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We describe herein the successful treatment of four patients with ischemic ulcers or gangrene of the fingers due to Buerger's disease by thoracoscopic sympathectomy, a new method of surgery which eliminates the difficulties associated with the traditional "open" approaches to the thoracic sympathetic chain, such as poor exposure, risk of damage to the adjacent structures, and postoperative pain. After the patients were placed in the lateral decubitus position with unilateral pulmonary ventilation, the thoracic sympathetic ganglia (T) from the lower third of T1 to T3 were resected endoscopically. The operative results were excellent, with improvement or complete resolution of the ulcer being achieved in all four patients. All of the patients were satisfied with the results in terms of ulcer healing, postoperative pain, and cosmetic appearance. Although a postoperative air leakage developed in one patient with a history of pulmonary tuberculosis, it was successfully treated with an adhesive agent. None of the patients developed Horner's syndrome. Thus, because thoracoscopic sympathectomy is easier to perform with a lower risk of complications than conventional thoracic sympathectomy, we recommend this operative approach as the procedure of choice for surgical thoracic sympathectomy.

We report herein the case of a 52-year-old man for whom a split pectoralis major myocutaneous flap was applied at the time of extended radical surgery for esophageal carcinoma with tracheal involvement, to avoid the postoperative complications of anterior trachcostomy such as tracheal necrosis and rupture of the major vessels. Laryngopharyngectomy and extended resection of the proximal trachea was performed through a manubrectomy, leaving the tracheal remnant only 4 cm above the carina. A pectoralis major myocutaneous flap was split into two with one piece being wrapped around the trachea at the anterior mediastinal tracheostomy site, and the other being placed between the trachea and brachiocephafic artery. The postoperative course was uneventful and the patient was discharged from hospital on the 34th postoperative day. A split pectoralis major myocutaneous flap may be effective not only for filling the dead space between the trachea and brachiocephalic artery, but also for reducing tension at the tracheocutaneous anastomosis and protecting against circulatory damage at the mediastinal tracheostomy site to minimize stomal retraction.

Using the hydrogen gas clearance method, a plate-type probe was attached to the surface of the cuff of an endotracheal tube in order to measure the ischemic changes in the tracheal mucosa produced by peritracheal lymph node dissection. In eight human subjects with intrathoracic esophageal carcinoma, the tracheal mucosal blood flow was 40.1 ml/100 g per minute after they had undergone a right thoracotomy and then decreased to 13.0 ml/100 g per minute after they had further received an extended radical operation preserving the right bronchial artery. No tracheal ulcers were seen. The same ischemic changes in the tracheal mucosa were also measured in dogs. The right bronchial artery contributes about one-third of the total blood flow to the trachea and this was thus calculated to be about 10-14 ml/100 g per minute.