Because of the occurrence of 3 cases of postoperative pulmonary thromboembolism (PE) in 212 patients who underwent thoracic surgery between 1998 and 1999, we introduced a preventive strategy consisting of elastic stockings, intermittent pneumatic compression socks, and walking on postoperative day 1; we have experienced no symptomatic PE in 902 patients thereafter. For one year from June 2004, we tested a comprehensive protocol to evaluate the risk-level of PE and to detect deep vein thrombosis (DVT). D-dimer was determined as useful to rule out preoperative DVT. However, the clinical classification was not effective for selecting patients to be treated with heparin during the perioperative period, because 51 (75%) of 68 patients with a thoracic malignancy were selected as being at the highest risk.

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Since 2004, 28 patients have undergone total thoracoscopic segmentectomy without mini-thoracotomy. In two cases, conversion to open thoracotomy was necessary. In 1 case, elective conversion to open lobectomy was performed due to an oncological factor. In another case, conversion to mini-thoracotomy was required due to arterial bleeding. In 26 patients undergoing this completed procedure, the operation time ranged from 147 to 313 min (median, 222 min), and blood loss ranged from 5 to 305 g (median, 98 g). Postoperative air leakage was not observed in 17 cases (65%). Chest tubes were left in place for 1-7 days (median, 1 day). One patient showed postoperative subcutaneous emphysema, and another developed a bronchial ulcer. There was no in-hospital mortality. Although thoracoscopic segmentectomy is a time- consuming technique that has not yet been sufficiently investigated, it is considered to be a safe and feasible operative procedure.

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Coccidioidomycosis is a fungal disease endemic in semi-arid areas of North, Central, and South America. This study describes the clinicopathological features of pulmonary coccidioidomycosis in five otherwise healthy Japanese individuals. All patients had returned to Japan from the USA and were pointed out as having abnormal shadows on chest X-rays during routine medical examinations. High-resolution CT scan showed a well-defined homogenous nodule or mass adjacent to the pleura. All patients underwent surgical wedge resection. Histopathological examination revealed encapsulated caseating epithelioid cell granulomas containing spherules and endospores characteristic of coccidioidomycosis. Pulmonary coccidioidomycosis is still very rare in Japan, but recently the incidence of the disease has greatly increased. It is important to consider coccidioidomycosis as one of the differential diagnoses when the travel history, symptoms, and HRCT findings are typical.

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Objective: When pleuritis or empyema does not respond to chest tube drainage and antibiotics, a surgical approach is needed. Tuberculous pleuritis is known to be related to high adenosine deaminase (ADA) levels in the pleural fluid. Our purpose was to evaluate the effect of surgery for pleuritis and empyema, and the relation of the ADA levels. Methods: We examined a series of 17 patients with empyema or pleuritis (empyema, n=10; pleuritis, n=7 including tuberculous pleuritis, n=4) who underwent surgery and were followed-up for six months retrospectively. We scored chest Xp findings to assess lung expansion as follows. Score 2: the CP angle is clearly observed. Score 1: the CP angle is dull but the diaphragm is clearly obsereved. Score 0: neither the CP angle nor diaphragm is clearly observed. We scored the chest Xp at preoperation, and the day after and, one week after, one month after, and six months after the operation. Respectively, we also assessed the adenosine deaminase (ADA) levels in pleuritis and empyema and compared the scores of chest Xp. Results: In the empyema group, postoperative lung expansion proceeded extremely well inspite of ADA levels. In the pleuritis group, low ADA levels (<40 IU/L) indicated a more favorable improvement. Conclusion: Scoring of chest Xp findings for pleuritis and empyema after surgery is useful to assess the effect of the operation objectively.

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We examined 3 cases of chest wall schwannoma. During operations, 2 cases were located between the parietal pleura and intercostal muscle (subpleural type). One case was located between the internal and external intercostal muscles (intramuscular type). CT scanning (mediastinal condition) findings in the 2 types: The subpleural type exhibited a sharp angle between the chest wall and tumor, smoothness of the tumor surface, and distinctiveness of the tumor structure. However, the intramuscular type exhibited a smooth angle between the chest wall and tumor, roughness of the tumor surface, and indistinctiveness of the tumor structure. Operative methods: Both types could be resected by thoracoscopic surgery. Regarding the subpleural type, first, we cut the parietal pleura around the tumor, then, the capsule of the tumor could be visualized. Next, we peeled beneath the capsle, ligated and cut the steel connected to the intercostal nerve, and resected the tumor. Concerning the intramuscular type, we cut the parietal pleura, split the muscle fibers, and resected the tumor. Under specified conditions, the intramuscular type may be more effectively resected by the extrapleural method. We must consider the appropriate operative method based on the clinical data.

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An 81-year-old man who received home oxygen therapy for chronic respiratory failure caused by emphysema suffered repeated episodes of spontaneous pneumothorax, and was admitted to our hospital because of pleurodesis failure by OK-432. The operation could be completed safely using percutaneous cardiopulmonary support (PCPS): V-V bypass (Veno-veno bypass) despite his severely impaired pulmonary function. The heparin-coated circuits facilitated the reduction of the ACT value, avoiding hemorrhage. Therefore, we consider PCPS with heparin-coated circuits to be an effective method of respiratory support for thoracic surgery in patients with a poor pulmonary function.

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An 87-year-old man had undergone left lower lobectomy for large cell carcinoma. Two years later, a small nodule inside the right upper lobe was noted. A second video-assisted thoracoscopic surgery (VATS) was performed, and the pathological diagnosis was well-differentiated adenocarcinoma. He has lived uneventfully for 3 years since the second VATS. Elderly patients with lung cancer show a good prognosis if they undergo lung lobectomy. If metachronous second primary lung cancer can be completely removed, surgery is recommended. VATS has become one of the treatments of choice for metachronous second primary lung cancer in elderly patients.

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Right aortic arch is a rare congenital malformation, with an estimated incidence of around 0.1%. We experienced two cases of right lung cancer with right aortic arch. Case 1, a 61-year-old man, was diagnosed with right lung cancer on a medical examination. Case 2, a 69-year-old man, was suspected of having right lung cancer during follow-up after surgery for gastric cancer. Both cases showed no cardiac anomalies. The left subclavian artery diverged from the descending aorta, and it corresponded to type B in the classification of Stewart-Edwards. Case 1 also showed Kommerell diverticulum. The bronchus, artery, and vein of the lung diverged normally, so we were able to perform standard lobectomy. According to embryology, the right recurrent laryngeal nerve encircles the right aortic arch. We must be careful not to injure it. It is difficult to dissect the upper mediastinal lymph nodes due to right aortic arch and descending aortic arch presence. We consider that it is possible to perform dissection of the upper mediastinal lymph nodes similarly to that for left lung cancer cases showing a normal anatomy.

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A 69-year-old man was admitted with an abnormal shadow on chest computed tomography. The patient was diagnosed with idiopathic pulmonary alveolar proteinosis at the age of 68. He had received GM-CSF therapy in the Department of Internal Medicine in our hospital. Chest CT showed a tumor, 2 cm in diameter, in the left anterior chest wall in May 2007. To rule out a malignant tumor, we performed surgery, and two tumors in the mediastinum were removed. Histopathological findings revealed epithelioid necrobiotic granuloma. Specimen culture identified Mycobacterium tuberculosis infection. Finally, he was diagnosed with mediastinal tuberculous lymphadenitis. He followed an uneventful postoperative course. Rifampicin and isoniazid were given daily 20 days after surgery. He is now doing well without any evidence of the recurrence of pulmonary alveolar proteinosis and tuberculous lymphadenitis 3 months after surgery.

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We report a case of sarcoidosis differentiated from metastatic lung tumor. The patient was a 58-year-old woman who underwent mastectomy for phillodes tumor of the right breast one year previously. Before surgery, a pulmonary nodule with a clear margin in the right upper lobe was detected. After surgery, the nodule swelled to a larger size and new other nodules appeared. Because these nodules showed a clear margin and she suffered from phillodes tumor, we suspected that these nodules were metastatic lung tumors. We performed right upper lobectomy with hilar lymph nodes resection. The pathological findings showed noncaseous epithelioid cell granulomas. In addition, bilateral hilar nodes were swollen. So, we diagnosed her with sarcoidosis. Typical parenchymal nodules in the lungs of sarcoidosis patients have irregular margins. Nodules with a clear margin are atypical as sarcoidosis. However, in cases whereby sarcoid granulomas infiltrate into intrapulmonary lymph nodes, they can be swollen with a clear margin, as in this case. So, if clear marginated parenchymal nodules with malignant disease are detected, we need to differentiate them from sarcoidosis.

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We experienced a case of bilateral pulmonary arteriovenous fistula with pneumothorax. A 38-year-old woman had chest pain and consulted our clinic with an initial diagnosis of a right pneumothorax in December 2007. Chest CT revealed collapse of the right lung and small bullae in the right upper lobe. It showed retiform shadows in the apex of the bilateral lungs and thick vessels in the left lung field. Because the pneumothorax did not improve by conservative treatment, we performed surgery. Intraoperative findings showed small bullae in the right upper lobe. The thick vessels seemed to be derived from the subclavicular artery and entered the lung near the bulla, and many expanded reticular vessels were noted around the influx region. Therefore, we diagnosed the case as pulmonary arteriovenous fistula with pneumothorax. We performed a partial resection under open thoracotomy. Macroscopic findings showed many bullae and irregular, expanded arteries and veins on the surface of the lung, leading to a diagnosis of arteriovenous fistula. Although pulmonary arteriovenous fistula is a rare disease, we should always take it into consideration and choose the best method based on the kind of influx and reflex vessels and the position of the fistula.

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A 75-year-old man underwent left lower lobectomy via video-assisted thoracic surgery because of clinical T1N0M0 primary lung cancer. He showed abnormal branching of the left A⁸⁺⁹, which branched from the left main pulmonary artery and descended between the left upper pulmonary vein and left upper bronchus. We mistook it as a mediastinal type of A⁴⁺⁵ and cut it after ligation. However, we noticed the error after interlobar dissection and reconstructed the distal A⁸⁺⁹ stump to the A⁴⁺⁵ stump by end-to-side anastomosis, without conversion to an open thoracotomy. This is the third case report of abnormal branching of the basal pulmonary artery, which branched from the left main pulmonary artery, in Japan.

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Fibrous dysplasia is not a rare disease in the orthopedic department. Ribs (especially the second rib) are sometimes involved, but symptomatic cases which require surgical resection are rare. We report a 48-year-old man with painful fibrous dysplasia which originated from the right second rib. Resection of the involved chest wall and reconstruction was performed, and his symptoms disappeared after surgery.

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We successfully treated bronchofistula by pedicled omentopexy using a combination of bronchofiberscopy and thoracoscopic surgery in a 61-year-old man, who received right pneumonectomy because of pulmonary cicatrization. A pedicled omentum was prepared through laparotomy and a small, two-finger-sized hole was made in the right anterior part of the diaphragm by finger rupture. The omentum was thoracoscopically brought into the right thoracic cavity and then into the right main bronchus using forceps, which was guided by oro-tracheal bronchofiberscopy, via the bronchofistula. The omentum was fixed to the bronchial stump by suturing and fibrin glue. The patient followed a favorable course and was discharged 82 days after surgery. This is the first report on the technique of omentopexy for postpeumonectomy bronchofistula using a combination of bronchofiberscopy and thoracoscopic surgery without open thoracotomy.

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A healthy 82-year-old man presented with a well-defined nodule approximately 10 mm in diameter on an X-ray photograph, which was found in the right upper lobe on CT scan. As a trans-bronchial lung biopsy failed to facilitate a diagnosis, the patient underwent apical segmentectomy of the right upper lobe. The nodule consisted of eosinophilic, amorphous material, which was stained with Congo red, and showed an apple-green color with polarized light. Partial loss of elastic fibers of an adjacent pulmonary artery with amyloid deposition was identified on microscopic examination. He showed no amyloidal deposition in any other organs, nor any diseases related to amyloidosis. We diagnosed this case as nodular pulmonary AL amyloidosis in the parenchyma of the lung.

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A 79-year-old female underwent surgery for right breast and pancreatic cancer. Eight months after the operation for pancreatic cancer, a tumor, suspected as primary lung cancer, was pointed out in the left lower lobe (S¹⁰) on CT. We decided on surgery because of no distant metastasis detected on PET and MRI. We performed VATS partial resection of the left lower lobe due to a metastatic tumor from pancreatic cancer based on the cytodiagnosis via intra-operative aspiration biopsy. Cases of resectable solitary lung metastasis from pancreatic cancer are very rare. The differentiation of this tumor as a metastatic tumor from pancreatic or primary lung cancer is difficult. However, we consider that cytodiagnosis via intraoperative aspiration biopsy is useful.

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A 75-year-old male was referred to our hospital because of dyspnea for two months. Chest CT showed a giant mediastinal mass with fat tissue density spreading to the anterior and middle mediastinum. He had multiple myelomas identified on further examination, but we decided on mediastinal tumor resection for the improvement of respiratory symptoms before multiple myeloma treatment. The sternum with myeloma was fragile and difficult to close with wire, and platelet transfusion was necessary for hemostasis due to decreased platelet levels caused by multiple myeloma. The tumor was well-capsulated and resected en bloc with the assistance of thoracoscopy to achieve a lateral view. The pathological diagnosis was “lipoma-like” liposarcoma, being a rare case combined with multiple myeloma.

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The patient was a 74-year-old man who complained of bloody sputum and cough. A chest radiograph showed atelectasis in the left upper lobe. Bronchoscopy revealed a mass in the left main bronchus. The biopsy findings suggested squamous cell carcinoma. A PET scan revealed FDG accumulation in the tumor of left main bronchus. The patient underwent left upper sleeve lobectomy. The resected tumor was composed of squamous cell carcinoma, adenocarcinoma, and osteosarcoma. The diagnosis was true pulmonary carcinosarcoma.

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We report a rare case of tuberculous osteomyelitis of the sternum. A 20-year-old man was admitted to our hospital due to the presence of a mass of the anterior chest wall and precordialgia. A CT scan demonstrated destruction of the manubrium and a soft tissue mass surrounding the sternum. The diagnosis was confirmed by pathological findings from biopsy material. A total of 6 months anti-tuberculous chemotherapy was administered. The patient was free of clinically evident recurrence 9 months after treatment.

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A 71-year-old man, with a history of surgically resected maxillary sinus cancer 10 years previously, was admitted to our hospital in February 2006 to undergo gastric cancer resection. Chest computed tomography (CT) revealed a nodule in each lung. Since the gastric cancer was clinically diagnosed to be submucosal, we diagnosed these nodules as maxillary cancer pulmonary metastases. Chest CT 3 months after gastric cancer resection showed lung nodule growth. We performed right lower lobe wedge resection, and the nodule was pathologically diagnosed as maxillary sinus cancer metastasis. Seven months later, CT showed left lung nodule growth and new nodule development. We also suspected these nodules to be maxillary cancer metastases, but there were no other lesions and the patient desired surgical resection. We performed left lower lobectomy combined with lingulectomy. These nodules were pathologically diagnosed as combined small cell carcinoma and poorly-differentiated adenocarcinoma. To our knowledge, this is the first case of triple cancer including synchronous multiple primary lung cancers with small cell carcinoma.

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We report a case of intralobar pulmonary sequestration of the left lower lobe that was treated by video-assisted thoracic surgery in a patient in his twenties. He was referred to our hospital upon being diagnosed with pulmonary sequestration after enhanced computed tomography (CT) revealed an aberrant artery branching directly from the descending thoracic aorta to the left lower lobe. After hospital admission, he was diagnosed with intralobular pulmonary sequestration by three-dimensional CT (3D-CT) and underwent video-assisted thoracic atypical segmentectomy of the left lower lobe. While video-assisted thoracic surgery for pulmonary sequestration is performed often, but only a few cases of intralobular pulmonary sequestration treated by video-assisted thoracic segmentectomy have been reported. It is often possible to visualize the feeding arteries and drainage veins with preoperative diagnostic imaging such as chest 3D-CT. Thus, we conclude that video-assisted thoracoscopic atypical segmentectomy for pulmonary sequestration is an effective means to minimize postoperative respiratory dysfunction.

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Congenital factor VII deficiency is a rare hemorrhagic disorder. We report a case of pneumonectomy for lung cancer combined with congenital factor VII deficiency. A 65-year-old man was admitted to our hospital because of an abnormal mass shadow in the left pulmonary hilum identified on a chest X-ray film and CT scan. The mass was diagnosed as squamous cell carcinoma by a cytology study. Laboratory data showed a prolonged prothrombin time and a decreased level on the thrombo test. Factor VII coagulant activity was reduced to 47 %. Left pneumonectomy was performed with the administration of recombinant activated factor VII (rFVIIa). The postoperative course was uneventful without bleeding. The use of rFVIIa seems to be effective to prevent perioperative bleeding on pneumonectomy in patients with congenital factor VII deficiency.

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We report a 26-year-old man with multiple cystic lesions in the right lower lobe of the lung. Although he was asymptomatic, he was pointed out as having an abnormal lung shadow at a group medical examination. A chest radiograph and CT showed multiple cystic lesions with an air-fluid level in the right lower lobe. A right lower lobectomy was performed through a mini-thoracotomy using thoracoscopy. The histopathological diagnosis was type I congenital cystic adenomatoid malformation (CCAM). His postoperative course was uneventful. He is currently alive with a good respiratory condition and no sign of recurrence. Surgical treatment is necessary for adult patients with CCAM to lower the risk of recurrent pulmonary infections and concomitant malignancies.

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A 57-year-old woman, whose neck was pulled upwards with a rope while operating a machine, showed mild dyspnea. As screening using 16-channel multidetector-row computed tomography (MD-CT) revealed mediastinal emphysema and a transected trachea, an emergent operation was performed on the day of the accident. Endotracheal intubation across the laceration was immediately conducted because laryngeal bleeding and swelling obscured the airway. The trachea was transected between the annular cartilage and first tracheal cartilage. The membranous portion of the trachea showed a remaining width of only 7 mm. The left recurrent nerve was definitely preserved, but the right unidentifiable. Primary end-to-end anastomosis was performed in a non-telescopic fashion with fourteen interrupted #3-0 PDS sutures. The dorsal three knots were tied on the inside of the tracheal wall, and the other eleven outside. The patient was discharged on the 33rd postoperative day with no marked complications. The 16-channel MD-CT modality is very useful in the early diagnosis of tracheal injury caused by blunt trauma when three-dimensional images are obtained, and should facilitate more frequent preoperative diagnoses.

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