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As a less invasive alternative to bronchoalveolar lavage (BAL), bronchoscopic microsampling (BMS) was developed to identify molecules present in the epithelial lining fluid (ELF) of the distal airways. Here, we evaluated the utility of BMS for serial collection of ELF in a canine lung transplant model.ELF was collected hourly by BMS up to 5 hours after reperfusion in a canine left lung transplant model. Tumor necrosis factor (TNF)-α levels in ELF were measured using an enzyme-linked immunosorbent assay and were compared with those in BAL fluid.Serial collection of ELF by BMS in graft lungs was possible without adverse effects. However, the partial pressure of oxygen was markedly decreased because of ischemia-reperfusion lung injury. Probe ELF absorption ranged from 1-18 µL. TNF-α expression was significantly elevated and detected for 5 hours after reperfusion, whereas it was very low in the sham-operated group (p0.05). TNF-α concentration in BAL fluid was less than one-hundredth of that in ELF.BMS was safe and effective for serial ELF collection in grafted lungs. Temporal changes in TNF-α corresponded with ischemia-reperfusion lung injury. This is the first study to adopt BMS to elucidate pulmonary function after lung transplantation.

胸膜孤立性線維腫瘍（Solitary Fibrous Tumor of Pleura：以下SFTPと略す）の外科切除症例3例に対し胸腔鏡操作が，又巨大SFTP症例での術前の血管造影が，腫瘍切除のアプローチの選択に有用であったので報告する．症例1：75歳，女性．胸部X線およびCTで右胸膜腫瘍（3cm）を疑い，胸腔鏡手術を施行した．右中葉臓側胸膜より発生したSFTPに対し，VATS（Video-Assisted Thoracic Surgery）腫瘍摘出術を施行した．症例2：67歳．女性．胸部CTおよびMRI上で右胸膜腫瘍（5.7×4.7cm）を疑った．胸腔鏡下に，壁側胸膜に有茎性のSFTPを確認し，小開胸を設置して鏡視下に腫瘍摘出術を施行した．症例3：59歳，女性．労作性呼吸困を伴った，診断未定の胸腔内巨大腫瘍（22×11cm）に対し，血管造影後にVATSを先行した．横隔膜部に有茎性のSFTPを確認し，後側方開胸に移行し，横隔膜と肺を一部分含んだ腫瘍摘出術を施行した．

我々は1994年より胸部外傷に対して積極的に胸腔鏡下手術を行ってきた．2005年6月まで34件の胸部外傷に対し胸腔鏡下手術を行った．年令は6から90歳（平均40.7歳），受傷原因は刺創21例，交通外傷11例，転落外傷2例であった．34例中2例は出血コントロール不良のため，標準開胸に切りかえた．胸腔鏡下手術を完遂できた32例の術式は，部分切除14例，止血7例，肺縫合もしくは修復術5例，審査胸腔鏡5例，気管支縫合術1例であった．鈍的外傷では（1）横隔膜破裂，血管損傷に対する審査胸腔鏡（2）持続する胸腔内気瘻（3）6時間で500ml以上の血胸，鋭的外傷では（1）刺創（2）汚染に対する胸腔洗浄，を手術適応とした．胸部外傷に対する手術療法はあくまで緊急開胸手術が主体であるが，その中に胸腔鏡下手術でも充分対応できる症例は存在する．

気管・気管支断裂損傷は, 鈍的胸部外傷の中で頻度は少ないが, 致命率は高い.われわれは, 受傷初期の胸部単純X線写真が診断に有用であった, 18歳男性のバイク外傷による右主気管支断裂損傷 (日本外傷学会, 気管, 気管支損傷分類Ib) の1例を経験した.胸部単純X線写真上, tracheobronchial stripeの描出, 進行性の縦走する気管と右主気管支周囲の透亮像, continuous diaphragm sign, 右側のNaclerio's V-signを認め, これらは縦隔気腫を示唆する所見であった.さらに, 奇静脈近傍の右主気管支陰影は不鮮明化し, その外側に血腫像を認めた.以上の所見から右主気管支断裂損傷が示唆された.手術は損傷部位を直接縫合閉鎖し, 救命した.

Background . Deep pulmonary laceration (DPL) is rare and its survival rate is low. The present study focused on the prognostic factors of DPL. Methods . The present study concerned 17 DPL patients treated in Tokai University Hospital between 1988 and 1998. The prognostic factors of DPL were compared with systolic blood pressure (SBP), PaO 2 , and the volume of intrathoracic blood loss. Characteristic findings of initial chest roentgenograms of DPL were investigated. Results . Eleven patients were saved and 6 patients died. An SBP of less than 80 mm Hg on arrival at the hospital and a blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival were poor prognostic factors. Hypoxemia on arrival was not a poor prognostic factor. Chest roentgenograms showed macular infiltrative shadow with moderate lung collapse and deviation of the mediastinal shadow toward the unaffected side. Selective bronchial occlusion with a Univent prevented suffocation by intrabronchial blood. Conclusions . Two poor prognostic factors of DPL are SBP less than 80 mm Hg on arrival and blood loss of more than 1,000 mL through the chest tube within 2 hours after arrival.

Many cancer patients suffer from rapidly-progressing dyspnea that is difficult to relieve.The subjects were 26 patients who had dyspnea that was difficult to relieve. The Numeric Rating Scale was used to evaluate their dyspnea. For all patients, the cause of the dyspnea was investigated by CT and x-rays.The principal causes of the dyspnea were pleural effusion that increased daily, complications from pneumonia, massive ascites, multiple metastatic lung tumors and atelectasis, recurrent laryngeal nerve paralysis and narrowing secondary airway compression. Dyspnea was caused by a variety of conditions that overlapped over time, intensifying patients' discomfort. Among 14 patients for whom we recommended treatment with sedation, only 8 of them consented. Among the patients who were treated with sedation, the median interval between the exacerbation of dyspnea and death was 16 days; among non-sedated patients it was 18 days.Palliative care physicians who specialize in the respiratory system can, to some extent, predict the occurrence of rapidly progressive dyspnea in cancer patients. It is important to explain the methods of relieving dyspnea to the patient, the patient's family, and the oncologist early, so that decisions on how to manage dyspnea can be made in advance.

We experienced a patient with an ileal artificial anus who suffered from abdominal pain caused by peritoneal dissemination of ovarian cancer, for which slow-release oxycodone was ineffective, but fentanyl patch proved effective. The patient was a 28-year-old female who developed abdominal pain caused by peritoneal dissemination on postoperative day 60 after radical hysterectomy and colostomy. For pain relief, administration of 10-mg slow-release oxycodone and 180-mg loxoprofen sodium was begun. When the dose was increased to 25 mg on postoperative day 240, the slow-release oxycodone in its original form was confirmed in feces from the artificial anus.When the same drug was changed to a fentanyl patch(12. 5 mg/hr), the pain was relieved. A palliative care doctor needs much knowledge regarding the changes in the patient's body with the progress and treatment of cancer, in addition to the drug mechanism.

The palliative care team's roles are to provide a symptom relief to cancer patients, help them accept their medical conditions, and offer advice regarding the selection of appropriate medical treatments to suit their needs. Seeking the comfort of their homes, patients prefer a home care of superior medical care provided at hospitals. In 2008, 25 of the end-stage cancer patients at hospitals were expressed their desires to have a home medical care, and 10 of them were allowed to do so. We considered the following contributing factors that a patient should have for a smooth transition from hospital care to home medical care: (1) life expectancy of more than 2 months, (2) no progressive breathing difficulties experienced daily, (3) good awareness of medical condition among patients and families, (4) living with someone who has a good understanding of the condition, (5) availability of an appropriate hospital in case of a sudden change in medical requirements, and (6) good collaboration between emergency care hospitals, home physicians, and visiting nurses. To treat the end-stage cancer patients at home, there is a need for information sharing and a joint training of physicians specialized in cancer therapy, palliative care teams, home physicians, and visiting nurses. This would ensure a sustainable "face-to-face collaboration" in community health care.

Blunt chest trauma resulting in massive hemothorax requires immediate attention. We investigated the diagnostic and prognostic utility of various clinical factors in patients with deep pulmonary laceration caused by blunt chest trauma with a view toward interventional treatment.We reviewed 42 patients with deep pulmonary laceration resulting from blunt chest trauma who were treated between 1988 and 2008. Various clinical factors were compared between survivors and nonsurvivors.Of the 42 patients, 29 (69%) survived. Median (25th, 75th percentile) systolic blood pressure at arrival was 102 (76, 121) mm Hg for survivors and 70 (60, 90) mm Hg for nonsurvivors (p = 0.015). The median heart rate at arrival was 107 (98, 120) beats/min for survivors and 130 (120, 140) beats/min for nonsurvivors (p = 0.014). Respiratory rate, Glasgow Coma Scale score, and arterial blood gas values did not affect prognosis. Blood loss through the chest tube at insertion was 500 (400, 700) mL for survivors and 700 (500, 1000) mL for nonsurvivors (p = 0.147) and within 2 hours of arrival was 850 (590, 1100) mm Hg and 1600 (1400, 2000) mL, respectively (p0.001). Blood loss during thoracotomy was 1170 (600, 1790) mL and 3500 (2000, 6690), respectively (p0.001).In patients with deep pulmonary laceration, hemorrhagic shock with systolic blood pressure less than 80 mm Hg and heart rate more than 120 beats/min leads to a poor prognosis. Emergency thoracotomy and pulmonary lobectomy should be performed before the intrathoracic hemorrhage reaches 1200 mL.

Injury to the right diaphragm is sometimes missed in the acute stage and is detected only when the rupture becomes more extensive, a diaphragmatic hernia develops, and dyspnea ensues. We report a case in which spontaneous right pneumothorax developed 46 months after blunt trauma due to a fall. Air had leaked into the right pleural cavity, passed through the injured right diaphragm, and entered the abdominal cavity; the patient presented with intraperitoneal emphysema.

Advantages and disadvantages have been reported for both internal pneumatic stabilization and surgical stabilization as treatments for anterior flail chest. We retrospectively investigated therapeutic outcomes and problems associated with pneumatic stabilization for anterior flail chest patients.Subjects were 43 patients admitted to Tokai University Hospital with anterior flail chest, 1988-1999. Pneumatic stabilization was performed with continuous positive pressure ventilation and a positive end-expiratory pressure of 10 cm H20 or higher. We analyzed mean times required for pneumatic stabilization, weaning, and mechanical ventilation; sternal fracture (presence vs. absence); survival, and other clinical variables.Continuous positive pressure ventilation was needed for 12.5 days and mechanical ventilation for 15.6 days. Flail chest was relieved by pneumatic stabilization alone in 42 patients; 1 patient with a displaced sternal fracture required sternal fixation. Four cases were complicated by pneumonia. Pneumatic stabilization allowed physicians to treat severe combined nonthoracic organ injuries during the acute phase. Forty patients survived, and 3 died from nonthoracic injuries (survival rate 93%).Anterior flail chest unaccompanied by sternal fracture can be relieved by pneumatic stabilization alone. We hope to combine pneumatic stabilization with simple surgical stabilization in anterior flail chest patients to shorten the mechanical ventilation period.

Since 1994, we have performed video-assisted thoracoscopic surgery in order to treat thoracic trauma. In general, emergency surgery is performed for trauma injuries incurred by knives. Between 1994 and 2005, we performed thoracoscopic surgery on eighteen cases of thoracic stab wounds. Among these eighteen cases, two were characterized by wounds to the internal thoracic artery, and they had to be switched over to open thoracotomy due to excessive bleeding. In conclusion, open thoracotomy should be performed in cases in which the patient is in a state of shock due to severe intrathoracic bleeding; however, in cases in which the vital signs are stable, thoracoscopic surgery may be carried out to stop intrathoracic bleeding, to repair the lung injury by suturing, as well as by performing a partial resection of the lung.

Background Endobronchial bleeding in patients with blunt chest trauma can lead to death by suffocation. The conditions leading to bronchial bleeding usually require surgical treatment; however, for diffuse lung contusion, conservative treatment is possible if the bronchial bleeding can be controlled. Methods Sites, methods, and outcomes of occlusion of the affected bronchus by endobronchial blocker used with a Univent endotracheal tube (Fuji Systems Corporation, Tokyo, Japan) in 35 patients (29 men, 6 women; mean age, 26 ± 13 years) with diffuse lung contusion, treated from 1988 to 2004, were analyzed. Results The right main bronchus was occluded in 7 patients, left main bronchus in 12, intermediate bronchial trunk in 9, and secondary bronchi in 7. Four patients who developed hypoxemia underwent differential ventilation. Bronchial occlusion was performed 118 ± 139 minutes after arrival and continued 26 ± 13 hours. Twenty-nine patients survived; 1 died of pulmonary abscess and 5 died due to brain injury. Conclusions Bronchial occlusion should be performed soon after trauma in patients with endobronchial bleeding. The Univent has three advantages in such patients: (1) it prevents the inflow of blood from the affected bronchus into the unaffected lung; (2) the tamponade effect of the endobronchial blocker stops bronchial bleeding; and (3) air embolus due to air flowing from the bronchus into the pulmonary veins can be prevented. Use of a tube for one-lung ventilation with which the trauma surgeon is familiar is advisable. The Uniblocker tube (Fuji Systems Corporation) allows occlusion of the affected bronchus without reinsertion of a single-lumen tracheal tube.

A 41-year-old man survived deep pulmonary and hepatic lacerations by treatment with fluid resuscitation, blood transfusion, thoracotomy, and transcatheter hepatic artery embolization. The patient was transferred to our hospital 46 minutes after his motorbike struck a station wagon from behind. Hemorrhagic shock with systolic blood pressure of 68 mmHg was observed. He showed nonresponse to 20-minute intravenous infusion of 1,500 mL of lactated Ringer's solution. The initial plain chest radiograph showed mediastinal deviation to the left, radio-opacity of the right lower lobe, and decreased radiolucency of the right thorax. Rapid drainage of 800 mL of blood through a right chest tube led to a diagnosis of a deep pulmonary laceration of the right lower lobe. Abdominal computed tomography revealed another deep laceration affecting 40% of the liver. A right lower lobectomy of the lung was performed at 169 minutes after arrival. After the thoracotomy,transcatheter arterial embolization of the right hepatic artery was performed. The patient was discharged on hospital day 57.Prompt diagnosis and appropriate treatment are necessary to save patients with multiple, severe blunt injuries. Advanced Trauma Life Support (ATLS) guidelines should be adhered to for appropriate early treatment of patients with severe trauma.

With a recent development of artificial respirator and intensive care, patients with severe chest trauma associated with flail chest can be increasingly saved. This time we experienced a 68-year-old woman with flail chest associating with linear fracture of the sternum and multiple fracture of the bilateral ribs who was successfully cured by 13-day internal fixation. In general, multiple fracture of the bilateral ribs with sternum fracture often becomes anterior type flail chest in the chest wall to cause delayed fixation, leading to a critical condition. Treatments of flail chest include (1) internal fixation due to an artificial respirator, (2) intermittent rib fixation (external fixation), and (3) combinated use of (1) and (2). For traumatic patients in an acute phase, we have employed the internal fixation as the first choice, because it is least invasive; permits to devote ourselves to the treatment of other important organs; and recent development of artificial respiratory and intravenous hyperalimentation affords a long-term management with artificail respirator. In patients with flail chest with fracture of the sternum like this case, the internal fixation appears valuable.

Patients with small adenocarcinoma of the lung (SACL) generally have a good prognosis. However, some SACL cases show lymph node metastasis, with poor prognosis. The expression pattern of 11p15 mucins (clustered on the p15 arm of the chromosome 11) is known to change during carcinogenesis in lung cancer.We evaluated the expression of the 11p15 mucins (MUC2, MUC5AC, and MUC6) in 79 surgical specimens of SACL cases by immunohistochemical analysis. Lymph node metastasis was estimated by pathological staging.Six (7.6%) and 11 (13.9%) of the 79 SACL cases showed MUC2 and MUC6 expression, respectively. Three SACL cases showed both MUC2 and MUC6 expression, and a significant correlation was found between MUC2 and MUC6 expression (Fisher's test, P = 0.033). Six (7.6%) SACL cases showed MUC5AC expression. Five of the 6 cases with MUC2 expression and 6 of the 11 cases with MUC6 expression were had lymph node metastasis. SACL cases with MUC2 or MUC6 expression showed a significantly higher incidence of nodal metastasis than those without expression (P0.001 and P = 0.006, chi(2) test, respectively). There was no significant correlation between MUC5AC expression and nodal involvement in SACL, whereas three of the six cases with MUC5AC expression showed lymph node metastasis. The SACL cases with MUC2 expression had a significantly poorer prognosis than those without MUC2 expression (P = 0.011, log-rank test).These results suggest that 11p15 mucins MUC2 and MUC6 are related to lymph node metastasis in SACL.

Background. Continuing to refine minimally invasive thoracoscopic surgical procedures, we have established the two-windows method. Methods. Skin incisions required by this method consist of a 2- to 3-cm skin incision posteriorly, and a 2- to 3-cm skin incision anteriorly in the fourth intercostal space, with the inferior angle of the scapula as the midpoint. We used this method to perform pulmonary lobectomies in combination with thoracoscopy and mediastinal lymph node dissection in 100 consecutive patients with lung cancer (preoperative diagnosis, stage I, T1 N0 M0). Results. The mean operative time was 2 hours 46 minutes, the mean blood loss was 68.2 mL, and the mean number of mediastinal lymph nodes dissected was 24.3. In developing this minimally invasive thoracoscopic procedure, which facilitates mediastinal lymph node dissection, we realized that it is best performed through the fourth intercostal space. Because the tracheal bifurcation can be seen directly below this level, surgical manipulation in this area can be easily performed. This enables the same extent of mediastinal lymph node dissection as that performed during a standard thoracotomy. Another advantage of this method is that a standard posterolateral thoracotomy incision can be made whenever necessary by simply connecting the two incisions. Conclusions. We believe that the two-windows method is capable of serving as the standard method for the surgical treatment of stage I lung cancer.

A patient had apical hypertrophic cardiomyopathy and left atrial myxoma. We believe that this is the first description of such a combination.