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A 33-year-old man underwent radical surgery for urachal cancer. Histology of the cancer revealed an adenocarcinoma of the urachus, Sheldon stage ⅢA. He developed a right lung nodule 23 months after the surgery. Partial lobectomy was performed;it revealed an adenocarcinoma compatible with urachal carcinoma. Additionally, 2 right lung metastases measuring 0.5 cm and 1.6 cm in diameter were found 12 months after partial lobectomy. The patient was treated with 4 different chemotherapy regimens including TS-1 and cisplatin, paclitaxel, folinic acid・fluorouracil・oxaliplatin(FOLFOX), and folinic acid・fluorouracil・irinotecan (FOLFIRI). Computed tomography reports showed progression of the pulmonary nodules, now measuring 1.4 cm and 10 cm in diameter. There was no evidence of distant metastasis except for in the lung and local recurrence. Right pneumonectomy was performed;the histology of the specimen confirmed urachal adenocarcinoma. Three months later, he developed cerebellar metastasis. The tumor was removed by neurosurgeons. The patient died of widespread metastases 6 months after the pneumonectomy.

A 72-year-old man underwent transverse colostomy for sigmoid colon cancer with multiple liver metastases. Subsequent chemotherapy effectively reduced liver metastases, and sigmoidectomy was performed. However, the liver metastases recurred and the patient developed stomal varices due to portal hypertension. To control the resulting massive variceal bleeding, we performed percutaneous sclerotherapy through a varicose vein, which was puncutured directly under ultrasound (US) guidance. Although the patient recovered from variceal bleeding, he eventually died due to the primary cancer.

A 74-year-old woman with advanced gastric cancer was admitted to our hospital. A central venous (CV) port catheter was implanted into the right subclavian vein for preoperative chemotherapy and parenteral nutritional management. On the 35th day after implantation, she complained of diarrhea, fever and dyspnea. The chest radiograph showed a right-sided massive pleural effusion. As the patient progressively fell into severe respiratory distress, endotracheal intubation was performed for management of respiration by mechanical ventilation. Initially, given the patient's symptoms, she was diagnosed with septic shock. Therefore, after placement of a CV catheter through the right femoral vein, in consideration of the possibility of a port infection, she was treated with thoracentesis and infusion of antibiotics. The patient gradually recovered, and again received parenteral nutrition through the CV port catheter. After the infusion was administered, she complained of dyspnea. A CT scan of the chest revealed a right pleural effusion and displacement of the tip of the CV port catheter out of the wall of the superior vena cava. We diagnosed delayed vascular injury (DVI), and the CV port catheter was removed. She soon recovered with conservative treatment. We speculated that the initial respiratory symptoms such as the pleural effusion were caused by DVI. DVI should therefore be recognized as a complication related to implanted CV port catheters.

A 77-year-old man was referred to our hospital because of massive opacification of the right hemithorax on chest radiography. Chest computed tomography (CT) revealed a 25×18-cm heterogeneous tumor in the right hemi-thorax. Chest CT scan obtained 6 years before the referral showed an 8×2-cm homogeneous lipomatous mass in the anterior mediastinum suggesting a well-differentiated liposarcoma. The follow-up chest CT scan obtained 12 months before the referral showed a 4×2-cm heterogeneous solid component within the lipomatous mass of the mediastinum suggesting the development of a dedifferentiated liposarcoma. The tumor was completely resected through a median sternotomy and anterior right thoracotomy. The pathological diagnosis was dedifferentiated liposarcoma originating from a well-differentiated liposarcoma of the anterior mediastinum.

A 74-year-old man was brought to our hospital for an acute exacerbation of respiratory failure. He had severe progressive dyspnea for a few days and had received home oxygen therapy for 4 years. Chest radiography revealed a giant bulla occupying the entire right hemithorax with a remarkable shift of the mediastinum to the left. Chest radiographies of previous 4 years had shown the bulla occupying half of the right hemithorax. It had expanded to its present size over the past month. Treatment consisted of immediate puncturing of the bulla followed by elective intracavity drainage. An urinary catheter was inserted into the bulla under local anesthesia. There was persistent aid leakage from the bulla. A histoacryl-lipiodol mixture was used for bronchial occlusion, and intracavity instillation of minocycline was performed to collapse the bulla. Air leakage from the bulla had ceased on the next day, and the bulla was completely eliminated.

Simultaneous bilateral spontaneous pneumothorax (SBSP) occurred in a 16-year-old male. He presented with severe dyspnea. Chest X-ray showed bilateral pneumothorax. Computed tomography revealed bilateral apical bullas. Chest tubes were promptly inserted bilaterally. The patient underwent single-stage bilateral video-assisted thoracoscopic surgery( VATS). Bilateral bullectomy was performed sequentially. Saline poured in to test for air leakage did not escape to the opposite pleural cavity, suggesting no pleuro-pleural communication. Post-operative course was uneventful. A bilateral single-stage VATS by a conventional lateral approach with intra-operative patient repositioning is a safe, feasible and familiar technique for treatment of SBSP.

A 80-year-old female with an eventration of the left diaphragm, which had been noticed with routine chest roentgenogram in 2006, presented with severe dyspnea and shock vital in 2012. The chest X-ray on admission disclosed elevation of the left hemidiaphragm, dislocation of the heart to the right. The diagnosis of eventration of the diaphragm was confirmed with a computed tomographic scan. She underwent diaphragmatic plication with endostaplers by thoracoscopic surgery. The postoperative course was uneventful except for transient reexpansion pulmonary edema. The patient was extubated on the 5th postoperative day. Dyspnea has disappeared after the operation. She was in a good condition without requiring any additional oxygen.

A 44-year-old female was presented to our department with a 4-day history of shortness of breath and chest pain. The chest X-ray showed pneumothorax with completely collapsed left lung. Thoracentesis was performed. She complained of dyspnea and the oxygen saturation decreased to 74% after thoracentesis. The 2nd chest X-ray and computed tomography demonstrated a left-sided pulmonary edema. A 67-year-old man came to our department complaining of persistent cough. The chest X-ray showed pneumothorax with collapsed right middle and lower lobes. Thoracentesis was performed. He complained of dyspnea and the oxygen saturation decreased to 87% after thoracentesis. The 2nd chest X-ray and computed tomography demonstrated an expanded right upper lobe, but also pulmonary edema in the right middle and lower lobes. Those patients were treated with supplemental oxygen without endotracheal intubation. Their oxygen saturation stabilized within 12 hours. They were successfully treated with the sole administration of oxygen.

A 65-year-old male was referred to our department because of an abnormal shadow on chest X-ray. He had been suffering from rheumatoid arthritis for 10 years. He had been treated with tumor necrosis factor antagonist(etanercept)for the past 3 years and 6 months. Computed tomography of the chest revealed an irregular shaped pulmonary nodule with the longest diameter of 4.3 cm in the left upper lobe. The diagnosis of lung carcinoma was made. He underwent video-assisted left upper lobectomy with lymph node dissection. Histological examination revealed poorly differentiated squamous cell carcinoma. The tumor was classified as stage ⅢA with T4(pm2)N1M0. No adjuvant chemotherapy was performed because he had recurrent arthralgia after operation and new anti-rheumatic-drug was required. He is free from disease with a follow-up period of 11 months.

We conducted a joint study of different duration of drug administration for oral adjuvant chemotherapy using camphor (HCFU) with patients having advanced colorectal cancer who underwent curative resection. The patients were randomly divided into 2 groups, according to length of HCFU administration (6-month group and 2-year group), and followed up for 5 years postoperatively. In total, 239 patients were originally enrolled, out of which 155 were chosen as subjects for this study. There was significant difference in the overall cumulative 5-year survival rate between the short-term group and the long-term group (78.1% vs 89.6%). Between the respective subgroup that was defined by tumor location (colon or rectum), no differences were observed, but there was significant difference in the subgroup that was defined by the presence/absence of lymph node metastasis (59.4% vs 83.9%). It appears that oral adjuvant chemotherapy with HCFU is more effective when administered for 2 years than for 6 months.

Retroperitoneal schwannomas are relatively rare. However, when the tumors occur, they can be large and difficult to diagnose at an early stage because of their vague symptoms. Although surgery is the only treatment, the choice of surgical approach depends upon pathological type, the degree of sacral destruction, and intrapelvic extension. If a large component is present presacrally, an anterior transabdominal approach should be chosen to gain control of the tumor bleeding. We report two cases of large schwannoma in the retroperitoneal presacral space that was removed by the anterior transabdominal approach. We performed an intracapsular piecemeal resection with preservation of the tumor capsule, and were able to remove the tumor gross totally without any postoperative deficit. For this reason, we think that retroperitoneal presacral larger schwannoma should be removed leaving the capsule intact and using the anterior transabdominal approach to prevent injury of the adjacent structures.

The purpose of this report is to evaluate the limited operation for peripheral minute adenocarcinoma of the lung. Firstly, 44 cases (47 lesions) of surgically resected minute peripheral lung adenocarcinoma, 10 mm or less in diameter, were reviewed using Noguchi's classification, and the correlation between high resolution CT (HRCT) images and the clinicopathological features was examined retrospectively. All type A and B adenocarcinomas (n = 14) had no recurrence and all cases were the air containing type by HRCT. Lymph node metastasis and lymphatic/vascular involvement were detected with type C, D, E, F and 3 cases among them were died for recurrence. Based on those results, from April 2000, intentional limited operation was prospectively performed for 14 patients (16 lesions) with peripheral nodule showing ground-glass opacity on HRCT. The pathological findings were type A (n = 9), type B (n = 5), and atypical adenomatous hyperplasia was one case (If the findings were confirmed type C, D, E, F by permanent section diagnosis, VATS lobectomy will be performed). We recommend limited operation should be performed in only type A or B adenocarcinoma and permanent section diagnosis is necessary to determine whether or not.

In this study we analyzed 33 cases which underwent complete surgical resection to assess the role of surgery in the treatment of patients with N 2 NSCLC. The 3 year survival rate was 33.3% and the median survival time was 26.1 months. The survival curve for patients with T 3 factor was statistically worse than those with T 1 or T 2 factor. Further, the survival curve for patients with p 2 or p 3 factor was significantly lower than than that for those classified as p 0. Patients classified with p 2 or p 3 had a survival rate under 2 years. Only one patient diagnosed as T 3 achieved 3 year survival. This patient had a pm1 tumor with p 0 factor. We thereby recommend that surgery should only be performed for those N 2 NSCLC patients diagnosed as T 1 or T 2 with a classification of p1 or less.

Clinical features of small cell lung cancer were studied in 15 cases. The overall 5-year survival rate of the patients with limited small cell lung cancer was 11.4%. Surgery played substantial role for long-term survival in limited SCLC. The 4-year-survival rate of the patients in stage I was 50%, and that of those in stage II and IIIA was 50% and 37.5%, respectively. In the two survivors over four years in stage IIIA, all tumor was categorized as pT3 disease. The 4-year-survival rate of the patients treated with PE was 100%, and that of those treated with another chemotherapy was 10%, and that difference is statistically significant (p < 0.05). There was no significant difference in prognosis of patients in any other factors such as location (central or peripheral), histological subtype, curability or R number, pT factor, pN factor, p stage or with or without thoracic irradiation. Surgical resection for limited SCLC should be recommended in patients with stage I, II and T3N0M0 or T3N1M0 disease. For the patients in stage IIIA, particularly in N2M0 disease, who showed partial response or no change after chemotherapy, surgery should be considered because those patients might have nonsmall cell carcinoma components.

We evaluated postoperative results in 49 patients (39 men, 10 women) who underwent pharyngoesophageal reconstruction with free-jejunal autograft following total pharyngolaryngoesophagectomy in the Department of Otolaryngology, Hokkaido University School of Medicine from 1989 to 1997. Evaluation was performed regarding the following points: 1) postoperative complications, 2) factors that determine the functional results of swallowing, 3) relation between forms of jejunal anastomosis and swallowing. The primary malignancy site was hypopharynx (39), cervical esophagus (4), larynx (3), thyroid (2) and trachea (1), Reconstructions were made with free jejunal autograft alone in 45 cases and with free jejunum in combination with gastric pull-up in 4. In patients who underwent reconstruction with jejunum alone, the anastomosis of the jejunum to the pharynx was performed in side-to-end fashion in 22, end-to-end in 18 and rho-shaped in 4. In the 1 remaining case, we used jejunal-patch graft. Postoperative complications including minor or nongraft related, occurred in 24 of 49 (49.0%) patients. Among these, graft-related complications were graft failure in 1 (2.0%), fistula formation in 3 (6.1%) and graft stricture in 2 (4.0%). Re-operations were required in one case of graft failure and 2 of fistula formation. Consequently, the overall graft-survival rate was 98.0% (48/49). Therefore, we considered the method of reconstruction to be a reliable procedure with a high-success rate. The swallowing function after reconstructive surgery was studied in 35 patients who underwent side-to-end (18) and end-to-end (17) anastomosis of the jejunum to the pharynx. We indicated that appropriate tension in the jejunum was the most important factor for adequate swallowing function. The end-to-end group had a higher rate of taking normal diet compared with the side-to-end group. The rate of swallowing dysfunction was only 5.9% (1/17) in the end-to-end group. On the other hand, 4 of 18 (22.2%) cases in the side-to-end group were regarded as having poor swallowing function. As a result we considered the end-to-end proximal jejunal anastomosis to be the more desirable form.

In our institutes, microvascular surgery has been effectively used in reconstructive digestive tract surgery, including esophageal reconstruction and hepatic arterial reconstruction. Free jejunal transfer combined with a gastric pedicle or microvascularly augmented elongated gastric pedicle has been utilized for total esophageal reconstruction. A microvascularly augmented jejunal pedicle or colonic pedicle has been applied in thoracic esophageal reconstructive cases with gastrectomy. Moreover, microvascular surgery has been performed in the reconstruction of the hepatic arterial system in the surgical treatment of pancreatic or bile duct cancer and living related-donor liver transplantation. Some pitfalls in selection of the recipient vessels and handling the intraperitoneal vessels for microvascular anastomosis are also described. Although microvascular surgery has been carried out by plastic and reconstructive surgeons in a team surgical approach, revisions in the medical educational system to create a new-type of surgeon with practical skills and clinical experience in both digestive tract and microvascular surgery will be required in future.

Metastatic lung tumor from renal cell carcinoma were studied in 29 cases. Eighteen patients were treated surgically, 11 were treated non-surgically. The overall 5-year survival rate with the patients of pulmonary resection was 53.5%, and that with those of conservative therapy was 0%, and this difference is statistically significant (p < 0.05). There was no significant difference in any characteristics such as sex, age, stage, grade, disease free interval, metastatic pattern and combination with or without interferon therapy. There was no significant difference in surgically treated patients with pulmonary metastasis in terms of any factors such as age, sex, stage, grade, disease free interval, pulmonary metastasis pattern, metastatic number, surgical procedure, combination with or without interferon therapy statistically. Analysis for the surgically treated patients with pulmonary metastasis from renal cell carcinoma shows no significant difference in prognosis with any characteristics. This result shows efficacy of surgery even if for the patients with synchronous bilateral multiple pulmonary metastasis from renal cell carcinoma.

A 42-years-old female was referred to the university hospital because of cystic lesions of the right superior mediastinum. Drainage tube was found at right supraclavicular fossa with prolonged lymphatic discharge. We diagnosed this case as a benign cystic lymphangiomas with CT scan and CT scan with cystography and chemical analysis of the contents of the cyst. Intralesional OK-432 therapy for cystic mediastinal lymphangioma was performed. OK-432 was administered through intralesionally placed drainage tube. Excellent result was obtained. A few weeks later, residual lymphatic discharge through drainage tube became stopped. No expansion of the mediastinal cyst was found after drainage tube removal. Intralesional OK-432 therapy for cystic mediastinal lymphangioma was very effective and useful, it should be recommended for the management of the first choice of therapeutic method for cystic mediastinal lymphangioma because of no neurological deficit after this treatment.

A 75-year-old man of chylothorax after anterior spinal fusion successfully underwent thoracoabdominal operation in order to ligate chyloleakage. Not only preoperative milk intake but also intraoperative administration of milk through nasogastric tube was useful for identification of the site of leakage. OK-432 was administered through locally placed and chest tube after operation, after which residual chyloleakage was stopped. lntraoperative administration of milk through nasogastric tube was useful and OK-432 injection through topical and chest tube may be effective, these should be recommended for management of chylothorax.

Thoracoscopy has become an important tool in the diagnosis and management of intrathoracic disease. The development of endoscopic suturing techniques and stapling devices for abdominal surgery dramatically expanded the potential of thoracoscopic surgery. Between 1993 and 1994, 43 patients underwent thoracoscopic surgery. Lung resection were performed on 23 patients for pulmonary nodules and on 9 patients for diagnosis of interstitial lung disease. Extirpation were performed on 2 patients for mediastinal tumor. A procedure done thoracoscopically is far less invasive and the postoperative pain and its consequences are drastically reduced. As endoscopic instrumentation develops, newer operations will become technically feasible. We think that indications for thoracoscopic surgery will expand in developing these techniques in the future, if thoracoscopic surgery is safer and more efficient.

The importance of unravel hemodynamics at the stomach and esophagus in patients with portal hypertension has been described for understanding pathophysiology and treatment of varices associated with portal hypertension. Microvascular Doppler sonogrlaphy (MF20) is a pulse Doppler method with 20 MHz which is able to measure velocity and direction of blood flow in microvessel. We invented transendoscopic microvascular Doppler sonography (EMDS) by connecting a tiny probe of one mm in diameter with an endoscopy. We evaluated direction of blood flow in the esophageal and gastric varices by EMDS and angiography in 21 untreated and 26 shunt-operated patients with portal hypertension. In all of untreated patients direction of blood flow in the varices was toward the probe (forward). Results obtained with EMDS were consistent with angiographic results available in 13 patients. Direction of blood flow after shunt operation was away from the probe in 21 out of 26 patients. The comparison with angiography revealed that post-operative patients with "away" blood flow in varices had maintained satisfactory shunt selectivity without hepatofugal collateral and it proved that the direction of blood flow was toward the shunt at lower pressure. In conclusion EMDS is useful as an evaluation method for hemodynamics in varices of the esophagus and stomach.

Ninety seven patients with metastatic lung tumors were treated surgically in our department. Second pulmonary resections were performed in 13 patients. They consists of 9 males and 4 females, their age ranged from 12 to 75 years old (average 54.4 years old). Tumors originate from sarcoma in 5 cases, laryngeal cancer, colorectal cancer, renal cell cancer in 2 cases respectively, oral cavity cancer and transitional cell cancer in 1 case respectively. No second pulmonary resection was performed in patients with metastatic lung tumors originating from lung cancer or breast cancer, because they metastatize not only lung but also general organs. No second pulmonary resection was required in patients with testicular tumor and choriocarcinoma, because chemotherapy take good effect on them.

Despite a recent trend of rapid increase in the incidence of lung cancer in Japan, lung cancer has been detected rarely among young patients. The findings in 15 patients under 40 years of age who underwent surgery for primary lung cancer at Cancer Institute Hospital (C.I.H.) are presented. Fourteen were located in the region of the periphery. Ten of the 14 peripheral lesions were adenocarcinoma. The chances of cure or even long survival are very small. The case report presents a case with lung cancer in a 22-year-old woman who was the youngest in C.I.H. On histological examination, the excised tumor proved to be moderately differentiated adenocarcinoma.