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重症筋無力症（Myasthenia gravis以下MG）患者連続110例に胸骨吊り上げ式内視鏡下拡大胸腺摘出術（吊り上げVATS extended thymectomy，以下吊り上げVATS-ET）を施行し，手術ならびに長期予後成績から本術式がMGに対する標準術式として許容できるか後ろ向きに検討した．過去9年間で開胸術へ術中変更になった4例を除く106例を対象とした．術後早期の手術成績は良好であった．手術時間の平均値は最初の3年間181分，最近の2年間127分であった．全MG患者の寛解率，有効率は術後6ヵ月25％，86％，1年28％，85％，3年31％，85％，5年37％，87％，8年50％，100％であった．吊り上げVATS-ETの合併症発生率は12.7％で左腕頭静脈損傷は2.7％であった．MGに対する吊り上げVATS-ETは手術成績と術後8年の予後成績から標準術式として許容できるが，有効性の科学的証明には他手術アプローチ法との長期予後の前向き比較試験が必要である．

肺硬化性血管腫は稀な良性腫瘍で，多発例の存在が知られる．患者は52歳女性．頚髄良性腫瘍の摘出術の際，甲状腺腫瘍と両側多発性肺腫瘤の併存が判明した．甲状腺腫瘍の細胞診は陰性であったが，多発肺転移を伴う甲状腺癌の可能性を否定しきれず胸腔鏡下手術を行った．両側一期的に楔状切除により全病変の摘出を予定したが，先に切除した右肺病変3個の術中迅速診断で肺原発腺癌（多発またはIV期）が疑われ，左肺病変2個は放置した．術後の病理診断は硬化性血管腫であった．多発性肺腫瘍は良性を示唆する画像所見であっても転移性腫瘍との鑑別は一般に困難で，とくに肺外の癌好発臓器に未診断の腫瘤性病変が併存している場合は一層困難となる．また一部の硬化性血管腫は腺癌との鑑別が困難な場合のあることが知られ，術中迅速診断によって手術の方針に影響する場合がある．

胸骨後で再建した有茎空腸が胸腔内にヘルニアを来したまれな1例を経験した. 症例は62歳の男性で, 30歳時に十二指腸潰瘍穿孔に対し幽門側胃切除術 (Billroth II法) を施行した. 平成12年, 胸部食道癌に対し術前放射線化学療法後に食道亜全摘, 有茎空腸胸骨後再建, microsurgery下に血行再建術を施行した. 術後経過は良好であったが, 2か月後より嘔吐と嚥下困難を来した. 胸部X線写真とCTにて縦隔右側に鏡面像を伴う. 胞様構造を認めた. 食道透視にて. 胞状に拡張した挙上空腸を認め, 右胸腔内ヘルニアと診断. 保存的治療で一時的に改善するも, 増悪を繰り返し手術を施行. 胸骨下半T型切開を加え, 屈曲蛇行した余剰空腸を切除し端側吻合した後, 前縦隔に縫着固定した. 術後経過は良好で嚥下困難は消失した. しかし, 初回手術から1年2か月後, 多発性骨, 肺, 脳転移にて死亡した.

背景．胸膜中皮腫において縦隔リンパ節転移が最初の可視病変で，かつその生検から確定診断に至る例は稀である．症例．患者は71歳女性．69歳時，腎癌術後2年経過時点での胸部CTで傍上行大動脈リンパ節の腫大を認められ，胸腔鏡下生検の結果中皮腫と診断されたが他に可視病変を認めず経過観察となった．2年後労作時息切れと左胸水貯留を認められ転医のうえ精査となり，胸腔鏡下胸膜生検によりびまん性胸膜中皮腫との診断に至った．現在化学療法継続中で十分な病勢のコントロールと良好なperformance statusを維持している．結論．孤立性のリンパ節転移が唯一の初期可視病変である中皮腫では，胸膜病変の顕性化の早期発見と，胸腔鏡下生検により遅滞なく確定診断を得ることが重要である．N2 diseaseの中皮腫の治療では，患者の状態に応じた化学療法の選択により良好な状態の維持が可能である．

胸腔鏡下に胸腺腫摘出術を施行後4ヵ月で重症筋無力症（post-thymomectomy myasthenia gravis; PTMG）を発症したため，発症後4ヵ月時点で一側胸腔鏡下手術により遺残胸腺摘出術を完遂した症例を経験した．症例は37歳女性で，前縦隔腫瘍を左胸腔鏡下胸腺左葉切除術にて完全摘出し，重症筋無力症非合併の正岡I期胸腺腫との診断を得たが，5ヵ月後，筋無力症状と血中抗アセチルコリン受容体抗体価の異常高値からPTMGと診断された（病型はOsserman IIB）．診断の3ヵ月後，右胸腔鏡下に遺残胸腺を周囲脂肪組織とen blocに摘出し，術後6ヵ月で寛解が得られた．重症筋無力症を合併しない非浸潤性胸腺腫では，比較的多様な術式選択が許容されると考えられるが，本症例のような予期せぬPTMGにも配慮し，再手術を含め，万一の発症に備えた対応が重要と考えられる．

非浸潤性胸腺腫21例に対する内視鏡下手術の成績を検討した. 対象は30-82 (平均50) 歳の女性16例, 男性5例で, 病期は正岡I期16例, II期4例, IVA期 (胸膜心膜播種) 1例で, 重症筋無力症合併は11例であった. 術式は胸骨挙上式内視鏡下手術 (吊り上げ法) による拡大胸腺摘出術17例, 一側の胸腔鏡下手術 (VATS) による胸腺亜全摘または部分切除術4例であった. 胸腺腫は全例肉眼的に完全に摘出し平均観察期間33ヵ月で再発を認めていない. 2例で胸骨正中切開に術中変更し, 副損傷は胸腺静脈損傷1例 (開胸せず) であった. 吊り上げ法とVATSの平均成績は各々手術時間213分と178分で, 術後入院日数は10日と11日, 術中出血量は129ml と233ml であった. 非浸潤性胸腺腫に対する内視鏡下手術は術後成績からも第一選択として許容できるが, 合併症回避と利便性向上のため, 慎重な術式選択が必要である。

肋骨に発生した黄色腫の一切除例を経験したので報告する. 症例は59歳男性. 検診時に胸部X線写真で腫瘤影を指摘されて入院. 胸部CT検査で右第4肋骨上に中心部低吸収域を伴う境界明瞭な高濃度の腫瘤を認めた. 悪性腫瘍の骨転移をはじめとする腫瘍病変の可能性が否定出来ないため外科的切除を行った. 胸腔鏡下に腫瘍の位置と切除範囲を決定し, 皮膚小切開を加え腫瘍を切除した. 組織学的に腫瘍は変性した骨組織に異型性の乏しい泡沫状の組織球が多数見られ肋骨原発の黄色腫と診断された. 良性疾患の黄色腫が肋骨に生じることは比較的まれであるが, 悪性腫瘍の肋骨転移をはじめとする骨腫瘍など種々の疾患との鑑別が重要である.

We examined 116 stage I-IIIA non-small-cell lung cancer (NSCLC) patients for intra-tumoral expression of thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) using TaqMan reverse transcription polymerase chain reaction (RT-PCR) assay to clarify the correlation between gene expression and the efficacy of 5-fluorouracil (5-FU) in patients with NSCLC. Patients who were administered 5-FU alone after surgery comprised the 5-FU group (n = 30), and those who underwent only surgery comprised the control group (n = 86). When dichotomized at the mean TS and DPD mRNA level, patients with low-DPD tumors who were administered 5-FU had a significantly better prognosis than those who did not receive adjuvant treatment (p = 0.041). In addition, in the 5-FU group, 10 patients with both low-TS and low-DPD tumors have not had any relapse, whereas 8 of the 20 patients with either high-TS or high-DPD tumors developed distant metastasis after surgery. Based on these results, the quantitation of TS and DPD mRNA levels may predict the efficacy of 5-FU after surgery for patient with NSCLC.

Thymidylate synthase (TS) is an enzyme that catalyzes an important DNA biosynthesis process. The gene expression of TS has not been reported in non-small-cell lung cancer (NSCLC) patients. To clarify the correlation between TS mRNA levels and clinicopathological features of NSCLC, we examined 70 Stage I and II NSCLC patients for intra-tumoral expression of TS using TaqMan reverse transcription polymerase chain reaction (RT-PCR) assay and immunohistochemistry methods. We also investigated the TS promoter 28 bp polymorphism in 48 cancer tissues using PCR amplification of genomic DNA. Lung cancer tissue showed higher TS mRNA levels than normal lung tissue (Mann-Whitney U-tests; p = 0.0020). Further, TS mRNA expression was correlated with immunohistochemical TS expression (p = 0.029). We obtained 2 different DNA fragments, which indicated triple-repeat (3R) and double-repeat (2R) type alleles. Cancer tissues with the 3R/3R genotype showed significantly higher TS mRNA levels as compared to those with other genotypes (p = 0.0019). The TS genotype was also correlated with immunohistochemical TS expression (χ2 test; p = 0.0079). The disease-free survival of the low TS mRNA level group was significantly better than those with high TS mRNA levels (log-rank test; p = 0.010), however, there were no significant differences found by immunohistochemical evaluation (p = 0.34) or TS genotype analysis (p = 0.11). A multivariate analysis revealed that high TS mRNA levels independently contributed to disease-free survival. The quantitation of TS mRNA levels is clinically more sensitive and useful for determining the prognosis of Stage I and II NSCLC patients than an immunohistochemical evaluation. © 2003 Wiley-Liss, Inc.

症例は55歳,男性.主訴は嚥下困難.食道胃透視,内視鏡検査にて食道癌(MtUt, 3型, 12cm長),胃癌(M, IIa+IIb, 3 cm大)と診断. CT検査にて食道癌の右肺浸潤が疑われT4と診断し,放射線(40Gy)化学療法(CDDP, 5'-DFUR)を施行した.終了2週目に発熱と,胸部X線にて右下葉肺炎を認めた.食道造影にて右下葉B6と膿瘍腔が造影され食道肺瘻と診断した. covered EMSを挿入し,肺炎の改善を図り, 19日後に手術を施行した.食道と右肺は固く癒着し,食道および右肺下葉を一塊として切除した.病理診断は,高分化扁平上皮癌, pT3, pN0, stage IIで,肺浸潤や瘻孔は明らかでなかった.食道気管支瘻を形成した食道癌に対するcovered EMS挿入は,肺炎の治療に有効であるとともに,術前処置としても有用な方法と考えられた.

胸腔鏡下手術の欠点の一つに, 術中の触診が出来ないことがあげられる.我々は, 胸骨下から術者の片手を挿入し, 触診下に行う胸腔鏡下手術 (Hand-assisted Thoracoscopic Surgery;HATS) を肺・縦隔病変26例に施行したのでその有用性と問題点について報告する.男性12例, 女性14例, 平均年齢58.1 (37-76) 才.肺12例, 縦隔10例にてHATSで手術を完遂しえた.肺部分切除術11例と縦隔嚢胞摘出術施行例6例の手術時間は平均それぞれ88分, 137分であった.右中葉切除術1例, 拡大胸腺摘出術4例もHATSにより施行しえた.HATSは, 操作の確実性が高く, VATSから開胸への前段階のオプションとして有用であった.また, 視認しにくい末梢性肺病変や縦隔腫瘍がHATSの最もよい適応と考えられた.一方, 標準開胸への移行を要した症例もあり, HATSの適応に関しては術前の充分な検討が必要である.

15年前の乳癌手術時に腫瘍が発見され, その後切除しえた巨大非浸潤性胸腺腫の1例を経験した.症例は87歳女性.1984年他院で左乳癌切除時の術前検査で前縦隔腫瘍を指摘された.乳癌術後2年間は定期的に胸部CT検査で経過観察されていたが, その後は放置されていた.1998年より喀痰が増量し, 労作時呼吸困難が出現, 1999年5月より咳嗽, 発熱, 血痰の症状が出現してきた.当科を1999年7月に受診, 胸部CTで前縦隔左側に15cm大の腫瘤像と下肺野の閉塞性肺炎像が認められた.同年8月手術を施行し, 胸骨縦切開と左横切開により腫瘍 (15×10×10cm) を全摘出した.病理組織所見はspindle cell typeの胸腺腫で, 被膜浸潤は認められず, 臨床病期は正岡1期であった.術後2年6ヵ月現在, 再発は認められない.本例は, 非浸潤性を長期に維持する性質をもつ腫瘍が非浸潤性胸腺腫の中に存在することを示唆する症例であったので報告した.

胃癌手術後に2度の結節型肺転移をきたしたが,いずれも肺切除術を施行し,長期生存を得ている早期胃癌の1例を経験したので報告する.症例は68歳(胃癌手術時),男性.胃癌術後8年目の外来検査で血中CEA値が上昇したため胸部CT検査を施行.右肺S3に3.5×3.0cmの腫瘤を認め,右肺上葉切除術を施行した.胃切除術後9年目,肺切除1年目,胸部CTで,左S4, S10にそれぞれ径5mm, 10mmの結節状陰影を認め,胸腔鏡補助下左肺部分切除術を施行した.いずれも病理組織で胃癌と同様の高分化型腺癌を認めた.患者は臨床上および画像診断上再発を認めず,胃癌術後15年,初回肺切除術後5年,生存中である.胃癌の肺転移症例は予後不良であるが,結節型肺転移は他癌の肺転移と同様に多発症例や再再発症例でも手術による完全切除で予後の改善が期待できる.

はじめに: 膵癌術後の胆汁中CEA値が肝転移再発の予測マーカーとなりうるか否かを検討した.方法: 膵癌治癒切除21例を対象とした. 肝転移群は13例 (6か月以内の早期肝転移群6例, 6か月以降の晩期肝転移群7例), 非肝転移群は8例であった. 術前, 術後の胆汁採取は胆管ドレナージチューブより行い, 胆汁中CEA値を測定した.結果: 病理組織学的諸因子と肝転移再発に相関を認めなかった. 術前胆汁中CEA値は, 肝転移群 (41±89ng/ml), 非肝転移群 (12±14ng/ml) で有意差を認めなかった. 術後胆汁中CEA値は, 肝転移群は295±432ng/mlで, 非肝転移群の67±62ng/mlより高値の傾向を示した. 早期肝転移群7例の術後胆汁中のCEA値は, 肝転移群は476±572ng/mlで, 非肝転移群に比べて有意に高値であった. また, 第14病日と, 第28病日の2回にわたって胆汁中CEA値を測定した13例の胆汁中CEA値の推移を検討すると, 早期肝転移群は, 術後経時的に胆汁中CEA値が増加した.結論: 胆汁中CEA値は膵癌術後早期の肝転移再発の予測マーカーとなりうることが示唆された.

背景. 肺癌と肺梗塞の合併は稀でないが, 肺梗塞巣と肺内転移巣との鑑別は難しい.症例. 62歳女性. 胸部レントゲン異常を指摘されて当院受診. 胸部CT上, 左下葉に2つの腫瘤様陰影を認め, 中枢側腫瘤の気管支搾過細胞診より肺腺癌と診断された. 末梢側腫瘤に関しては同一肺葉内転移の可能性を考えてStage IIIB (T4N0M0) と判断した. 左下葉切除術を施行し, 切除標本より末梢側腫瘤は肺梗塞巣と判明し, 術後臨床病期はStage IA (T1N0M0) であった.結論.主病変以外に同一肺葉内に異常陰影を認める場合は, 肺梗塞の合併も念頭に置くことが大切と考えられた.

Background: To clarify the usefulness of the diagnosis and treatment of mediastinal masses, by video-assisted thoracoscopic surgery (VATS), we performed a retrospective multi-institutional study to delineate the type of approach, histopathology, and complications associated with these entities. Methods: We analyzed 150 patients who underwent the VATS procedure at several institutions between 1991 and 1999. Results: VATS resections were performed using various combinations of the "pansternal approach." The unilateral thorax approach was applied in 135 patients, the bilateral thorax approach combined with the suprasternum approach in seven patients, the unilateral thoracic approach combined with the supraclavicular approach in three patients, the infrasternal approach in three patients, and the bilateral thoracic approach combined with both the infrasternal and the suprasternal approaches in two patients. Thoracoscopic resections or biopsies diagnosed 140 benign and 10 malignant mediastinal masses. There were operative complications in nine patients (6%). Eight patients (5.3%) were converted to conventional thoracotomy. Conclusion: VATS is a safe, effective, minimally invasive technique that can facilitate the resection of mediastinal masses when the pansternal approach is applied as appropriate for the location of the tumor.

症例は15歳の女性. 主訴は下腹部痛. 13歳時, 腹痛にて施行したCT検査で脾腫 (容積1,150cm3) を指摘されるも位置異常を認めなかった. 今回, ジェットコースターに乗った後に下腹部痛を来し来院.CT検査にて脾臓を正位に認めず, 下腹部に腫瘤 (容積810cm3) を認めた. 超音波検査, 血管造影にて広範な脾梗塞を伴う遊走脾と診断し, 腹腔鏡下脾臓摘出術を施行した. 術中所見では脾周囲靭帯は欠失し, 脾臓は腹腔内に遊離していた. 脾動静脈をEndo GIA40mmR にて切離後, 腹腔内で脾臓をTissue MorcellatorR を用いて粉砕し摘出した. 手術時間は145分, 出血量は50mlであった. 病理所見は梗塞を伴った正常脾であった. 第6病日に退院し, 術後2年目の現在経過良好である. 遊走脾に対する腹腔鏡下手術の報告は自験例を含め5例で, メッシュによる脾固定3例, 脾摘2例であった. 自験例は広範な脾梗塞と脾腫をともなっていたため, 脾摘を行った.

集学的治療により長期生存がえられている縦隔原発悪性リンパの2手術例を経験したので報告する.胸部X線で異常陰影の指摘を受け, CT検査で前縦隔の巨大な腫瘍が発見された.入院後, 針生検でdiffuse large B cell lymphoma with sclerosis (DLBCLS) と診断され, CHOPを主体にした化学療法が施行された.化療後, 放射線治療 (Co60, 50Gy) を行い, その結果, 腫瘍は著明に縮小した.今後の治療方針の決定を目的に残存腫瘍に対して手術を施行し, 2症例とも腫瘍を全摘出した.術後の病理組織診断では, 腫瘍内にviableな腫瘍細胞は認められずpathological CRと診断された.術後8年, 4年の現在, 再発徴候は認められず健存である.文献的考察から, 縦隔原発DLBCLSに対する治療は, 正確な組織亜系診断, 化学放射線療法の先行, 治療反応例に対する残存腫瘍の可及的全切除であると考えられる.

消化管出血により出血性ショックに陥った膵頭部動静脈奇形 (AVM) に対し, 緊急幽門輪温存膵頭十二指腸切除術を行い救命しえた1例を経験した. 患者は57歳の男性. 繰り返す十二指腸潰瘍からの出血と腹痛の精査目的のため施行した腹部血管造影検査にて膵頭部AVMと診断された. 他院にてAVMへの塞栓術を2回施行するも症状軽快せず, 当院に転院. 手術待機中に大量吐血からショック状態に陥り緊急手術となった. 胃十二指腸動脈の結紮にても出血を制御できず, 救命のため幽門輪温存膵頭十二指腸切除術を施行した. 病理組織検査にて膵周囲から十二指腸粘膜下層にかけての大小不同の動静脈および潰瘍底に露出する静脈が認められた. 術後は多臓器不全, DICに陥ったが, 回復し, 第76病日に退院した. 術後19か月の現在, 再発を認めない. 膵AVM報告66例中の膵頭十二指腸切除施行例は12例であるが, 緊急手術による救命例は自験例のみであった.

A rare case of primary clear cell adenocarcinoma of the retroperitoneum is reported. A 58-year-old woman, who underwent total hysterectomy and bilateral salpingo-oophorectomy for cervical carcinoma at the age of 44 years old, was pointed out having a tumor of the ascending colon. On close examination, an 8×6cm huge pelvic tumor was found out by computed tomography. Transrectal needle biopsy of the tumor showed adenocarcinoma of unknown origin. She underwent an ileocecal resection and a resection of the retroperitoneal tumor. The tumor was located in the retroperitoneal cavity at the left side of the rectosigmoid. It was adherent to the rectal mesocolon, stump of the vagina and bladder. Histological examination showed clear cell adenocarcinoma of the retroperitoneum, and the colon tumor was revealed to be well differenciated adenocarcinoma, m, n0. The patient received chemotherapy for ovarian carcinoma because both this tumor and ovarian clear cell adenocarcinoma seemed to be of miillerian origin. There have been no signs of recurrence as of 14 months after the surgery. As far as we could review, no such case as clear cell adenocarcinoma arising from the retroper-itoneum like our case has been reported in Japan.

前縦隔腫瘍に対する胸腔鏡下手術は, 胸骨が最大の妨げとなり, 胸骨正中切開手術に匹敵する鏡視野の確保ができず, そのため積極的に施行されることが少ない.われわれは左腕頭静脈直下に局在した31歳, 女性の成熟型嚢胞性奇形腫に対して胸骨下部をラパロリフトにより挙上し, 縦隔鏡及び胸腔鏡下に切除した症例を経験した.術中に胸腺静脈と思われる部位より出血を認め, 胸腔鏡からのアプローチによる対応が遅れ850mlの術中出血が認められた.剣状突起下アプローチによる鏡視下良性前縦隔腫瘍切除術は, 術後の創痛が少なく, 早期退院が可能となる手術アプローチである.しかし, 本例のような術中の予期せぬ出血に対しては, 左右の胸腔からも鉗子を挿入する全方位型手術の迅速な採用が必要である.

Background and Objectives: We describe a case of granulocyte colony-stimulating factor (GCSF) and interleukin-6 (IL-6)-producing lung cancer. Methods A 53-year-old man underwent left upper lobectomy under diagnosis of lung cancer. The tumor obtained by a preoperative biopsy was analyzed. Results Preoperative data showed leukocytosis with left-shift of leukocytic morphology and thrombocytosis and an elevated serum GCSF level. Histological examination revealed poorly differentiated adenocarcinoma. A cell line, named LCAM, was established from the tumor and the cytokines in the culture medium were measured by enzyme immunoassay. GCSF and IL-6 were produced in large amounts by LCAM, but granulocyte-macrophage colony-stimulating factor (GMCSF) and interleukin-3 (IL-3) were not. A proportion of LCAM expressed GCSF receptor on the cell surface, but IL-6 receptor could not be detected. LCAM proliferation was inhibited in the culture with antihuman GCSF antibody in a dose-dependent manner. Conclusions We suggest that LCAM proliferation is positively regulated by GCSF. J. Surg. Oncol. 64:347–350, 1997. © 1997 Wiley-Liss, Inc.

We treated a patient with postlobectomy persistent alveolar fistula using a tissue expander, which is a prosthesis widely used in plastic surgery. The patient had thoracic empyema develop after right bilobectomy for lung cancer, and consequently underwent drainage of empyema followed by muscle flap closure for alveolar fistula. A residual space remained, and air leak persisted. However, implanting and expanding a tissue expander enabled us to tightly fix the flap on the raw pulmonary surface, which eventually solved the air leak. The tissue expander greatly contributed to muscle flap closure for a persistent alveolar-pleural fistula with a large remaining thoracic space.

Objective To evaluate the impact on patient survival of video-assisted thoracoscopic surgery (VATS) thymectomy for the treatment of early-stage thymoma, by comparing the intermediate-term oncologic outcomes with outcomes after open thymectomy. Methods Eighty-two patients who underwent complete resection of a Masaoka stage I or II thymoma between November 1998 and December 2011 were reviewed. Results The patients included 32 men and 50 women (median age, 57 years; range, 20-90 years), of whom 44 had stage I thymoma and 38 had stage II thymoma. Seventy-one patients underwent VATS, of whom 4 (5.6%) underwent conversion to open thymectomy; the remaining 11 patients underwent planned open thymectomy. Thirty-six patients underwent total thymectomy and 46 underwent partial thymectomy. Operative mortality was nil. The tumor stage, tumor size, and proportion of patients who underwent total thymectomy were not significantly different between the open and VATS thymectomy groups. The median follow-up period was 49 months (VATS, 48 months; open, 52 months). There was a significant difference between the 2 groups for the estimated 5-year overall survival (VATS, 97.0%; open, 79.5%; P = .041) but not in the estimated 5-year recurrence-free survival. Conclusions Our findings indicate that the intermediate-term oncologic outcomes after VATS thymectomy for early-stage thymoma are as favorable as outcomes after open thymectomy. Further follow-up is still required to evaluate the long-term outcomes after VATS thymectomy.

Pancreatic fistula following total gastrectomy with distal pancreatectomy can cause massive intraperitoneal bleeding from the the exposed main vessels. It is known as a fatal postoperative complication. We here report three cases of postoperative intraperitoneal massive bleeding due to pancreatic fistual.These three patients underwent distal pancreatectomy with total gastrectomy for a gastric cancer. Pancreatic fustula occurred postoperatively in all three cases, leading to massive intraperitoneal bleeding. Emergency operation for hemostasis was successfully carried out in all cases. In addition, we used an occlusion balloon catheter in order to control the bleeding from the abdominal aorta with a favorable outcome. We consider that this catheter is quite effective against excessive intraperitoneal bleeding, because it reduced a loss of blood and maintained the hemodynamic state.

We treated a patient with solitary fibrous tumor of the pleura (SFT) whose angiograms demonstrated its feeders and strongly contrasted tumor stain. Although no one has clearly identified the specific features of SFT on angiograms, SFT can be suspected in the clinical setting if a localized chest wall tumor presents with the feeders and strongly contrasted tumor stain shown by angiography.

Radical operations for lower esophageal cancer, including lymph node dissection in the upper, middle and lower mediastinal and the upper abdominal regions were performed through a left oblique thoraco

Superior vena cava (SVC) and inferior vena cava (IVC) pressures were measured serially during laparoscopic cholecystectomy in which the intra-abdominal pressure was maintained at 12mmHg. The influences of alteration of position from 15 degrees head-down to 15 degrees head-up and of the operative procedure of holding the gallbladder up to the right subphrenic space on SVC and IVC pressures were mild. IVC pressure was maintained almost equal to the intra-abdominal pressure during prolonged continuous pneumoperitoneum lasting longer than 60min, while SVC pressure did not change significantly during operation. The discrepancy between SVC and IVC pressures underwent no change during continuous pneumoperitoneum.

Serum levels of pancreatic isoamylase, trypsin and pancreatic elastase 1 were observed serially in 17 patients who underwent radical operation for gastric cancer with dissection of the anterior capsul

A 58-year-old man who complained of an abdominal tumor was admitted to our hospital. Abdominal CT scan showed that a 15-cm tumor occupied the entire right upper abdomen and that there were ascites and liver metastases. A liver biopsy was performed. The liver biopsy showed a small cell carcinoma pattern, but no definitive origin of the tumor was determined. Considering the extensive peritoneal invasion and multiple liver metastases, he received 2 / courses of cisplatin/etoposide chemotherapy, but his tumor became larger with concomitant abdominal pain and nausea. The patient suddenly died due to multiple organ failure caused by tumor necrosis. The autopsy revealed a pathological diagnosis of primary small cell carcinoma of the pancreas.

An asymptomatic 42-year-old man was diagnosed with a posterior mediastinal mass, most likely a nonfunctioning, benign, neurogenic tumor for which thoracoscopic surgery was initially indicated. However, the systemic blood pressure rapidly increased to a critical level immediately after starting the surgical manipulation of the tumor, which was suggestive of a hyperfunctioning pheochromocytoma. The tumor was removed after controlling the blood pressure and was histologically diagnosed as a pheochromocytoma. The patient had an uneventful course, and the tumor was proven to be sporadic through further postoperative investigations. The possibility of extraadrenal pheochromocytoma should be considered in the preoperative diagnosis of an intrathoracic paraaortic tumor, even in an asymptomatic patient.

The purpose of this report is to discuss the appropriate choice of procedures for video-assisted resection of thymoma according to factors such as the presence of myasthenia gravis or location of the tumor. We evaluated the short-term results of thoracoscopic surgery for 30 consecutive cases of noninvasive thymoma. Unilateral thoracoscopic partial (or subtotal) thymectomy (UTPT) was employed in patients with nonmyasthenic thymoma localized to the unilateral mediastinum, and extended (or total) thymectomy by an infrasternal mediastinal approach (ETIS) in myasthenic cases or those in which total thymectomy was considered inevitable. UTPT was performed on 11 nonmyasthenic patients, and ETIS on 19 (13 myasthenics and six nonmyasthenics). Three patients in the ETIS group underwent conversion to sternotomy because of pericardial dissemination, pleural adhesion, and vascular injury, respectively. The mean surgical duration was 163 min and 224 min and mean blood loss was 123 g versus 149 g for UTPT and ETIS, respectively. Post-thymomectomy myasthenia occurred in a patient after UTPT who made an excellent recovery to remission after the re-UTPT. There has not been any recurrence detected for 48 months of mean postoperative follow-up. Our trial regarding the choice of total or partial thymectomy in thoracoscopic surgery for thymomas yielded acceptable results that warrant further investigations into long-term survival and recurrence after longer-term observation of patients undergoing these procedures.

Fourteen years have passed since video-assisted thoracic thymectomy (VATS-T) began to be used to treat diseases of the thymus. Indications for VATS-T have been expanded by ensuring sufficient space for easy endoscope manipulation using the sternum-lifting method. A variety of VATS-T techniques are available, including the cervical approach, bilateral VATS, infrasternal approach, and others. Although these techniques have the common feature of not involving sternotomy, they differ from each other in terms of the extent of thymectomy. In Japan, bilateral VATS (involving neck incision combined with sternum lifting) or the infrasternal approach (based on the full-directional technique) is often used for extended or maximal thymectomy in myasthenia gravis patients. In a short-term prospective study, VATS-T was shown to be more beneficial than sternotomy in myasthenia gravis patients and those with noninvasive thymoma. With the overall trend toward increased performance of minimally invasive surgery, VATS-T has been more widely adopted as a surgical approach for patients with diseases of the thymus. However, as the number of patients treated with VATS-T has increased, problems specific to endoscopic surgery have become an increasing concern. Whether VATS-T can be considered truly beneficial for patients will depend on the success or failure in solving these problems and the results of long-term prospective studies on the prognosis of patients after treatment with this procedure.

A 66-year-old woman had a recurrent desmoid tumor in the right thoracic apex. The tumor infiltrated the brachial plexus and eventually rendered the upper right extremity functionless. The tumor was removed by aggressive wide resection of the right upper hemithorax with simultaneous amputation of the functionless right arm. Reconstruction of the chest wall was accomplished, utilizing the soft tissues of the remnant arm as a pedicled flap to cover the full-thickness defect. Aggressive wide resection of the chest wall with limb amputation is technically challenging but unavoidable in some cases of recurrent desmoid tumor.

From 1997 to 2005, we performed endoscopic surgery on the thymus in 163 patients with myasthenia gravis or thymoma. The outcomes in these patients were analyzed, with the following conclusions obtained. Endoscopic extended thymectomy is acceptable as a standard operative procedure for myasthenia gravis patients. Endoscopic surgery on the thymus is indicated for stage II or less advanced cases of thymoma according to Masaoka classification. When hand-assisted thoracoscopic surgery (HATS) is used for surgery on the thymus, median sternotomy is not required. If applied only to cases in which it is truly indicated, endoscopic surgery on the thymus can be expected to shorten operative time compared with conventional operative procedures requiring median sternotomy and to serve as minimally invasive surgery in the true sense of the term.

A 72-year-old male was diagnosed as having a thoracic tumor in the left chest wall five years after resection of primary pancreatic somatostatinoma. The tumor was suggestive of metastasis to the chest wall or to the left lung from the previously resected somatostatinoma based on the abnormally elevated serum somatostatin level. Percutaneous biopsy confirmed that the lesion was an islet cell tumor and thoracotomy demonstrated metastasis to the left third rib without involvement of the left lung. Our case represents a rare documentation of somatostatinoma metastatic to the chest wall for which complete resection was performed.

Thymectomy is one of therapeutic modalities for patients with myasthenia gravis. Since 1998, we have performed video-assisted extended thymectomy, which is much less invasive than traditional method. However, its optimal perioperative management has not been established.From April 1998 to December 2003, 40 patients with myasthenia gravis underwent video-assisted extended thymectomy in our hospital. Anesthesia was maintained with propofol, sevoflurane and epidural anesthesia. No muscle relaxant was used. Operations were performed in supine position and required differential lung ventilation of both sides in turn for manipulation. A central venous catheter was inserted in the femoral vein to prepare for unexpected bleeding or other hemodynamic changes.Seven patients presented hypoxemia under differential lung ventilation and needed bilateral lung ventilation or addition of CPAP to nondependent lung. Unexpected bleeding from the left innominate vein occurred in two patients and required median sternotomy. Severe hypotension caused by compression of the heart during operation was observed in twenty-one patients. Extubation in the operating room was successful in all patients except one with severe bulbar paralysis before preoperative period.It is important to examine both surgical techniques of video-assisted surgery and physiological features of myasthenia gravis for anesthetic management of video-assisted extended thymectomy.

The Japan Society of Medical Physics (JSMP) Task Group published Standard dosimetry of absorbed dose in external beam radiotherapy (Standard dosimetry 01) as a new high-energy photon and electron dosimetry protocol in 2002. In this study, we present Standard dosimetry 01 as the JSMP-01 protocol for the convenience of users. This protocol is based on using an ion chamber having a (60)Co absorbed dose to water calibration coefficient, N(D,w), which is calculated from a (60)Co exposure calibration coefficient, N(c). We present dose comparisons between a reference chamber and various plane-parallel chambers. The absorbed dose to water was compared at the calibration depth of 5 cm for a (60)Co beam and d(c) = 0.6R(50) - 0.1 (cm) for electron beams according to JSMP-01. The absorbed dose to water calibration coefficients, [N(D,w)](Co) and [N(D,w)](18E), for the plane-parallel chambers were also determined by (60)Co and electron beam cross-calibrations using a reference chamber. The dose for the plane-parallel chambers derived from [N(D,w)](Co) and [N(D,w)](18E) was compared to that for the reference chamber using electron beams. The JARP chamber in the Kyushu Regional Center which meets third-order standards in Japan was used as the reference chamber. The doses for the plane-parallel chambers determined according to JSMP-01 agreed with that for the JARP chamber within 1% and 2% for (60)Co and electron beams, respectively. For electron beams, the doses for the plane-parallel chambers calculated from [N(D,w)](Co) and [N(D,w)](18E) were within 1.5% and 1.0% compared to those for the JARP chamber, respectively, except for the Exradin A10 chamber.

The Japan Society of Medical Physics (JSMP) Task Group published Standard dosimetry of absorbed dose in external beam radiotherapy (Standard dosimetry 01) as a new high-energy photon and electron dosimetry protocol in 2002. In this study, we present Standard dosimetry 01 as the JSMP-01 protocol for the convenience of users. This protocol is based on using an ion chamber having a (60)Co absorbed dose to water calibration coefficient, N(D,w), which is calculated from a (60)Co exposure calibration coefficient, N(c). We present dose comparisons between a reference chamber and various Farmer-type cylindrical chambers with different wall materials. The absorbed dose to water was compared at the calibration depths of 5 cm for a (60)Co beam, 10 cm for photons, and d(c) = 0.6 R(50) - 0.1 (cm) for electrons according to JSMP-01. The JARP chamber in the Kyushu Regional Center which meets third-order standards in Japan was used as the reference chamber. The absorbed dose to water for the Farmer-type chambers determined according to JSMP-01 agreed with that for the JARP chamber within 1% for photon and electron beams. The doses obtained by JSMP-01 and the Japan Association of Radiological Physics protocol (JARP-86) were also compared for photon and electron beams. For the Farmer-type chambers with photon beams, JSMP-01 results were up to 1.5% higher than JARP-86 results. For electron beams JSMP-01 results were higher than JARP-86 results by 1.3-2.8%.

The prognosis of patients with differentiated thyroid cancer is relatively fair, with a 10-year survival rate above 80%. One of the important prognostic factors is cancer invasion to the airway. For the last 25 years we have been performing combined resection of the trachea and larynx and have reported a relatively good 10-year survival (67.7%) and improved quality of life (QOL). However, operative complications associated with the procedure, especially insufficiency of the anastomosis and bleeding from large vessels, are life-threatening. Of 40 patients who underwent resection of the trachea, insufficiency of the anastomosis occurred in 4 and subsequent massive bleeding from carotid artery due to neck infection in 2. Tracheal resection should be carried out carefully by avoiding insufficiency. We have concluded that combined resection is a good treatment choice for survival and good QOL when performed for local control in patients with differentiated thyroid cancer.

We report that an earlier thoracoscopic clipping of the thoracic duct was advantageous in a case of post-operation chylothorax that occurred following thoracic aneurysm surgery. A 61-year-old man developed chylothorax on postoperative day 2 following graft replacement of the descending thoracic aorta using a left-sided thoracotomy. Since a replaced graft infection is lethal, earlier thoracoscopic clipping of the thoracic duct through the right side chest wall was indicated. The patient underwent thoracoscopic clipping on postoperative day 7 and was successfully treated. The duration of drainage was 2 days and oral intake was started on the seventh day. From our results, we recommend a thoracoscopic procedure through the opposite (right) side chest wall in the early stage of chylothorax development following thoracic aneurysm surgery.