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Background and objective: To ensure the safety of bronchoscopic practice, the Japan Society for Respiratory Endoscopy conducted a national survey to investigate the current state of procedure for this technique. Methods: A questionnaire survey about procedures carried out during the whole of the year 2010 was mailed to 538 facilities accredited by the society. Results: Responses were obtained from 511 facilities (95.0%). Rigid bronchoscopes were used in only 18.5% of the facilities, while mobile/thin bronchoscopes were used in ≥50%, and fluoroscopy systems were used in 99.8%. Biopsies were performed after discontinuation of therapy in patients receiving antiplatelet drugs and anticoagulants in 96.7% and 97.4% of the facilities, respectively. Atropine was administered for premedication in 67.5% of the facilities, a decrease from previous surveys. Intravenous sedation was given in 36.1% of the facilities. In 21.9% of these, the procedure was conducted in the outpatient clinic for ≥70% of patients. A bronchoscope was orally inserted in ≥70% of patients in 95.7% of the facilities. Intravenous access was maintained during the examination in 92.5% of the facilities, oxygen saturation was monitored during examinations in 99.0%, oxygen was administered in 97.6% and resuscitation equipment was available in 96%. In 98.6% of the facilities, bronchoscopes were disinfected using an automatic washing machine, with glutaraldehyde used in 42.2%. Conclusions: Japan-specific characteristics of bronchoscopic practice were identified. Whether procedures used in Japan meet international guidelines with respect to safety should be monitored continuously. In addition, a Japanese evidence-based consensus is needed.

Objective Substantial evidence suggests that human synovial mast cells (MCs) are involved in the pathogenesis of rheumatoid arthritis (RA). A plausible pathway for the activation of synovial MCs is through IgG receptors, given the prevalence of circulating IgG isotype autoantibodies and synovial immune complexes in patients with RA. However, IgG receptor expression on human synovial MCs remains uncharacterized. The aim of this study was to identify which IgG receptor(s) on synovial MCs are responsible for MC activation in immune complexes. Methods Synovial tissue specimens were obtained from patients with RA or patients with osteoarthritis (OA) who were undergoing joint replacement surgery, and synovial MCs were enzymatically dispersed. Cultured synovium-derived MCs were generated by culturing synovial cells with stem cell factor, and receptor expression was analyzed using fluorescence-activated cell sorting. Mediators released from MCs were measured using enzyme immunoassays or enzyme-linked immunosorbent assays. Results Primary synovial MCs and cultured synovium-derived MCs obtained from both patients with RA and patients with OA expressed Fce receptor I (FceRI), FcγRI, and FcγRII but not FcγRIII. Cultured synovium-derived MCs induced degranulation and the production of prostaglandin D2 and tumor necrosis factor α (TNFα) through FcγRI. The aggregation of FcγRII caused histamine release from cultured MCs but not from primary MCs. Histamine release induced by aggregated IgG was significantly inhibited by neutralizing anti-FcγRI monoclonal antibody and anti-FcγRII monoclonal antibody. Conclusion With regard to the FcR expression profile, synovial MCs from patients with RA and patients with OA were similar. FcγRI was responsible for producing abundant TNFα from synovial MCs in response to aggregated IgG. Immune complexes may activate synovial MCs through FcγRI and FcγRII.

Background and objective: In order to survey the current status of the use and complications associated with respiratory endoscopy, the Japan Society for Respiratory Endoscopy conducted a nationwide postal questionnaire survey. Methods: The survey was mailed to all 538 facilities certified by the society. The subjects were patients who underwent respiratory endoscopy in 2010. The numbers of procedures, and associated complications and deaths were investigated according to lesion and procedure using a specific inventory. Results: The inventory was completed by 483 facilities (89.8%). The total number of diagnostic flexible bronchoscopy procedures performed was 103 978, and four patients died (0.004%). The complication rate according to lesion ranged from 0.51% to 2.06%, with the highest rate being observed in patients with diffuse lesions. The complication rate according to procedure ranged from 0.17% to 1.93%, with the highest rate being observed in patients who underwent forceps biopsy. The complication rate after forceps biopsy of solitary peripheral pulmonary lesions was 1.79% (haemorrhage: 0.73%, pneumothorax: 0.63%), and that after endobronchial ultrasound-guided transbronchial needle aspiration of hilar and/or mediastinal lymph node lesions was 0.46%. Therapeutic bronchoscopy was performed in 3020 patients; one patient (0.03%) died due to haemorrhage induced by insertion of an expandable metallic stent. The complication rate according to procedure was highest for foreign body removal (2.2%). Medical pleuroscopy was performed in 1563 patients. The highest complication rate was for biopsy without electrocautery (1.86%). A total of 228 facilities (47.2%) experienced breakage of bronchoscopes and/or devices. Conclusions: Respiratory endoscopy was performed safely, but education regarding complications caused by new techniques is necessary.

To investigate retrospectively the treatment strategies for chronic expanding hematoma (CEH) of the thorax. We reviewed the medical records of six patients treated for CEH of the thorax at our institution between October 1996 and October 2006. All of the patients had a history of thoracic surgery or tuberculosis with a latent period of 12–55 years before onset. One elderly patient with ischemic heart disease and in poor general health demonstrated a substantial improvement of symptoms after undergoing arterial embolization twice instead of surgery. The remaining five patients underwent either pleuropneumonectomy or a total capsule excision, following which their clinical condition improved remarkably. All six patients were discharged from the hospital. Arterial embolization was performed before surgery, and the amount of intraoperative bleeding ranged from 905 ml to 6 590 ml (average: 2 396 ml). Chronic expanding hematoma of the thorax may occur after thoracic surgery and a tuberculosis infection; however, considering the risk of massive bleeding during surgery, the decision to perform surgery should be made with extreme care.

症例は，31歳，女性．肺葉内肺分画症の診断で左肺下葉切除を施行された．術後第2病日よりドレーンの排液が白濁し，エーテル法，ズダンIII染色，TG値より乳糜胸と診断された．禁食と末梢静脈栄養で加療し，ドレーン排液も透明化したが，第12病日の排液の再検で乳糜が証明された．これ以上の保存的加療は困難と考えられ，第14病日よりオクトレオチドの持続皮下注を開始した．投与開始後すみやかにドレーンの排液は著減した．4日後に排液を再検し，乳糜は証明されず，さらに2日間持続皮下注射を継続し，胸腔ドレーンを抜去した．その後再燃は認めず，第23病日に軽快退院した．近年，難治性乳糜胸に対してオクトレオチドの有用性が報告されるようになった．従来の保存的加療が無効である乳糜胸では，オクトレオチド投与は，他療法と比べても比較的安全であり，治療法の選択肢の一つになりうると考えられる．

大血管手術以外の周術期に発症した非常に稀な脊髄梗塞の1例を経験したので報告する．症例は70歳男性，左肺癌に対して硬膜外併用全身麻酔下に，左上葉切除およびリンパ節郭清を施行した．術後3時間後より，右下肢，右手関節以下の麻痺が認められた．硬膜外カテーテルの影響が考えられたため，直ちに硬膜外注入を中止した．翌日になりさらに麻痺が進行し，頭部・脊椎MRIが施行されたが，診断がつかなかった．術後第3病日に施行された頚胸髄MRIでC1からTh2までの広範囲の脊髄梗塞が認められた．ステロイド，高浸透圧性利尿剤の投与で麻痺の改善傾向を認めたため，27病日リハビリ病院転院となった．

症例は，65歳の女性．健診の胸部X線検査で，縦隔の拡大を指摘され，当科紹介受診．胸部CT検査で，前縦隔に境界明瞭で内部不均一な45mm大の類円形腫瘤を認め，胸腺腫の疑いで手術（腫瘍摘除および胸腺全摘術・右肺部分切除術・左腕頭静脈形成術）施行．病理検査では，胸腺癌（扁平上皮癌）であった．左肺S6にも小結節影を認めていたが，本人の希望で経過観察とした．術後放射線療法を施行し，経過観察中，左肺S6の結節影の増大傾向を認めた．胸腺癌の肺転移，もしくは原発性肺癌と考えられ，手術施行．術中病理で腺癌の診断が得られ原発性肺癌と判断し，下葉切除術およびリンパ節郭清を施行した．術後6ヵ月の時点で再発は認めず，引き続き外来経過観察中である．本邦における胸腺癌と肺癌の重複癌の報告例は本症例が9例目であった．胸腺癌と肺癌の重複癌の報告はきわめて稀であり，報告した．

We investigated the cause of pneumothorax recurrence after thoracoscopic surgery and the effectiveness of staple line reinforcement with fleece-coated fibrin glue (TachoComb) in the prevention of postoperative pneumothorax recurrence.From April 3, 1992 to the end of December 2005, thoracoscopic bullectomy was performed on 499 patients of primary spontaneous pneumothorax. The causes of recurrence were investigated on 39 patients on the basis of surgical observations, preoperative chest computed tomography, and so on. The most common cause was new bulla formation (37 cases), 19 of which were apparently related to the staple line (within 1 cm of the staple lines) and 15 of which were not related to the staple line. After 2000, we stopped using forceps to grasp lungs and we have reinforced the staple line by applying fleece-coated fibrin glue.The staple line reinforced with fleece-coated fibrin glue, or sprayed with fibrin glue solution and the untreated group (bullectomy only with staples) were compared, and the recurrence rates were 1.22%, 7.25%, and 10.00%, respectively (P = 0.0006021).The recurrence rate after thoracoscopic bullectomy with fleece-coated fibrin glue was significantly lowered and we consider this procedure to be the treatment of choice for the management of spontaneous pneumothorax.

症例は，70 歳男性．数年前より，右肺上葉に嚢胞性病変を認めていた．その後，右気胸を発症し前医で肺嚢胞縫縮術を施行されたが，その際に一部切除された嚢胞壁より扁平上皮癌が認められ，当科に紹介となった．当科にて右上葉切除を施行し，病理組織検査では，嚢胞壁は多列線毛上皮で構成されており，気管支性嚢胞壁発生の肺癌と診断された．気管支性嚢胞壁に肺癌が発生した症例は本邦では会議録含め 6 例目であり非常に稀であった．

肺切除後に発症した急性肺血栓塞栓症の2例を経験したので報告する.症例1は55歳, 女性.左肺腺癌の診断で, 左上葉切除術施行.術後第二病日, 離床時にショック状態から心肺停止状態となり直ちに心肺蘇生を行ったが, 胸部レントゲン写真や心電図等では肺血栓塞栓症特有の所見は認められなかった.しかし, 心肺停止発症から5日目の肺血流シンチグラムで両肺野の欠損が認められ, 術後肺血栓塞栓症と診断された.直ちに肺動脈圧を測定後, 血栓溶解療法と抗凝固療法を施行した結果, 肺血流シンチグラムでは右上下肺野の欠損はほぼ消失した.症例2は57歳, 男性.右肺扁平上皮癌の診断で, 右全摘除術を施行.術後第三病日, 離床時にショック状態となり心肺停止状態となる.直ちに心肺蘇生を行うが血圧が触れず, 臨床所見から術後肺血栓塞栓症と診断し, 心肺蘇生を行いながら血栓溶解療法を開始した.しかしいずれの治療も無効で死亡した.剖検では肺動脈本幹から左肺動脈主幹を経て末梢につながる血栓を認めた.

症例は47歳, 男性.会社員.既往歴に特記すべきことはない.平成9年11月の検診では異常なかったが, 平成10年11月の胸部X線で異常陰影を指摘された.画像上左胸腔内に小児頭大の腫瘤があり, 肺静脈, 舌区および胸壁浸潤が疑われた.生検でthymomaと診断され化学療法 (ADOC) を2コース施行した.効果は縮小率11%でNCであった.その後胸骨正中切開に後側方開胸を追加して, 拡大胸腺摘出術, 心膜合併切除, 左上葉切除, S6合併切除を行った.切除標本で腫瘍は心膜および左上葉に浸潤し, 正岡III期であった.断端の腫瘍細胞は陰性で, 完全切除であった.免疫組織学的検討ではbc1-2とKi67 (MIB-1) で高い染色性を示し, 高度の細胞増殖能を示した.また013 (MIC2) による染色で腫瘍内浸潤リンパ球は未熟リンパ球と考えられ, 胸腺癌ではなくatypical thymomaと診断された.リンパ球表面マーカーの解析は胸腺腫と胸腺癌の鑑別に有用であった.

Thoracoscopic surgery has increased due to the improvement in video endoscopic surgical equipment and technique. From March 1992 to October 1995, 183 patients underwent thoracoscopic surgery at our hospital. 112 cased had spontaneous pneumothorax, 31 mediastinal tumor, 17 mediastinal disease. 11 diffusse intersitial lung disease, 7 pleural disease and 5 giant bulla. In the patients with benign mediastinal tumors (seven cases), we easily resected the tumors, but in four of the ten cases of mediastinal biopsy, we had to covert to open thoracotomy. The procedure for diffuse interstitial lung disease and pneumothorax, a wedge resection of the lung, was performed using an endoscopic stapling device (Endo-GIA) . 125 operations in 112 cases of spontaneous pneumothorax were performed. 15 cases were needed to convert to open thoracotomy due to multiple bullae in six cases, severe adhesion in three, and so on. The postoperative recurrence rate in spontaneous pneumothorax was approximately 10%. Reoperation was carried out in six cases (ten times) . In five cases, reoperation was carried out using only thoracoscopic procedures. We conclude that thoracoscopic surgery for spontaneous pneumothorax is warranted, but careful observation and exploration during operation during operation are necessary.

In order to survey the current status of the use and complications associated with respiratory endoscopy, the Japan Society for Respiratory Endoscopy conducted a nationwide postal questionnaire survey.The survey was mailed to all 538 facilities certified by the society. The subjects were patients who underwent respiratory endoscopy in 2010. The numbers of procedures, and associated complications and deaths were investigated according to lesion and procedure using a specific inventory.The inventory was completed by 483 facilities (89.8%). The total number of diagnostic flexible bronchoscopy procedures performed was 103 978, and four patients died (0.004%). The complication rate according to lesion ranged from 0.51% to 2.06%, with the highest rate being observed in patients with diffuse lesions. The complication rate according to procedure ranged from 0.17% to 1.93%, with the highest rate being observed in patients who underwent forceps biopsy. The complication rate after forceps biopsy of solitary peripheral pulmonary lesions was 1.79% (haemorrhage: 0.73%, pneumothorax: 0.63%), and that after endobronchial ultrasound-guided transbronchial needle aspiration of hilar and/or mediastinal lymph node lesions was 0.46%. Therapeutic bronchoscopy was performed in 3020 patients; one patient (0.03%) died due to haemorrhage induced by insertion of an expandable metallic stent. The complication rate according to procedure was highest for foreign body removal (2.2%). Medical pleuroscopy was performed in 1563 patients. The highest complication rate was for biopsy without electrocautery (1.86%). A total of 228 facilities (47.2%) experienced breakage of bronchoscopes and/or devices.Respiratory endoscopy was performed safely, but education regarding complications caused by new techniques is necessary.

Background A large body of evidence has demonstrated that treatment with omalizumab is clinically effective for the management of moderate to severe allergic asthma, emphasizing the importance of IgE in the pathogenesis of allergic asthma. We hypothesized that IgE accelerates FceRI-mediated responsiveness of "immature" human mast cells (MCs) and that omalizumab downregulates the acceleration. Objectives To examine when MC progenitors acquired the ability to degranulate following FceRI aggregation, whether IgE accelerates the responsiveness of immature MCs following FceRI aggregation, and whether omalizumab regulates such an acceleration. Methods Gene expression was examined using a microarray and quantitative reverse transcription polymerase chain reaction. Protein expression was investigated using FACS. Histamine release was examined using an EIA. Results The time-course analysis of the mRNA expression of MC-related genes, including FceRI, in Kit + sorted cells during the differentiation and histamine experiments revealed that the expression level of FceRI in 5 week (w)-cultured MCs was not sufficient to induce degranulation following FceRI aggregation but that 5 w-cultured MCs were fully responsive to calcium ionophore. By addition of IgE in culture medium FceRI expression level and FceRI-mediated histamine release of 5 w-cultured MCs were significantly increased compared with those without addition of IgE, whereas the expression level of tryptase and number of MCs was not affected. Omalizumab significantly inhibited IgE-dependent enhancement of FceRI expression level and FceRI-mediated histamine release. Conclusions High levels of IgE in the microenvironment in vivo may upregulate the responsiveness of immature MCs to allergens. Omalizumab may inhibit the IgE-mediated responsiveness of not only mature MCs, but also immature MCs.

近年手術手技の向上やすぐれた合成縫合糸の発達にともない, 気管あるいは気管支の端々吻合が行なわれる機会が多くなってきた.しかし, これらの吻合においては, 吻合部の緊張, 気管軟骨組織による吻合部位の硬度, さらに吻合部の肉芽形成, 吻合部狭窄等, 他の臓器吻合にない問題がある.今回, 我々は最近開発された長期間抗張力を維持し, またモノフィラメントである合成吸収性縫合糸二種類 (ポリグリコネート, ポリディオキサノン) について犬をもちいて気管吻合を行ない病理組織学的検討および縫合糸の抗張力等についての実験的検討をした.その結果, この二種類の合成吸収性縫合糸は, 異物反応も少なく, 吻合部粘膜の再生も良好で, 長期に十分な抗張力を維持していた.さらにモノフィラメントのため縫合操作性にもすぐれ, 気管気管支吻合に有用な縫合材料と考える.

Background In human subjects platelet-activating factor (PAF) concentrations are markedly increased in the plasma after anaphylactic reactions, and these correlate strongly with the severity of the response. The mechanism for the systemic spread of mast cell (MC) activation in anaphylaxis is often assumed to relate to the hematogenous spread of allergen, but this is implausible, and amplification mechanisms need to be considered. Objective We have investigated the ability of PAF to induce human MC degranulation using skin, lung, and peripheral blood (PB)–derived cultured MCs and the signaling pathways activated in PB-derived MCs in response to PAF. Methods The expression of PAF receptor was investigated by means of RT-PCR and Western blot analysis. Cell-signaling pathways in PB-derived MCs in response to PAF were investigated by analyzing the effect of various inhibitors and the silencing of phospholipase C (PLC) mRNA on PAF-mediated histamine release. Results We show for the first time that PAF induces histamine release from human lung MCs and PB-derived MCs but not skin MCs. Activation of PAF receptor–coupled G αi leads to degranulation through PLCγ1 and PLCβ2 activation in human MCs. PAF-induced degranulation was rapid, being maximal at 5 seconds, and was partially dependent on extracellular Ca 2+ . Conclusion Our findings provide a mechanism whereby PAF mediates an amplification loop for MC activation in the generation of anaphylaxis.

A 63-year-old man visited our hospital with a complaint of recurrent pneumonia in right upper lobe (S2). Bronchofiberscopy was carried out and a polypoid tumor was detected at the orifice of right B2.The histological examination of biopsy specimens revealed the atypical cell infiltration in the bronchial mucosa. However it was not unclear whether the polypoid tumor was malignant or not. Therefore surgical approach was chosen to obtain the difinite diagnosis and then the right upper lobectomy was performed.The histopathological study of the ressected lung indicated the inflammatory pseudopolyp.Inflammatory pseudo-polyp is relatively rare disease in comparison with tumor polyp, and it is quite important to differentiate from malignant tumor.It might be suggested that the bronchofiberscopy should be performed when a patient has experienced the recurrent pneumonia in the same pulmonary region.

In our hospital, we have seen six cases with non-malignant esophago-bronchial fistulae. There were four men and two women ranging in ages from 42 to 72. Five of them had a past history of pneumonia. The chief complaints in five of the cases were coughing and fever.All of them were diagnosed under esophagography. Broncho-fiberscopy was ineffective for diagnosing this disorder. All cases were surgically treated without-operative mortality.In four cases, fistulectomy was carried out. In the remaining two, the division of fistulae were performed. In one case, the fistula was communicated to the left main bronchus, while in the remaining cases they were communicated to the right lower lobe.By clinical course and pathological examination, four of them were diagnosed as congenital, and the remaining ones were found to be acquired. The post-operative courses were uneventful except for in one case, which seemed to have been acquired, and this case suffered from respiratory distress for three weeks.In the treatment of esophago-bronchial fistula, surgical treatment must be selected as soon as possible.

NOD2, an intracellular sensor of bacteria-derived muramyl dipeptide (MDP) has been implicated as a key player in intestinal immune health and disease. Mast cells (MCs) have been reported to be increased in the gut of patients with inflammatory bowel disease. However, NOD2 expression and its role in human primary MCs are unknown. The number of NOD2(+) intestinal MCs was significantly increased in the Crohn's disease (CD) specimens compared to Ulcerative colitis (UC) specimens and controls. IFN-gamma upregulated NOD2 expression in MCs. CXCL10 and urokinase-type plasminogen activator (uPA) upregulation was specific to MCs activated by MDP compared to MCs activated by LPS and IgE/anti-IgE. MDP-induced upregulation of ICAM-1, VCAM-1, and uPA was specific to MCs compared to mononuclear cells. The number of CXCL10(+)NOD2(+) intestinal MCs was significantly increased in the CD patients. Our results suggest that NOD2(+) MCs have specific pathogenic roles that involve the recruitment of inflammatory cells in CD.

We herein report a case of T4 esophageal carcinoma, which was resected after chemo-radiation therapy. In addition, the metachronous lung metastasis was also resected. A 59-year-old female with esophageal carcinoma, which invaded the left main bronchus, underwent chemo-radiation therapy (the combination of systemic chemotherapy of 5-FU/CDDP and external radiation therapy) from January 2004. After the therapy, although the imaging showed a downstaging of esophageal carcinoma, a severe esophageal stricture appeared with ingestion defective. So hyper-alimentation was performed. After the state of nutrition was improved, esophagectomy was performed on March 2004 without a complication. Histopathological study revealed that no viable cells remained. Nine months after esophagectomy, chest CT scan revealed that a solitary pulmonary tumor appeared in S6 of the right. The solitary tumor enlarged gradually. On August 2005, a surgical resection for the solitary pulmonary tumor was performed. Histopathologically, the lesion was compatible for metastasis from esophageal carcinoma. The patient is alive without recurrence more than 23 months after the last surgery.

Background With the recent widespread use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), there have been occasional reports on complications associated with its use. Previous reviews on EBUS-TBNA have been limited to studies by skilled operators, thus the results may not always be applicable to recent clinical practice. To assess the safety of EBUS-TBNA for the staging and diagnosis of lung cancer in Japan, a nationwide survey on its current usage status and complications associated with its use was conducted by the Japan Society for Respiratory Endoscopy (JSRE). Methods A questionnaire about EBUS-TBNA performed between January 2011 and June 2012 was mailed to 520 JSRE-accredited facilities. Results Responses were obtained from 455 facilities (87.5%). During the study period, EBUS-TBNA was performed in 7,345 cases in 210 facilities (46.2%) using a convex probe ultrasound bronchoscope, for 6,836 mediastinal and hilar lesions and 275 lung parenchymal lesions. Ninety complications occurred in 32 facilities. The complication rate was 1.23% (95% confidence interval, 0.97%-1.48%), with hemorrhage being the most frequent complication (50 cases, 0.68%). Infectious complications developed in 14 cases (0.19%) (Mediastinitis, 7; pneumonia, 4; pericarditis, 1; cyst infection, 1; and sepsis, 1). Pneumothorax developed in 2 cases (0.03%), one of which required tube drainage. Regarding the outcome of the cases with complications, prolonged hospitalization was observed in 14 cases, life-threatening conditions in 4, and death in 1 (severe cerebral infarction) (mortality rate, 0.01%). Breakage of the ultrasound bronchoscope occurred in 98 cases (1.33%) in 67 facilities (31.9%), and that of the puncture needle in 15 cases (0.20%) in 8 facilities (3.8%). Conclusions Although the complication rate associated with EBUS-TBNA was found to be low, severe complications, including infectious complications, were observed, and the incidence of device breakage was high. Since the use of EBUS-TBNA is rapidly expanding in Japan, an educational program for its safe performance should be immediately established.

Recently, the number of tracheal resection has increased. We have performed 3 tracheal resections for primary tracheal cancer: 1 for mucoepidermoid carcinoma, and 2 for adenoid cystic carcinoma. A 72-year-old male with adenoid cystic carcinoma had a resection of a cervical tracheal segment and reconstruction with a heavy Marlex-mesh roll. Two years and six months later, the patient died of pulmonary metastasis.A 42-year-old male with mucoepidermoid carcinoma had a lower tracheal segmental resection; 12 years after the operation the patient is alive and well.A 65-year-old female complained of dry cough for 3 months; a history of dyspnea was also elicited. Tomograph and CT showed a tumor in her middle thoracic trachea. A diagnosis of adenoid cystic carcinoma was made by bronchoscopic biopsy.Median sternotomy was carried out and 2.5cm of the trachea was resected under high frequent jet ventilation with end-to-end anastomosis by monofilament suture material (4-0 PDS, 17 interrupted sutures). The patient is alive and well 5 years after the operation.

A total of 12 cases of anterior mediastinal germ cell tumors observed in our laboratory for 30 years from 1957 to 1986 were classified into 6 types according to the additionally modified Dixon and Moore's classification and the therapies and prognoses of each type were investigated and the following results were obtained.1. There are various nomenclatures used to describe germ cell tumors in anterior mediastinum and their classification has not yet been established, therefore our classification seemed practically useful in the surgical clinical field.2. In the cases of Type II (embryonal carcinoma pure, or with seminoma) and VI (yolk sac tumor) prognoses were extremely resistant to treatment whereas that of Type III was satisfactory.3. AFP and hCG used as a tumor marker were very useful as an indicator for chemotherapeutic effectiveness and the recurrence of postectomy, and the immunohistochemical study of ectomized tumors was inevitable which was useful for postoperative classification and therapy.4. Prolonged survival can be expected by combining radiotherapy with operation in the treatment of Type III. Furthermore, it is desirable to additionally perform chemotherapy after operations when a positive picture was found immunohistochemically.5. For the patients with germ cell tumors producing AFP, adjuvant surgery was applied after chemotherapy using cisplatin as a main agent, then the prognostic convalescence of the difficult anterior mediastinal germ cell tumors could be predicted.

Recently cases of carinal resection have increased. We have performed 6 carinal resections; 5 for lung cancer and 1 for tuberculous stenosis. Sleeve pneumonectomy was carried out in 4 cases. In the remaining 2 cases, the trachea was sutured to the right bronchus intermedius and to the left main bronchus.Right posterolateral incision was made in 4 cases and median sternotomy was made in 2 cases. Median sternotomy is the favorable incision for selected cases. Three of the 6 patients who underwent carinal resections died within a month, 1 died of myocardial infarction, 1 died of disruption of suture line and 1 died of pneumonia.One case with Y-shaped reconstrution died of massive hemoptysis during laser surgery to the granulation tissue at the anastomotic site. Autopsy revealed bronchopulmonary arterial fistula.In carinal resections complications frequently occur, postoperative mortality rate is high and the number of long-term survivors is small as compared to that with standard resections. Postoperative management is very important.