Rat air leak models were closured by fibrin glue, sheeted fibrin glue, and polyglycolic acid mesh combined with fibrin glue. The sealed sites including pleural surface were evaluated by both histology and ultra micromorphology. Adhesion between the sealed site and chest wall was observed for sheeted fibrin glue and polyglycolic acid mesh combined with fibrin glue, but not for fibrin glue. In all methods, fibroblast growth was observed on the pleural surface following air leak sealing, and angiogenesis was also observed when using sheeted fibrin glue and polyglycolic acid mesh combined with fibrin glue. Mesothelial cells were not observed using any method. In addition to inflammation, the pleural surface was thought to have thickened due to the extracellular matrix produced by the increased number of fibroblasts. In particular, when utilizing the polyglycolic acid mesh combined with fibrin glue, the thickening of the pleural surface was attributed to the transfer and migration of fibroblasts to the pleural defect, functioning of the applied polyglycolic acid mesh as a scaffold for cells, the subsequent involvement of growth factors in the body, and tissue remodeling due to the extracellular matrix produced by fibroblast cells. Sealant materials are reinforcement of the pleura by pleural thickening through a procedure similar to tissue engineering techniques. In conclusion, for development of the tissue adhesive, it is necessary improvement of the biocompatibility, control of the inflammation, prevention of the adhesion, to synchronize with the movement of lungs during respiration.

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Surgical treatment for elderly patients with secondary pneumothorax was retrospectively reviewed. Between January 2000 and December 2006, 7 patients over 80 years old underwent surgical treatment for pneumothorax in our hospital. In 2 cases, because of very poor general conditions, thoracoscopic loop ligation covered with polyglycolic acid sheets followed by intrapleural administration of diluted fibrin glue to prevent recurrence was performed, under the local and epidural anesthesia. In other 2 cases, thoracoscopic surgery under general anesthesia assisted with percutaneous pulmonary support (PCPS) was conducted since they had an extremely impaired respiratory function. The remaining 2 cases underwent thoracoscopic surgery under ordinary general anesthesia. No postoperative complication was encountered in cases treated by local and epidural anesthesia. Severe cardiopulmonary complications were observed in 5 cases with general anesthesia. One postoperative death was experienced in a case with PCPS due to cardiac failure. It was considered to be important to choose the method to surgically treat elderly patients based on the functional reserve of vital organs case by case.

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TissueLink^TM (TL) is a device developed for the purpose of liver excision, and comprises mono-polar coagulation equipment which requires saline as mediation. We have used TL in bulla surgery, and have reported good results since 2005. Furthermore, in order to introduce TL into clinical use, multi-institutional clinical studies have been performed, and the results are as follows. TL ablation was performed for small bullae: 48 patients (60 lesions), and large bullae: 27 patients (31 lesions). Complications: postoperative air leakage occurred in only three patients with small bullae, with none in large bullae. The causes of complications were overlooked bullae, poor ablation, and unknown. For small bullae, the cause was only TL ablation, bullae disappeared, and the postoperative complications were also slight. Complications were not observed in large bulla surgery. By carrying out TL ablation for large bullae, which requires lobectomy, reduction and tylosis of the wall were possible, and, as a result, bullae excision with an automatic suture device was easily performed. As mentioned above, it is thought that TL could be introduced as a new device in surgery for bullae.

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The purpose of this study was estimate the efficacy of buttress staple with polyglycolic acid (PGA) felt after thoracoscopic bullectomy for primary spontaneous pnemothorax (PSP). Between July 1995 and December 2000, 164 consecutive patients with PSP were treated by thoracoscopic simple bullectomy. Conversely, between December 2000 and August 2007, buttress staple with PGA felt was performed in 201 consecutive patients with PSP. Recurrence occurred in four patients (2%) in the buttress staple group, and fifteen patients (9%) in the simple bullectomy group. Buttress staple with PGA felt is effective for the prevention of post operative recurrence.

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Previous reports demonstrated that water seal is equivalently efficient or rather superior to continuous suction for the management of postoperative thoracic drainage after pulmonary resection. Although we generally use water seal on chest tube management after lung resection, in case of massive air-leakage, we occasionally need to convert to continuous suction from water seal that is intrinsically efficient to stop air-leakage. Here, we reviewed our chest tube management under a water seal. From January 2006 to October 2006, 90 surgeries were performed for pulmonary resection and the medical records were conducted retrospectively. After closing the chest, −10 cm H₂O suction starts and continues by checking expansion of the operated lung, for about 30 minutes. Then, we change the management to a water seal. Nine cases (10%) required conversion from water seal to continuous suction. The reasons to convert to suction were expanded subcutaneous emphysema (n=5), lung collapse (n=3), and retained pleural effusion (n=1). In case of massive air leakage after surgery in water seal, we need careful consideration for subcutaneous emphysema and lung collapse.

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Lipoma of the diaphragm is an extremely rare entity. The patient described was a 43-year-old woman, who was admitted to our hospital with an abnormal shadow on her chest CT scan. The preoperative diagnosis was a strongly suspected lipoma of the diaphragm, but the possibility of highly differentiated liposarcoma could not be ruled out. The primary tumor, measuring 6.5×3.6×2.9 cm, located above the left hemidiaphragm, was resected, and a final diagnosis of spindle cell lipoma originating in the diaphragm was made.

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An asymptomatic 67-year-old male visited our hospital with an abnormal shadow on a chest X-ray. Chest CT showed multiple nodular shadows in the bilateral lung fields. He was diagnosed with silicosis and has been followed-up for three years. For the last one year, one of the nodules in S² of the right lung enlarged rapidly. Bronchoscopic examination did not reveal malignancy. Therefore, lung biopsy was performed under video-assisted thoracic surgery (VATS). The pathological diagnosis was progressive massive fibrosis (PMF). PMF often shows similar findings to lung cancer on CT images. In the present state, lung biopsy may be necessary to distinguish between PMF and lung cancer in cases of silicosis.

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We describe a successful closure of a bronchial stump by pedicled latissimus dorsi muscle to prevent bronchopleural fistula after pneumonectomy, because of poor nutrition and bronchial inflammation. A 65-year-old patient with bronchial carcinosarcoma developed atelectasis and pneumonia of the right lung due to a tumor totally obstructing the right main bronchus. The postoperative course was uneventful, without bronchial-pleural fistula and empyema development. Latissimus dorsi muscle flap patch closure of the bronchial stump is a useful technique in patients with poor nutritional conditions.

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A 13-year-old junior high school student was diagnosed with a primary mediastinal mixed germ cell tumor extensively invading the right chest cavity. On further qenetic examination, it was revealed he was a Kleinfelter's syndrome. Curative surgery was achieved using a hemi-clamshell approach followed by chemotherapy. Postoperative histopathological examination revealed that the yolk-sac component was almost necrotic. It is important for therapy of non-seminoma germ cell tumor to obtain a histological diagnosis, and employ a combination of chemotherapy including cisplatine and curative surgery.

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Recently, 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) has come to be considered a useful tool for the diagnosis of lung cancer. Especially, FDG-PET is very sensitive to the detection of lung cancer appearing as solid tumors on chest computed tomography (CT) scanning. However, false negative cases are still sometime reported. We report two cases of mucinous type of bronchioloalveolar carcinoma with negative FDG-PET scanning. Mucin of malignant cells can be a cause of false-negative FDG-PET scanning. Clinicians should note that FDG-PET-negative lung tumors might be a mucinous type of bronchioloalveolar carcinoma.

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A case of benign schwannoma arising in the brachial plexus with intrathoracic extension is presented. Intrathoracic growth of schwannoma of the brachial plexus has been reported in only 13 cases in the literature. The patient was a 25-year-old woman who was pointed out to have an abnormal shadow at the right pulmonary apex on routine chest X-ray examination. CT and MRI showed that the tumor extended to the lowest trunk of the brachial plexus. We selected a transmanubrial approach (TMA) and resected the tumor by enucleation, since it was confirmed to be a benign schwannoma at biopsy. We performed the operation without major postoperative neurological disturbance.

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A 9-year-old boy, injured in a traffic accident, was brought to our hospital. He was unconscious (Japan coma scale 200), and there was extensive cutaneous emphysema from the chest to neck. Blood gas analysis identified severe respiratory failure. Chest computed tomography (CT) showed the discontinuity of the right main bronchus. We suspected right bronchial rupture and performed an emergency operation with extracorporeal membrane oxygenation (ECMO). Immediate right thoracotomy showed that the main bronchus was completely severed, and end to end anastomosis was performed. Furthermore, there was bronchial rupture of the carina, but we couldn't continue the operation because of decreased oxygenation. Two days after the operation, bronchoplasty was performed by median thoracotomy. The postoperative course was uneventful, and he was discharged after 44 days, being able to walk. In this severe case, we could save his life through prompt and combined modality therapy from diagnosis with CT to two surgical operations.

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Mucoepidermoid carcinoma of the thymus is rare, accounting for less than 2% of thymic carcinomas, and the treatment strategy has not yet been elucidated. We present two cases of mucoepidermoid carcinoma of histologically low- and high-grade. We encountered a 58-year-old man with high-grade mucoepidermoid carcinoma. Thymectomy with lymph node dissection and intrathoracic chemo-thermotherapy following the operation was carried out. Only six months after the initial treatment, PET-CT scan showed recurrence to the adrenal gland. Eight months after resection, PET-CT scan revealed recurrence to the jejunum. The patient is being treated with systemic chemotherapy. The other case was a 53-year-old man with a low-grade tumor treated with multimodality therapy, as we previously reported. He underwent complete resection, and the specimen revealed low-grade mucoepidermoid carcinoma. However, the tumor recurred to the chest wall and pleura in 57 and 69 months respectively. Therefore, he was treated with re-resection, systemic chemotherapy, intrathoracic chemo-thermotherapy, and irradiation. He died of tumor progression with multiple metastases to the liver, vertebra, spleen, and kidney at 93 months after the initial resection.

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A 66-year-old man was found to have a mass shadow in the right upper lung field and underwent further examinations, which revealed a 35 mm squamous cell carcinoma (SCC) in the periphery of the right S² and a nodular, endoscopically-early SCC at the orifice of the right B⁷. He was diagnosed as having synchronous double lung cancer and underwent right upper lobectomy with mediastinal lymph node dissection for SCC in the right S², and the pathological stage was II B (pT3N0M0). Three months after surgery, carbon ion radiotherapy with 61.2 GyE was performed for another SCC at the bifurcation of the right B⁷, resulting in CR. He is presently alive with no evidence of recurrence 5 years and 3 months after surgery. Heavy ion radiotherapy is superior in terms of the local control of multiple lung cancer,and is considered to be one of the radical treatment options for secondary cancer.

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The patient was a 19-year-old man. He underwent chest wall resection and reconstruction for desmoid tumor of the right chest wall at another hospital in July 2001. After the operation, he didn't go to the hospital for treatment. In April 2005, an abnormal shadow was detected on his chest X-ray film. A CT scan showed an irregular tumor on the right chest wall from the second rib to the 7th rib around the previous operative scar. We performed an operation to remove the tumor with the chest wall and reconstruct the chest wall using an autogenous rib graft and Composix Mesh. The patient has remained well without sign of recurrence for one year and ten months after treatment.

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Although the incidence of coccidioidomycosis in Japan is still rare, it is one of the most severe mycoses because of its infectious and pathogenic nature. We report a case of pulmonary coccidioidomycosis diagnosed by video-assisted thoracic surgery. The patient was a 52-year-old male with an abnormal shadow on a chest X-ray during a medical check-up. He had stayed in Arizona in the United States for one year. Chest CT demonstrated a mass lesion measuring 2.5×1.9 cm in the left thoracic cavity. Thoracoscopic partial resection of the lung was performed, and histopathological examination revealed typical spherules in the resected specimen.

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A 72-year-old woman had a left rib tumor that was detected 50 years ago. At that time, surgery wasn't indicated. From February 2006, she had complained of left back pain and a left supraclavian tumor. Computed tomography revealed a 9.0 cm tumor that originated from the left first rib. Open biopsy found a giant cell tumor of the bone. We planned surgery. After embolization of the feeding artery, surgery was performed by transmanubrial approach and posterior approaches. The adhesion around the tumor was tight, but there was no invasion of the subclavian vein. We could extirpate the tumor with the first and second ribs.

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A 32-year-old woman suffered from cough and fore-chest pain and was admitted to our hospital for the treatment of mediastinal tumor. Chest X-ray and chest computed tomography (CT) showed a large mass that had expanded on the left side of the anterior mediastinum. We preoperatively diagnosed it as invasive thymoma and performed a median sternotomy. Extended thymectomy with partial resection of the lung was performed. Microscopically, the multinodular tumor consisted of malignant cells containing Hodgkin/Reed-Sternberg cells, separated by fibrous tissue, which were positive for anti-CD15 and anti-CD30 antibody. Classical Hodgkin's lymphoma, nodular sclerosis Hodgkin's lymphoma, was diagnosed. Hodgkin's lymphoma usually originates in lymph nodes and is rare in the thymus. This patient underwent radiotherapy and is currently free from the disease at 10 months post-operatively. The patient will be followed carefully, because Hodgkin's lymphoma has a favorable prognosis with appropriate treatment.

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A 53 year-old man was referred to our hospital with a fever and right chest pain. Preoperative chest CT scan demonstrated a solitary huge mass shadow in the right upper lobe. Though the diagnosis was not defined by bronchoscopy, it was difficult to differentiate the lesion from neoplasm. A right upper lobectomy with parietal pleural resection and mediastinal lymph node dissection was performed. After the operation, inflammatory reactions were still seen, and angitis appeared. Laboratory findings showed an elevated serum anti-neutrophil cytoplasmic antibody (c-ANCA) level at 13 days post-operatively. Also, histo-pathologically, he was diagnosed with Wegener's granulomatosis (WG). Treatment with steroid and cyclophosphamide was started, and he responded well. Pulmonary WG can present with multifocal lung involvement, and examples of solitary lung lesions have been reported only rarely, but it is necessary to take it into consideration as one of the differential diagnoses. C-ANCA determination is useful in diagnosis.

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A 56-year-old women noted numbness on the bottom of the left foot from about September, 2004, and experienced walking difficulty from January, 2005, and lumbago from February, 2005. She therefore underwent a neurological checkup at our hospital. Chest X-ray film showed a tumor shadow about 6 cm in diameter to the left of the mediastinum. Chest CT and MRI revealed a 50×35 mm left paravertebral hemisphere-shaped mass with extrapleural sign at the level of Th3-5. In addition, the tumor extended into the spinal canal through the T4-T5 intervertebral foramen, and the thoracic spinal cord was being compressed by it (Dumbbell type). Aortic angiogram showed dense vascularity and irregular tumor staining from the main feeder, the fourth intercostal artery. During the operation, the paravertebral part of the tumor was initially completely removed by open thoracotomy. When some feeding arteries were resected, the tumor shrank. Then, in the prone position, the intraspinal and foraminal tumor was removed through a Th3-5 laminectomy. Pathological examination demonstrated angiolipoma consisting of a combination of mature adipose tissue and multiple small blood vessels. After surgery, the patient's spastic palsy disappeared and she could walk normally 2 months postoperatively. There has been no sign of recurrence for two years following resection. Angiolipomas arising from the mediastinum are extremely rare; to our knowledge, only three cases have been reported, and all these cases were accompanied with extension into the spinal canal.

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A 27-year-old man was referred to our hospital due to abnormal findings on chest X-ray. Although he had no symptom, chest CT showed a 35 mm diameter mass in the anterior mediastinum, invading the left brachiocephalic vein to the superior vena cava (SVC) indicated by a defect of contrast medium. Teratoma was suspected. Incision was made from the left brachiocephalic vein to the superior vena cava with temporary cross-clamping of the SVC and brachiophalic veins. The teratoma had invaded the left brachiocephalic vein. We resected the teratoma and left brachiocephalic vein, and partially resected the SVC. Since the risk of invasion due to teratoma is high, a thorough preoperative examination is very important.

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A 29-year-old female with a desmoid tumor was treated with resection of a portion of the posterior chest wall, including the 1st to 5th ribs. Postoperative radiotherapy and hormone therapy were given because the surgical margin was positive. After the operation, the left shoulder was immobile since the scapula collapsed into the chest wall defect. Fixation of the scapula with Marlex mesh was performed, and she was able to raise her arm afterward. She is currently doing well without recurrence 5 years after surgery. Fixation of the scapula is effective for immobility of the shoulder after a chest wall resection.

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A 56-year-old Japanese male, given a diagnosis of polymyositis (PM) with Sjögren's syndrome, was admitted to our hospital. Bilateral pneumothorax occurred after asymptomatic pneumomediastinum. Therefore, bilateral tube drainage was started and air leakage continued for about a month. Video-assisted thoracoscopic surgery for bilateral pneumothorax was performed, and the air leakage disappeared. To our knowledge, this report is not only the second case of polymiositis that was received surgery of pneumothorax, but also the second case of polymiositis complicating asymptomatic pneumomedastinum.

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A 57-year-old man was referred to our hospital with fever. He had a history of recurrent pneumonia. Under a diagnosis of pneumonia, antibiotic treatment was administered, but an abnormal shadow on chest roentgenogram was not improved. Chest CT demonstrated a mass shadow about 6 cm in diameter in the left lower lobe, and an aberrant artery arising from the descending aorta supplying the left lower lobe. Aortography showed a systemic artery from the descending thoracic aorta supplying the mass, but venous return from the mass was not identified. A diagnosis of anomalous systemic arterial supply to the normal basal segments was established and surgery was performed. During surgical exploration, the borderline between the normal and abnormal area was not clear. Left lower lobectomy was performed with ligation and cutting of the abnormal vessel. The resected specimen demonstrated that the mass, measuring 6 cm in diameter, was a dilated systemic artery with a thrombus, supplying the left basal segment. In cases of recurrent pneumonia or showing a lack of improvement of abnormal shadows on chest roentgenogram, an anomalous systemic arterial supply to the normal basal segments must be included in the differential diagnosis, and, once the diagnosis is established, an appropriate surgical procedure based on the findings must be performed.

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