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This article describes the perioperative complications, perioperative risk assessment, and perioperative management of patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease, especially idiopathic pulmonary fibrosis( IPF), which are the leading diseases in respiratory dysfunction. In COPD, testing for forced expiratory volume during the first second and pulmonary diffusing capacity is important and an algorithm for testing has been presented by the Japanese Association for Chest Surgery. Acute exacerbation of IPF is the leading cause of postoperative mortality in Japan, and risk factors are being analyzed. To reduce the occurrence of postoperative complications, it is important to carry out a risk assessment, select appropriate surgical strategy, and implement a well-planned perioperative management.

The subxiphoid approach in thymectomy provides better visibility around the left brachiocephalic vein than the lateral thoracic approach. Robot-assisted thoracoscopic surgery is easier to parform than video- assisted thoracoscopic surgery for surgery of the upper mediastinum, because the forceps can be moved with many joints. Robot-assisted thymectomy using the subxiphoid approach may be less traumatic and less invasive than median sternotomy. We must continue to devise surgical procedures to make oncologically curative surgery more minimally invasive.

The number of lung transplantation performed in Japan is extremely low compared to other countries, whereas we have 10 facilities certified as cadaveric lung transplantation in Japan, meaning that there are low volume centers. By August 2021, we performed lung transplantation in 21 cases for 12 years, therefore, our facility should be considered as low volume center. Surgical outcomes at low volume centers are generally considered poor. However, the overall five-year survival rate of total cases was 84.8%, and that of cadaveric cases was 94.4% in our hospital. It was better than the average of about 73% of all facilities in Japan. These data suggested that the accreditation system in Japan is functioning well. On the other hand, there may be a disparity between facilities. At our facility, we are actively performing inverted lung transplantation so as not to lose the opportunity for transplantation, and we have performed it in three cases so far and have achieved good results.

The apical invading lung cancer is the tumor infiltrating to the thoracic inlet, in other words, the 1st rib or the higher chest wall. Tumor arising in the posterior apex is invasive to the vertebral body, the sympathetic trunk, and the brachial plexus. Pancoast tumor is well known with typical triads, which is invasive to the sympathetic trunk and the brachial plexus in the posterior apex of the lung. Tumors originating in the anterior apex are called anterior apical tumors, and they often involve the subclavian vein and artery. Trimodality therapy is recommended to treat the apical invading lung cancer. Induction chemoradiotherapy followed by surgical resection lead to good local control and complete resection rate. Surgical approach should be selected based on the tumor location in the extreme apex. High posterolateral approach and hook approach are chosen for the tumor in the posterior apex. Anterior approaches developed by Masaoka, Dartevelle, Grunenwald, and Korst are suitable for the tumor in the anterior apex that are often invasive to the subclavian vessels. Surgical outcome depends on completeness of resection. Based on the preoperative evaluation of involved structures, appropriate surgical approach is important to achieve complete resection of the apical invading lung cancer.

We performed salvage surgery after chemoradiotherapy(CRT) in a patient with thymic basaloid cell carcinoma. A 46-year-old man with an abnormal chest shadow on X-ray findings was referred to our hospital. Computed tomography revealed a partially solid tumor along with a multilocular cyst in the anterior mediastinum with mediastinal lymph node swelling infiltrating to the superior vena cava(SVC). Positron emission tomography revealed FDG accumulation (SUVmax 7.94)in the tumor. Pathological findings of a tumor biopsy specimen obtained by thoracoscopy led to a diagnosis of thymic basaloid cell carcinoma. Following CRT (ADOC+RT:60 Gy), a complete resection (R0)with replacement of the SVC was performed. The postoperative course was uneventful, and the patient was alive at 20 months after surgery with metastasis to the cervical lymph nodes and bone.

A 58-year-old male underwent right lung transplantation from a brain-dead donor, after which acute rejection developed that was resistant to steroid pulse therapy. Rabbit-derived anti-thymocyte globulin (rATG) therapy was successful for controlling the rejection. However, following that therapy, the patient was affected by an opportunistic infection and suffered from repeated empyema. It is important to pay attention to immunosuppressive agent levels in blood following treatment, because ATG is a potent immunosuppressive drug and its effects can continue for more than 6 months after administration.

To avoid a pneumonectomy procedure in patients with locally advanced lung cancer, extended resection including bronchovasculoplasty is an option to preserve the lung parenchyma. A triple-plasty operation involving the bronchus, pulmonary artery, and pulmonary vein is sometimes termed “auto-lung transplantation” and divided into two distinctive procedures. In one, “transposition” of the preserved lung is performed in an in vivo manner, while the other is a type of “bench surgery” performed in an ex vivo manner. To protect the lung graft from ischemic-reperfusion injury, the excised lung should be irrigated with lung preservation solution. Excision of the lung graft is easier with the bench surgery approach as compared with conventional surgery, and it was reported that there is no prolongation of operative time. This bench surgery method for lung cancer is a new, challenging surgical entity, and its utility is expected to be assessed in the near future.

An anterior mediastinal sarcoma is a very rare type of mediastinal tumor. A 45-year-old female visited our hospital with swelling in the right anterior chest wall. Radiographically, the tumor was found to originate from the thymus and to infiltrate to the major pectoral muscle through the 1st intercostal space. Positron emission tomography revealed fluorodeoxyglucose accumulation at a standardized uptake maximum value of 16.1. Percutaneous needle biopsy showed the pathological findings of sarcoma. The tumor was resected along with the thymus and chest wall tissues including the right hemi-manubrium of the sternum, clavicle head, 1st and second ribs, and major pectoral muscle. After 4 months, tumor relapse occurred at the site of needle biopsy and additional resection was performed. At 10 months after the 2nd surgery, the patient was free from disease. From histologic and immunohistochemical findings, the tumor was diagnosed as spindle cell sarcoma.

A 71-year-old woman was referred to our department for a nodular lesion in the left lung. She had been followed by urology department in our hospital for 6 years since right nephrectomy for ureter cancer. Chest X-ray and computed tomography (CT) scan demonstrated a small nodular shadow in the left lower lobe. The lung tumor was removed by wedge resection, and pathologically diagnosed during the operation as a metastasis from the ureter cancer. The lung tumor consisted of clear cells similar to the ureter cancer. However, the final pathological diagnosis changed to a primary lung cancer based on the findings of stratified differentiation and cancer cell nests in the tumor. Immunohistochemical staining for ureter epithelium-related antigens confirmed the diagnosis. Although we recommended left lower completion lobectomy, the patient refused additional surgery. She is suspected to have local recurrence in the left lower lobe 18 months after the surgery.

A 68-year-old woman was referred to our hospital due to a left chest abnormal shadow on chest film. She had a history of occupational exposure to organic solvent for about 30 years until 10 years ago. Computed tomography (CT) scan demonstrated a nodular shadow 12 mm in diameter in the left lower lobe. As a lung cancer was suspected, partial resection of the lobe including the small lesion was performed. Since mucosa-associated lymphoid tissue(MALT) lymphoma was diagnosed by intraoperative pathological examination, we finished the operation without any more lung resection. The diagnosis was finally confirmed by histological finding of small lymphoid cell proliferation and positive staining for CD20. Chronic inflammation, such as Helicobacter pylori infection, is considered to be a cause of MALT lymphoma. We speculate that the long term exposure to organic solvent may develop the disease by continuous chemical stimulation to bronchus.

Resection of lung cancers with tracheal and carinal involvement is rare and its role remains uncertain. We review our experience with tracheocarinal resection and reconstruction. Seven tracheocarinal resections were performed without anastomotic complications, local recurrence, or operative mortality. Six carinal reconstructions (3 using the montage method and 3 the single-stoma method) were performed without local recurrence or operative mortality. Two of the 6 had anastomotic complications. One case of stenosis required metallic stent insertion, and another case of hemoptysis underwent complete pneumonectomy. Tracheocarinal resection and reconstruction provide acceptable results in terms of local control and operative mortality, except for anastomotic complications. Patients should be carefully selected for surgery when there is anticipated mediastinal lymph node invovement.

Because pulmonary metastasis is considered to be systemic spread of hepatocellular carcinoma (HCC), indication of pulmonary resection as a treatment for it is not well-described. We retrospectively reviewed clinical records of the patients who underwent pulmonary resection for metastases from HCC in our hospital. Seven patients, 6 men, 1 woman, and the mean-age 65.4 year-old, underwent pulmonary resection from April in 2001 to March in 2010. During the same period, we carried out pulmonary resection for 122 patients with metastases from other malignant diseases. Therefore, pulmonary resection for HCC metastases accounted for 5.4% of the total pulmonary metastasectomy. One of the 7 patients, a 70 year-old man, survives for 69 months after right middle lobectomy for solitary HCC metastasis. Other 6 patients with multiple pulmonary metastases or with increased level of alpha-fetoprotein (AFP) before pulmonary resection died of systemic recurrence. The mean survival time of 7 patients was 20 months and was 11.8 months except the long-time survivor. From our results, patients with multiple pulmonary metastases from HCC or with increased serum level of AFP before surgery should be carefully selected as candidates for pulmonary metastasectomy.

We report a case of metastatic diaphragm tumor from uterine corpus cancer. A 72-year-old female had a tumor on right diaphragm 4-years after operation for uterine corpus cancer. After chemotherapy, tumor resection was performed by right lung basal segmentectomy, partial liver resection, and partial diaphragm resection. The pathological examination revealed adenocarcinoma, compatible with uterine corpus cancer, metastasizing in diaphragm and involving lung and liver. After the operation, a local recurrence occurred at parasternal lymph node, which is considered to be present on the efferent route of lymph flow from diaphragm.

Tumors of the tracheobronchus consist of tracheobronchial gland tumor, squamous cell carcinoma, and other tumors. Tracheobronchial gland tumors, such as adenoid cystic carcinoma or mucoepidermoid carcinoma, are rare tumors, and resemble salivary gland tumors pathologically. Surgical complete resection should be considered if possible. Radiotherapy alone results in less survival compared to complete resection. Radiotherapy or palliative bronchoscopic recanalization is a choice of therapy when unresectable. Over all survival rate after operation has been reported to be 66-79% at 5-year and 51-57% at 10-year. Mortality of the surgery is less than 5% in Japan. Adjuvant radiotherapy is often adopted when surgical margin is pathologically positive, since adenoid cystic carcinoma is thought to be radiosensitive tumor.

An 85-year-old male with superior sulcus tumor was referred to our hospital complaining right brachial pain and omalgia. Chest computed tomography showed right apical lung tumor involving the 1st rib, and bronchoscopy established a diagnosis of squamous cell carcinoma, cT3NOM0. After concurrent chemoradiotherapy [cisplatin (CDDP) + 60 Gy], functional examination indicated him to be tolerable to lobectomy, and he underwent right upper lobectomy + chest wall resection (1st-3rd ribs) + lymph-node dissection. Pathological examination revealed that the effect of chemoradiotherapy was Ef. 3. The postoperative course was uneventful. He is free from recurrence for 7 years after the surgery.

We report a case who had undergone operation of very early malignant pleural mesothelioma (MPM). A 58-year-old woman admitted to first visited hospital because of pleural effusion of the right side. She received a diagnosis of epithelial type MPM which had been confirmed from a pleural biopsy spacemen obtained by thoracoscopy under local anesthesia. An abnormal change of the pleura could not be detected on chest X-ray and thoracic computed tomography (CT) scan after chest drainage. She was referred to our hospital for surgery, and was undergone an extrapleural pneumonectomy followed by postoperative treatment with cisplatin puls gemcitabine. Pathologically, the disease was diagnosed as stage IA based on the classification of International Mesothelioma Interest Group (IMIG). There is a no evidence of the relapse 9 months after the operation. An early diagnosis of the MPM is very difficult. The thoracoscope with local anesthesia was very effective for early diagnose of a MPM.

Both thyrotracheal anastomosis and carinoplasty are relative rare procedure in routine clinic. We reported each 2 cases of thyrotracheal anastomosis and carinoplasty in 51 cases of tracheobronchoplasty. Thyrotracheal anastomosis with partial cricoidectomy was performed in patients with subglottic stenosis for postintubation stenosis and thyroid cancer using suprahyoid release. Each case need re-intubation after surgery. Montage carinoplasty was performed in 2 patients with advanced lung cancer. Right upper lobe was end-to-side anastomosed to trachea in 1 case, and right basal segment was to left main bronchus in another. It was important both diameter in bronchus and mobilization of the residual lung for this procedure.

Objective: We evaluated the outcomes of bronchoplasty (BP) and pulmonary arterioplasty (PAP) for treatment of patients with lung cancer., Subjects: We studied 33 patients who underwent BP and/or PAP over the previous 7 years at our institution., Methods: A telescope procedure was utilized for anastomosis of a tubular excision performed in the bronchus. One patient received induction chemoradiotherapy, in whom the anastomosis section was covered with an intercostal muscle flap to assure anastomosis completion, then PAP was performed under heparinization., Results: BP including a sleeve resection was performed in 15 patients, while that with a wedge resection and partial side wall resection was performed in 7 and 1 patient, respectively. PAP was performed in 18 patients, and a combination of BP and PAP was used in 8. The seam was incomplete in 2 patients and stenosis was recognized in the anastomosis section in 1. No local recurrence at the anastomosis site was seen in any of the 33 cases. The survival rate for patients who underwent BP was similar to that of those who underwent a standard resection for primary lung cancer., Conclusion: Our results indicate that BP and PAP are safe and useful surgical procedures for patients with lung cancer.

A case of 42-year-old man with postintubation subglottic stenosis underwent primary thyrotracheal anastomosis. Since trachea had been incised longitudinally for previous tracheostomy, tracheal resection came to be longer. Therefore, we had to anastomose the incised trachea with thyroid cartilage even after the suprahyoid release. After the operation, he suffered from the tracheal collapse at the incised portion of the trachea One week after intubation, tracheal patency was achieved. We recommend horizontal incision for tracheostomy in patient with subglottic stenosis, when the following surgical approach is considered.

Because pneumonectomy causes a high-risk of perioperative mortality and morbidity, we have tried extended sleeve lobectomy (ESL) for patients with locally advanced lung cancer. The purpose of this study is to analyze the risk of complications and local relapses of ESL. Twelve patients underwent ESL, one-lobe and segment resection for 7, bi-lobe resection for 4, and bi-lobe and segment resection for 1. There was no hospital death. Two of 12 patients (17%) had an anastomosis complication. One (8%) had a staple line relapse. We conclude that ESL is a practicable technique for locally advanced lung cancer to avoid pneumonectomy.

To evaluate the susceptibility of patient with focal interstitial pneumonia (IP) to postoperative acute exacerbation, and to determine whether measuring serum level of several markers is useful for early detection of postoperative IP or not, we analyzed a total of 753 patients with primary lung cancer underwent thoracotomy. Twelve (1.6%) had postoperative IP. Eight of the 12 died due to IP and 9 of the 12 had focal IP findings on chest computed tomography (CT). Chest CT of 477 patients were reviewed retrospectively, and 51 (10.7%) had IP findings (diffuse 2.1%, focal 8.6%). Postoperative IP occurred in 17.6% of patients with IP findings, but only in 0.7% without such findings (p<0.01). Values of serum KL-6 decreased after lung resection. There were no changes in the value of serum TNF-alpha, IL-1beta, thrombomodulin and sICAM-1 after surgery. We conclude that focal IP is a risk factor of postoperative IP, and that it is not useful to measure serum markers for early detection of postoperative IP.

A pilot trial of combined chemotherapy with paclitaxel, doxorubicin and cisplatin was conducted in patients with advanced endometrial cancer. Between June 2000 and March 2002 8 patients were treated with combined chemotherapy, consisting of paclitaxel, 135 mg/m2; doxorubicin, 30 mg/m2; and cisplatin, 50 mg/m2 (TAP therapy). Patients received 3 to 5 courses of TAP therapy every 4 weeks. The major adverse effect was myelosuppression. All patients had grade 3 or 4 neutropenia, but did not have any severe infection with uncontrollable fever. Only 1 patient discontinued additional therapy due to grade 3 thrombocytopenia after 3 cycles. Grade 2 neurotoxicity occurred in 5 patients, but grade 3 was not observed. Among 5 patients with measurable tumors, 4 achieved partial response and 1 had no change of tumor size, indicating a response rate of 80.0%. We found that TAP therapy was feasible with G-CSF support and shows potential for high efficacy in advanced endometrial cancer.

We developed new surgical technique of pulmonary segmentectomy by ultrasonic scalpel to sever intersegmental pulmonary tissue and absorbable sealing materials to cover the cut surface of lung. This method is expected to preserve more anatomical lung volume than the segmentectomy with surgical stapler. Two cases of post surgical recurrent lung cancer, 3 cases of pulmonary metastasis and 4 cases of primary lung cancer were applied this technique to preserve function. Among 3 materials examined, best result was obtained with polyglycolic acid felt (PGAF:Neoveil). PGAF is a very soft and thin (0.15 mm depth) new absorbable material that is able to closely adhere to irregular sections of the lung with fibrin glue and effectively seals air leakage. Mean chest drainage period after surgery in 6 cases with PGAF was 3.3 days. Excellent lung expansion was obtained immediately after the surgery and PGAF was disappeared completely on chest CT within 1 year. Although the possible superiority of this method is suggested in the present study, further comparative study is necessary to clarify the advantage of this new technique.

Video-assisted thoracoscopic surgery (VATS) for patient with lung cancer is seemed to be more genetic in future. It is because of small wound, little ache and short hospitalization. However, dissection of lymph-nodes is necessary since it is lung cancer. Because the thoracoscopic lobectomy is performed in the limited space, troubles those we cannot predict can happen. So surgical techniques of to prevent troubles are important. And this is the first step to avoid postoperative complication. It is necessary that to grasps a state of the patient and not to leave perioperative troubles.

Purpose: To report the long-term status of acrylic intra-ocular lenses., Cases: We describe two cases of increased light scattering on the surface of acrylic intraocular lenses ten years after implantation. The scattering was non-symptomatic and visual acuity was normal. Biomicroscopy and a Scheimpflug photography system showed that the scattering apparently derived from the anterior surface of the lens, but no deposit or membranous structure was observed on the lens surface., Conclusion: Surface scattering from acrylic intra-ocular lenses is a new finding in long-term observations. A possible etiology may be structural changes of the internal polymer.

Although lobectomy is the standard surgical treatment for primary lung cancer, it is unclear whether lobectomy will be benefit for patients with metachronous lung cancer. The purpose of this study is to evaluate the difference of benefit between lobectomy and limited resection at second lung resection. Forty-eight patients, who had already undergone lobectomy due to primary lung cancer, undergoing second lobectomy (n = 30) or limited resection (n = 18) for metachronous lung cancer were investigated. The over-all 5-year survival rate of second operation was 51.9%. Although there was no significant difference of 5-year survival rates between lobectomy and limited resection, 50.4% and 49.4%, respectively, lobectomy for T1N0 subset prolonged the survival compared to limited resection, 5-year survival rates, 69.6% and 31.7%, respectively. However, lobectomy resulted in more postoperative complications and less preservation of lung function. Lobectomy should be considered the surgical procedure of choice for patients with metachronous T1N0 lung cancer when lung function is preserved.

The outcome, anastomotic complications, and recurrence rate after bronchoplasty carried out in 198 patients with bronchogenic carcinoma in our institutions were evaluated retrospectively. The outcome of bronchoplasty was reasonable (5-year survival rate of 58%), but that of patients with adenocarcinoma was poor (5-year survival rate of 13%) because of their advanced stage and less complete resection. The complications of anastomosis occurred in 8.2% after bronchoplasty. Postoperative pneumonia significantly increased the risk of complications. There was no difference in the incidence of complications between patients who received end-to-end and telescope-type anastomosis. Local recurrence at the anastomosis occurred in 4.9% who underwent bronchoplasty, but in 28% who underwent carinal resection. Lymph node metastasis was a risk factor for local recurrence. Twenty patients with early superficial squamous cell carcinoma in the central bronchus were treated with photodynamic therapy without local recurrence. This new modality may be of benefit to selected patients.

In November, 1999, U.S. Food and Drug Administration approved a highly sensitive CRP(hs-CRP) assay that could assist medical doctors to predict the risk of cardiovascular accidents. Many doctors are now interested in the assay and trying to elucidate the relationship between serum CRP levels and cardiovascular diseases. In the past, it was difficult to establish a valid reference interval of serum CRP because of the poor analytical sensitivity and difficulty in sampling reference individuals. We have established a reference interval of serum CRP for the hs-CRP assay(Dade Behring). The study population consisted of 7,224 individuals(21-81 years old) who received a regular medical check-up. Potentially abnormal samples were excluded, depending on the results of other laboratory tests related to serum CRP variation. The upper limit of the reference interval was 0.15 mg/dl. The serum CRP was higher in smokers than in non-smokers, especially in men.

Purpose: To compare the effect of antioxidants on radical-initiated peroxidation of retinal homogenate., Methods: Lipid peroxides in bovine retinal homogenate were induced by 5 mM FeNO3 (Fe), 25 mM 2, 2'-azobis(2,4'-dimethylvaleronitrile) (lipid-soluble, AMVN) or 50 mM 2,2'-azobis (2-amidinoprpane) dihydrochloride (water-soluble, AAPH) and the preventive effects of antioxidants were measured. Phosphatidylcholine hydroperoxide (PC-OOH) was analyzed with high performance liquid chromatography (HPLC) as the endpoint biomarker., Results and Conclusion: Troglitazone, an oral hypoglycemic agent, inhibited PC-OOH production by Fe and AMVN. Therefore, it may be effective for protecting against oxidative stress on the inner surface plasma membranes and subcellular organelle. Quercetin has radical scavenging effects on both sides of the membrane, because it prevents PC-OOH production by AMVN or AAPH. These results demonstrate the usefulness of an in vitro screening test that can accurately and rapidly determine the capacity of an antioxidant against lipid peroxidation or oxidative stress.

55-year-old woman was admitted to our hospital for cough. Chest X-ray films showed a giant tumor shadow in right anterior pleural cavity. Pulmonary arteriography showed a feeding artery from the branch of right superior trunk. We diagnosed the tumor might be mesothelioma from visceral pleura with stalk. We operated the patient and the tumor was turned out to be mesothelioma pathologically. The patient had a postoperative re-expansion pulmonary edema and recovered in a week. She lives well without recurrence for 3 years 8 months.

A 53-year-old woman was admitted to our hospital for chest abnormal shadow. Chest CT showed a mediastinal cyst. Tumor resection was performed and the cyst turned out to be a cystic lymphangioma with bloody fluid. There were many lymphocytes in the fluid. She lives well without recurrence.

We presented 7 cases who were performed the second lobectomy for the second lung cancer after the first successful lobectomy on the contralateral lung (3 cases for right upper lobectomy + left lower lobectomy and 4 cases for right upper lobectomy + left lower lobectomy). In 6 patients, the predicted postoperative FEV1 estimated by multiplying the preoperative FEV1 by the fraction of perfusion to the contralateral lung was less than 800 ml/m2BSA, which is our first cut-off for identifying lung resection candidates. Unilateral pulmonary arterial occlusion test (UPAO) revealed that total pulmonary vascular resistance (TPVRI) in 3 of those 6 patients was lower than 700 dyne.sec.cm-5/m2BSA, our second cut-off for lung resection. More precise postlobectomy pulmonary hemodynamics in another 3 of those 6 patients were then estimated by adapting selective pulmonary occlusion test (SPAO). Since TPVRI during SPAO was lower than the cut-off value, it was suggested that second lobectomy would be feasible with low incidence of post operative cardiopulmonary complication. There was no serious complications in all 7 cases during their postoperative course. We believe that more precise prediction of postoperative pulmonary hemodynamics by adapting UPAO and SPAO could be one of the tools to minimumize postoperative cardiopulmonary complications in those patients needed second lobectomy for the second lung cancer after the first successful lobectomy on the contralateral lung even though their impaired lung fung function.

68-year-old female was introduced our hospital for productive cough and dyspnea. Chest X ray film showed right upper mediastinal mass and tracheal stenosis. Chest CT showed mediastinal mass with calcifying lesion. ESR at 1 hour was 50 mm and CRP was 1.08 micrograms/ml. Because of progressive dyspnea, the operation was performed without further assessment. We found a mass of adhesive lymph nodes by the side of trachea. We removed it and it turned out to be tuberculous lymphadenitis. Postoperative PPD skin test showed strongly positive reaction. She has taken medication by antituberculous drugs and lives well without complications.

Qualitative studies have been made on the motives for rehabilitation of post-CVA 14 clients at homes by semi-constitutional questions. As a result, rehabilitating motives were classified into 8 influential factors such as prospects for future, sense of satisfaction for living, change in sense of self personality, change in personal relations, change in family-relation, attitude towards the post-CVA symptom, emotional mainstay, sense of health, and composing factors as with positiveness, voluntariness and subjective individuality. The contents of the influential factors and number or the manners of connections were characteristic of individuals. Among them, 4 factors such as change in family-relation, change in personal relations, change in sense of self-personality, sense of satisfaction for living have constituted the attitudes towards relation between oneself and the other after falling into the sickness. In order to elevate the motives for rehabilitation of clients at homes, it is necessary to enhance the affirmative influential factors by making assessment of influential factors and constituting factors of individual motives in a sense of individual subjects, and also, the assistance is necessary to make negative influential factors on the motives related affirmatively.

To understand the effects of thoracoscopic approach to thoracotomy on lung function, we investigated the changes in lung function after thoracoscopic operation (n = 7) and compared them to those after standard posterolateral (n = 5) or muscle-sparing thoracotomy (n = 6). In 18 patients with benign lung tumor in which surgical treatment resected in partial resection of the lung tissue, we measured TLC, VC, RV, FEV1.0, FEV1.0%, Peak Flow and DLco preoperatively and at 2, 4 weeks postoperatively. In the standard posterolateral or muscle-sparing thoracotomy groups, FVC, TLC, FEV1.0 and Peak Flow decreased to about 80% of preoperative value at 2 weeks. At 4 weeks after operation, these values showed to increase some what, but did not reach to the preoperative value. Whereas, the thoracoscopic procedure group, did not show the decrease in lung function through the time course. There was not significant different between standard posterolateral and muscle-sparing thoracotomy. We conclude that thoracoscopic approach is an useful technique to thoracotomy because of its minimizing after thoracotomy effect of lung function loss.

29 patients over 75 years of age in 221 patients undergoing resection of lung cancer from January of 1990 through December of 1994 were studied for the occurrence of expectoration disturbance (atelectasis), the effect of epidural anesthesia for protection of it. Atelectasis was observed in 8 (27.6%) of 29. In a group received epidural anesthesia (EA) during the early postoperative phase, 1 of 5 patients developed atelectasis. In 192 patients below 75 years of age, atelectasis was observed in 40 (20.8%) of them, so in a group received epidural anesthesia (EA) during the early postoperative phase, only 2 of 42 patients (4.8%) developed atelectasis. This value was significantly lower than that value (25.3%) in a group without EA. In conclusion, in the group below 75 years of age, EA during the early postoperative phase may be useful in inhibiting the occurrence of atelectasis, an important one of the postoperative lung complications.

Formyl peptide (fMLP) by itself does not increase eicosanoid levels in rat lungs, but eicosanoid levels and edema do increase if endotoxin (ETX) is given before an fMLP challenge. The role of pulmonary intravascular leukocytes in fMLP-induced eicosanoid production in rat lungs was studied, as was the effect of a calcium antagonist (Ro 40-5967). ETX increased the levels of 6-keto PGF1 alpha, but not the levels of TXB2 or LTB4. A second challenge with fMLP in ETX-primed rats resulted in increased production of these three eicosanoids, and increased neutrophil accumulation, as assessed by myeloperoxidase assay. The calcium antagonist attenuated both the production of eicosanoids and the accumulation of neutrophils in the lung. The levels of both 6-keto PGF1 alpha and TXB2 correlated well with lung neutrophil accumulation. Leukocytes isolated from the pulmonary vasculature released TXB2 and LTB4 when stimulated with fMLP in vitro. The amount of these eicosanoids released from pulmonary intravascular leukocyte suspension was well correlated with neutrophil counts in a leukocyte suspension. These data indicate that fMLP-induced production of eicosanoids in the lung, especially production of TXB2, is mediated by pulmonary intravascular neutrophils, and that calcium antagonists can attenuate eicosanoid production by decreasing the accumulation of neutrophils in the lung.

To study the role of cyclooxygenase metabolites in changes in the pulmonary vasculature induced by mechanically activated white blood cells (WBCs), the effects of activated and inactive WBCs, and of a cyclooxygenase inhibitor, were studied in isolated perfused lungs from Sprague-Dawley rats. WBCs were activated by gentle agitation in a glass container for 10s. Baseline measurements were made, and then activated or inactive WBCs were added to the perfusate. Perfusion was stopped for 90 minutes, and then started again. The effects of the cyclooxygenase inhibitor meclofenamate on the pulmonary vascular filtration coefficient and on pulmonary vascular resistance were also measured. In the group that received activated WBCs, the pulmonary vascular filtration coefficient and the pulmonary vascular resistance were about 2.5 times and 3.3 times higher, respectively, than those in the group that received inactive WBCs. However, this apparent increase in the filtration coefficient caused by activated WBCs was partly blocked by meclofenamate. Histological examination indicated that meclofenamate did not prevent the adhesion of WBCs to the pulmonary vascular endothelium. These date indicate that WBCs that have been made to adhere to vessel walls can induce pulmonary vascular injury via cyclooxygenase products.

We studied pulmonary vascular injury evoked by mechanically activated white blood cells (WBCs). In isolated perfused rat lungs, changes in pulmonary vascular resistance were measured, and a gravimetric method was used to measure the pulmonary vascular filtration coefficient, which was taken as an index of pulmonary vascular injury. WBCs were activated by gentle agitation in a glass container for 10 sec. The filtration coefficient was measured under baseline conditions, and then inactive or activated WBCs were added to the perfusate. The perfusion was stopped for 90 minutes and then the lungs were reperfused. The expression of CD18 on the surface of WBCs was measured by flow cytometry. The filtration coefficient and the pulmonary vascular resistance in lungs exposed to activated WBCs were about 2.5 times and 3.3 times higher, respectively, than those in the lungs exposed to inactive WBCs. These results indicate increases in resistance and in pulmonary vascular permeability. The results of flow cytometry indicated that the mechanical agitation increased the expression of CD18 on the surface of WBCs. In conclusion, WBCs in which adhesiveness has been increased can induce pulmonary vascular injury and can increase pulmonary vascular resistance.

In order to determine the changes in pulmonary ventilation-perfusion imaging after lobectomies, we examined 11 patients using radioaerosol inhalation and perfusion scintigraphies, before and after the operations. We employed 99mTc-labeled albumin aerosol generated by a jet nebulizer for the inhalation imaging, and 99mTc-labeled macroaggregated albumin for the perfusion imaging, respectively. Prior to the operations, there were no (major) defects of imagings on the lung fields. Immediately after the operations, however, we could not detect any abnormal findings on chest roentgenograms, we found detects of imagings on the lung fields in either inhalation or perfusion scintigraphy whose area were mismatching. It took more than 3 weeks for these defects of imagings to disappear. In conclusion, these findings suggest that postoperative hypoxemia might be occurred by these mismatchings.

To clarify the precise of cellular immunity mechanism in pulmonary tuberculosis, we investigated the amount of IL-2 in patients with untreated active pulmonary tuberculosis. When serum adenosine deaminase (ADA) activity was examined using enzyme assay, an abnormally high level was observed in all patients (29.0 + 11.6 IU/ml, mean + SD; 4.5-17.8, normal range). Likewise, the level of serum-soluble interleukin-2 receptor (IL-2R) measured by ELISA showed abnormal high level in all patients (844.3 + 584.8 IU/ml; 80-300, normal range). When stimulated using PHA, the peripheral lymphocyte's ability to produce IL-2 revealed no difference between control subjects and patients. It was, however, noted that the lymphocytes of the patients significantly suppressed IL-2 responsiveness when compared to the control subjects (P less than 0.05). The serum IL-2 concentration measured using RIA could not be detected in any of the patients as was the same for control subject. All of the above mentioned results suggest that T-cell activation which caused increment in serum ADA activity and soluble IL-2R occurred in active pulmonary tuberculosis. The suppressed IL-2 responsiveness in the peripheral lymphocytes of patients proposes the possibility of soluble IL-2R reduction by the negative feedback mechanism in IL-2-sensitive lymphocytes.

Diffuse panbronchiolitis in two brothers is reported. The elder brother aged 46, was admitted in May 1983 due to severe dyspnea and productive cough, which had gradually worsened over several years. He had severe hypoxemia and hypercapnia. He died at age 47 of respiratory failure due to pseudomonas infection despite antibiotic therapy. The younger brother, at age 41, was admitted in March 1983 due to fever, productive cough, and abnormal shadows on chest X-ray films. He showed mild hypoxemia and his symptoms improved with antibiotic treatment. Since then he has been followed as an outpatient for over 7 years while taking 400 mg of Erythromycin per day, and he has had no exacerbation. These two cases had different clinical courses despite the facts that both had similar conditions of chronic sinusitis and appeared to be exposed to no special environmental or occupational hazards. These facts suggest that not only intrinsic factors, such as defenselessness of airways, but extrinsic factors such as viral, mycoplasmal, or bacterial infection may act together on the mechanisms of the onset and progression of diffuse panbronchiolitis.

We compared the prediction of postoperative pulmonary function in two groups: chronic pulmonary emphysema (CPE) group (n = 30) and normal control group (n = 41). These patients had a lobectomy because of lung cancer. We measured pulmonary function test (FVC, EFV1, TLC, FRC, RV, DLco), and pulmonary perfusion scan before and after surgery. We found correlation between the predicted and measured postoperative values very close in control group. Whereas, in CPE group, these correlations were very low especially in FVC and FEV1. We also calculated the pulmonary function on the operated and the non-operated sides. The correlation were very high without FEV1 in control group and all the measured values did not correlate to the predicted values. On the non-operated side, the correlations were high in both control and CPE groups. From these results we can conclude that it is difficult to predict the postoperative pulmonary function in the case of chronic pulmonary emphysema.

To clarify the immunological aspect of tuberculosis, we investigated serum adenosine deaminase (ADA) activity, T and B cell percentile in total peripheral mononuclear cells, peripheral T cell subpopulation and their relationship with other inflammatory parameters in 20 patients with active pulmonary tuberculosis. Serum ADA activity showed abnormal high level in all patients in nontreated phase with significant regression after three months treatment by anti-tuberculous drugs (P less than 0.05). In addition, significant positive correlation was observed between serum ADA activity and erythrocyte sedimentation rate at 1 hour (r = 0.56). Concerning about peripheral T cell subpopulation studied by two colour flow cytometry with FITC-conjugated anti-CD4 and phycoerythrin-conjugated anti-HLA-DR antibody, there was positive correlation between CD4(-) HLA-DR(+) T cell and serum ADA activity (r = 0.59) without any abnormal frequency of each T cell subpopulation. Additionally, after the treatment of pulmonary tuberculosis, significant increase of T cell percentile in total peripheral mononuclear cells were observed (P less than 0.005). In conclusion, these results may suggest serum ADA activity could be a parameter of activity of pulmonary tuberculosis and reflect the function of activated suppressor/cytotoxic T cell.

Pulmonary intravascular macrophages (PIMs) reside in the alveolar capillaries of sheep lung. However, the role of PIMs activation in the mechanism of increasing pulmonary microvascular permeability is not clear. We determined, using awake sheep with chronic lung lymph fistulas, the effects of intraarterial infusion of latex beads emulsion (1 microns in diameter) on lung lymph-dynamics. Sheep were divided into 3 groups; control, low dose latex and high dose latex groups. In control group, their lymph-dynamics were stable during the experimental period. In low dose latex group (5.46 x 10(9) beads/kg), lung lymph flow increased during the infusion period, but lung lymph protein clearance did not change. In high dose latex group (5.46 x 10(10) beads/kg), lung lymph flow began to increase during the infusion period and remained high, and lung lymph protein clearance increased significantly during and after the infusion of latex beads emulsion. The latex beads mainly distributed to lungs, and 70% of the beads were caught by PIMs in their phagosomes. These findings suggest that the activation of PIMs through their phagocytic uptake of circulating microparticles increases pulmonary microvascular permeability.

A case of reexpansion pulmonary edema during thoracotomy is presented. A high edema fluid-plasma protein concentration ratio suggested an increase in pulmonary vascular permeability. A marked increase in the percentages of polymorphonuclear leukocytes (PMN) and high concentration of PMN-elastase in edema fluid suggested activated PMN-mediated vascular endothelial injury, which caused an increase in permeability. Edema fluid and plasma contained high concentrations of Thromboxane B2 and 6-keto-PGF1 alpha at the stage of increased permeability. This suggested these chemical mediators participated in the mechanisms of increased permeability in reexpansion pulmonary edema.