining with human antilymphocyte monoclonal antibodies was also performed. CD8 positive cells (suppressor/cytotoxic T cell) were observed in the perivascular region at the second postoperative day, and CD8 positive cells and CD4 positive cells increased in number as the rejection progressed. Judging from the positive immunological cross reactivity between Japanese monkey and human, the early diagnosis of the acute rejection of the grafted lung may be possible by detecting the perivascular CD8 cells, even in the human-beings.

Coronary artery bypass grafting in a patient with cryoglobulinemia

Coronary artery bypass grafting (CABG) was performed in a patient with cryoglobulinemia. In order to decrease the concentration of cryoglobulin, the patient underwent double filtration plasmapheresis (DFPP) pre- and postoperatively as well as during cardiopulmonary bypass. Bypass surgery was performed under total cardiopulmonary bypass, moderate systemic hypothermia, and ventricular fibrillation without aortic crossclamping. No adverse effects of cryoglobulin appeared during the peri- and postoperative course. Technical considerations for open heart surgery in patients with cryoglobulinemia are described.