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da Vinci's greatest attractions are the fine images acquired with a high-resolution 3-dimensional( 3D) endoscope and the precise operation by forceps equipped with an articulated arm. We believed that complicated procedures can benefit from robot-assisted surgery. We have been actively performing collection and sewing of viable tissue using da Vinci Xi for the purpose of preventing bronchial stump fistulas. Of the 44 cases of lobectomy performed by the end of November 2019 using da Vinci Xi, 13 cases underwent bronchial stump covering. The covering procedure was intended for patients with conditions such as diabetes and a history of internal use of steroids. As the dressing, pedicled intercostal muscle was used in 4 cases, and free pericardial fat tissue was used in 9 cases. A good visual field was obtained by appropriately turning the oblique mirror upside down. The smoke emission effect of AirSeal was useful for securing the visual field. The dressing was sutured and fixed using 3-0 or 4-0 Prolene( SH) cut to a length of 10 to 12 cm. The postoperative course was good and bronchial stump fistula did not occur in all cases.

Background: According to the aging in Japan, surgery of lung cancer with cardiovascular disease is increasing. Among them, the merger of the heart and large blood vessel disease would be expected to be directly linked to the perioperative management., Materials and Methods: We conducted a retrospective analysis of 1,005 patients who had undergone surgical resection of primary lung adenocarcinoma between January 1997 and June 2014 at Hokkaido University Hospital. Among them, 81 patients had more than one cardiovascular disease., Results: The median age was 71 years old. Men are 62 cases(76%). 64 cases (79%)had smoking history. Ischemic heart disease( IHD) was 29 cases(33%), followed by atrial fibrillation(Af), arrhythmia other than Af, valve disease and macrovascular disease. Anticoagulant or antiplatelet therapy were preoperatively done in 41% of IHD cases, 39% of Af cases. Thirty four% of IHD, 50% of vascular disease received the treatment other than medication. Video-assisted thoracic surgery was performed in 67 cases(83%). Lobectomy, sublobectomy were performed for 59 cases(73%), 19 cases(23%), respectively. Postoperative complications were occurred in 32 cases(40%). Two patients(2.5%)died in hospital without discharge. Univariate analysis revealed tumor size, pStage, lymph node dissection, operation time or blood loss were correlated with postoperative complication., Conclusions: For the patients with cardiovascular disease, careful evaluation of surgical indication, perioperative management is required.

Background: Most of mediastinal tumors are benign cysts and neoplasms. Resection is indicated for cystic lesions because of possibility of malignancy, compression symptom and possible rupture in future. However careful observation might be appropriate for asymptomatic tumors without risk of malignancy. Although video-assisted thoracoscopic surgery (VATS) is increasingly performed, its indication is still controversial., Patients and Results: Among 37 mediastinal cystic lesions with confirmed pathological diagnosis, 17 were neoplasms. All of 20 non-neoplastic lesions have cyst wall thinner than 5 mm. Five cases( 29%) of neoplastic lesions have cyst wall thinner than 5 mm. Three of them underwent preoperative fluorodeoxyglucose-positron emission tomography( FDG-PET) or PET-computed tomography( CT). All 3 neoplastic lesions with thin wall showed accumulation of FDG. None of non-neoplastic cyst had FDG accumulation. Ninety-seven patients underwent surgical resection for mediastinal tumors. Out of 51 VATS, 2 were converted to open thoracotomy. One patient with thymoma had ipsilateral pleural recurrence after VATS. Tumor sizes of those 3 patients were larger than 7 cm., Conclusions: Cystic mediastinal tumor with wall thickness less than 5 mm and no FDG accumulation might be observed without resection because it is very unlikely to be a neoplasm. Mediastinal tumor larger than 7 cm might not be suitable for VATS.

Limited pulmonary resection is performed mostly based on the size of lung cancer and ground-glass opacity (GGO). It has been proposed to determine the indication of segmentectomy according to hilar lymph node involvement. There is a potential risk of underestimation for lymph node involvement since there may be a skip mediastinal lymph node metastasis without hilar involvement. We propose to use standardized uptake value( SUV) max of primary lung cancer as an indicator of non-invasive lung cancer. None of 44 small-sized lung cancers with SUVmax lower than 1 had lymph node metastasis or vessel invasion. A small-sized lung cancer ≤ 2 cm with SUVmax ≤ 1 is indicated wedge resection if GGO area is greater than 75% of tumor. Segmentectomy is indicated if the GGO area is less than 75%. We also propose selective lymphadenectomy for small-sized lung cancer. The lower mediastinal lymphadenectomy may be omitted if a small-sized tumor is located in the right upper lobe or the left upper segment. The upper mediastinal lymphadenectomy may be omitted if a small-sized lung cancer is located in the lower lobe and if the lower mediastinal lymph node involvement is excluded.

Descending necrotizing mediastinitis (DNM) is a life-threatening condition, in which infection arising from deep neck tissue spreads downwards into the mediastinum. Contrast-enhanced cervico-thoracic computed tomography (CT) scan is vital for appreciate of the extent and location of mediastinal involvement. Treatment of DNM begins with intravenous administration of a broad-spectrum antibiotic covering both aerobes and anaerobes. Immediate transcervical drainage and debridement with or without transthoracic mediastinal drainage should be considered. Transthoracic mediastinal drainage has to be performed when the mediastinal infection has spread below the carina and/or the Th4 vertebra. Moreover, it is important to determine whether additional drainage is required by evaluation using regular CT imaging. The overall reported mortality rate since 1960 has been 31%, but from 1999 to 2008 it has been 15.5%.

We have reported in this journal in vitro susceptibilities of clinical isolates to antibiotics every year since 1992. In this paper, we report the results of an analysis of in vitro susceptibilities of 12,919 clinical isolates from 72 centers in Japan to selected antibiotics in 2007 compared with the results from previous years. The common respiratory pathogens, Streptococcus pyogenes, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae maintained a high susceptibility to fluoroquinolones (FQs). The resistance of S. pyogenes to macrolides has been increasing every year and this was especially clear this year. Most strains of Enterobacteriaceae except for Escherichia coli showed a high susceptibility to FQs. Almost 30% of E. coli strains were resistant to FQs and the resistance increased further this year. FQs resistance of methicillin-resistant Staphylococcus aureus (MRSA) was approximately 95% with the exception of 45% for sitafloxacin (STFX). FQs resistance of methicillin-susceptible S. aureus (MSSA) was low at about 10%. FQs resistance of methicillin-resistant coagulase negative Staphylococci (MRCNS) was higher than that of methicillin-susceptible coagulase negative Staphylococci (MSCNS), but it was lower than that of MRSA. However, FQs resistance of MSCNS was higher than that of MSSA. FQs resistance of Enterococcus faecalis was 22.5% to 29.6%, while that of Enterococcusfaecium was more than 85% except for STFX (58.3%). In clinical isolates of Pseudomonas aeruginosa derived from urinary tract infections, FQs resistance was 21-27%, which was higher than that of P. aeruginosa from respiratory tract infections at 13-21%, which was the same trend as in past years. Multidrug resistant strains accounted for 5.6% in the urinary tract and 1.8% in the respiratory tract. Acinetobacter spp. showed high susceptibility to FQs. The carbapenem resistant strains, which present a problem at present, accounted for 2.7%. Neisseria gonorrhoeae showed high resistance of 86-88% to FQs. The results of the present survey indicated that although methicillin-resistant Staphylococci, Enterococci, E. coli, P. aeruginosa, and N. gonorrhoeae showed resistance tendencies, and other species maintained high susceptibility rates more than 90% against FQs, which have been used clinically for over 15 years.

Emergency coronary artery bypass surgery was performed in nineteen patients including five chronic hemodialysis patients. In fourteen patients (non-dialysis patients), ten patients required preoperative IABP and four required PCPS for cardiogenic shock. Four patients died (29%); three from LOS and one from sudden death. Most of them (3/4) were preoperative cardiogenic shock. In other five patients (dialysis patients), four patients had conventional CABG, while one received off-pump bypass surgery for calcified aorta and brain complication. All five patients received arterial in situ conduit and continuous hemofiltration in the early postoperative period for controlling water and electrolyte. Two patients died (40%); one from arrhythmia and one from deterioration of original disease (SLE encephalopathy) but no one died from LOS. These methods of surgical modification and perioperative management for chronic hemodialysis patients are considered very useful.

To clarify the relationship between glitter-cells and urine osmotic pressure, neutrophils were isolated from venous blood of 4 normal volunteers and incubated in urine specimens with different osmotic pressures. Glitter-cells were detected in the urine with 100-400 mOsm/l. The rate of glitter-cells in neutrophils incubated for 4 hours were significantly less than those incubated for 0 minute (p < 0.05). We clinically investigated the relationship between the presence of glitter-cells in fresh urine and the site of urinary tract infection (UTI) or organisms isolated from urine. Fresh urine samples were obtained from 95 patients (55 male and 40 female). Urine samples were examined for bacteriuria by the quantitative culture method, and significant bacteriuria was defined as more than 10(5)/ml of bacilli for midstream urine or as more than 10(4)/ml for urine collected by catheterization. Leukocytes and glitter-cells in the unspun and unstained urine were counted on a disposable slide using a counting chamber. Patients with upper UTI showed a significantly higher incidence of glitter-cells than patients with lower UTI (p < 0.05). Patients with glitter-cells had a significantly higher incidence of polymicrobial infections than those without glitter-cell (p < 0.05). These findings suggest that patients with glitter-cells in the urine show upper UTI (pyelonephritis) and polymicrobial infections.

Routine urinalysis is performed as a screening test for urinary tract infection (UTI) in out-patients or in-patients. We assessed the usefulness of microscopic examination of unspun and unstained urine using a disposable slide with counting chambers (Kova Slide 10 grid, Miles-Sankyo) for diagnosis of significant bacteriuria. 173 fresh urine samples were obtained from 173 subjects (89 male and 84 (female), including 117 inpatients, aged from 0 to 96 years. Urine samples were examined for bacteriuria by the standard culture method and counting chamber method. Significant bacteriuria was defined as 10(5)/ml or more of bacilli for midstream urine and urine collected by bags and 10(4)/ml or more for urine collected by catheterization and from indwelling catheters. Urine leukocytes were also counted on disposable slide. The rapid dipstick test (N-multistix-SG-10, Miles-Sankyo) of leukocyte esterase activity and nitrite were measured in the urine specimens read by a photometer (Clinitek-10, Miles-Sankyo). Significant bacteriuria was diagnosed by standard culture method in 67 urine samples. Close correlation was obtained between bacterial counts determined by the bacterial culture and counting chamber method (Spearman's correlation coefficient p < 0.001). Sensitivity and negative predictive value for significant bacteriuria were 94.0 and 95.1%, respectively, when bacteriuria or pyuria was present in the counting chamber. Dipstick test had a sensitivity and negative predictive value of 86.6 and 89.9%, respectively, when either leukocyte esterase activity of + or more, or nitrite of + was found. In out-patients, both sensitivity and negative predictive value were as high as 100% in counting chamber method. Thus, we can conclude that urine microscopy on disposable counting chambers is a very sensitive, simple, time-saving and lost-effective method for diagnosis of UTI.

IgE-mediated mechanisms are important in immediate hypersensitive reactions (IHR) to buckwheat. However, a part of subjects with high IgE for buckwheat show no IHR to buckwheat ingestion. Inspite of cross-allergenicity between buckwheat and rice, rice ingestion rarely induces IHR even in subjects with high IgE for rice unlike buckwheat-induced IHR. We speculated that there were some relationships between the presence of IHR to buckwheat and recognition of cross-allergenic determinants on buckwheat components with rice components. We examined IgE-RAST for rice in 58 subjects with positive IgE-RAST for buckwheat. IgE-RAST for Dermatophagoides pteronyssinus (Dp), egg white and cow's milk as unrelated antigens with rice were also assessed for a comparison. Subjects (n = 33) without IHR to buckwheat showed higher IgE-RAST values for rice than those (n = 25) with IHR, whereas there were no differences in IgE-RAST values for Dp, egg white and cow's milk between two groups with and without IHR. IgE-RAST values for buckwheat showed significant close correlations to those for rice in subjects without IHR to buckwheat but not in those with IHR. There were no significant correlations between IgE-RAST values for buckwheat and for Dp, egg white or cow's milk in both groups with and without IHR. These results suggested that the IgE from subjects without IHR to buckwheat recognized cross-allergenic determinants with rice on the buckwheat components.