Spontaneous pneumothorax occurred in 106 patients, who were treated with 117 operations 41 thoracotomies, 63 video-assisted thoracoscopic surgeries <VATS>, and 13 VATS followed by thoracotomies. A comparison of the three treatments showed that the median operating time, duration of chest tube drainage and length of postoperative hospital stay were significantly shorter with VATS than with the other two operations. Intraoperative blood loss with VATS was significantly less than that with the other operations. In conclusion, VATS significantly decreased operating time, blood loss, duration of chest tube drainage and postoperative hospital stay.

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The microenvironmental compartmentalization and cell regulation in lymphoid follicles often recognized in the thymuses of patients with myasthenia gravis were evaluated immunohistochemically with anti-tenascin and antibcl-2 mAB and the results compared with those in the mediastinal lymph nodes.
The thymic lymphoid follicle tissue was surrounded by tenascin-associated connective tissues which revealed finely linear fibers at the sides of the cortex-medulla junctions, but adjacent to the medulla there was a meshwork of fibers. In contrast, in lymph nodes there was no tenascin surrounding the connective tissues around the follicles and only weakly immunostained fibers in the walls of blood vessels in the interfollicular areas.
In the thymic lymphoid follicles, there were many bcl-2-positive cells in the mantel zone and medulla, and several scattered but densely immunostained cells were seen even in the germinal center of the follicle, but no positive cells were observed in the germinal center of the lymph nodes, although many positive cells were seen around the mantel zone and the interfollicular area.
These findings suggest that the lymphoid follicles in the thymuses of patients with myasthenia gravis are compartmentalizated by extracellular matrix tenascin-containing connective tissue which might regulate cell selection and migration. The bcl-2 overexpression in the germinal centers of their thymuses may provide the evidence of enhancement of survival for abnormal B cells that produce autoantibody through the tenascin network around the follicles.

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Thoracoscopic extended thymectomies in conjunction with collar incisions of the neck were performed in two patients with myasthenia gravis without thymoma. The alleviation of clinical symptoms of myasthenia gravis (Osserman type IIB and type I) was encountered in both patients after the surgery. Although this surgical procedure has several disadvantages such as time-consuming, it has various advantages such as : 1) the possibility of extended thymectomy without median sternotomy, 2) smaller wound, 3) minimal surgical stress, and 4) less postoperative pain. The present method was concluded to be an appropriate procedure for an extended thymectomy in cases of myasthenia gravis without a thymoma.

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We treated 55 patients with bilateral spontaneous pneumothorax, (10 simultaneous and 45 metachronous), 15.4% of the total 356 patients treated surgically for spontaneous pneumothorax in our hospital from 1982 to March 1995. The characteristics of bilateral simultaneous pneumothorax, were : 1) high incidence in adolescents, 2) frequent history of unilateral spontaneous pneumothorax. The characteristics of bilateral metachronous pneumothorax, were : 1) high incidence in 3rd decade, 2) frequent contralateral occurrence within two years after unilateral thoracotomy.
For bilateral simultaneous pneumothorax, bilateral simultaneous surgery is recommended. For bilateral metachronous pneumothorax, bilateral simultaneous surgery is recommended for patients in 2nd or 3rd decade.
Teenagers with unilateral spontaneous pneumothorax should be under careful observation for contralateral spontaneous pneumothorax.

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Of the 680 patients with primary lung cancer treated at our hospital had small peripheral tumors 3 cm or less in diameter : 126 adenocarcinomas, 24 squamous cell carcinomas, 6 adenosquamous carcinomas, 4 small cell carcinomas, 2 large cell carcinomas and 6 carcinoids. We evaluated the feasibility of video-assisted surgery and limited surgery as curative operations for small peripheral lung cancer.Among the n2 tumors 2-3 cm in diameter, there were 19 adenocarcinomas (26.4%) and 2 squamous cell carcinomas (12.5%) : and among the pm tumors 2-3 cm in diameter, there were 11 adenocarcinomas (15.3%). Resection equivalent to lobectomy and standard node dissection are necessary for tumors of this size.
Of the n2 tumors 1-2 cm in diameter, 6 were adenocarcinomas (13.6%), of the pm tumors 1-2 cm in diameter, 3 were adenocarcinomas (6.8%) and was a squamous cell carcinoma (12.5 %). We think that lobectomy with standard node dissection is necessary for tumors of this size particularly for adenocarcinomas.
Tumors up to 1 cm in diameter with no node or intrapulmonary metastasis may be treated with video-assisted surgery or limited surgery after various factors have been evaluated.
We conclude that if video-assisted surgery or limited surgery is being considered for primary lung cancers more than 1 cm in diameter precise preoperative assessment is essential.

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The incidence of intraoperative air-leaks of bronchial stumps after closure of bronchus was reviewed in 150 pulmonary resections for lung cancer patients. There were 14 air-leaks in 77 stapled cases (lobectomy, 10 ; bilobectomy, 4; and pneumonectomy, 0). There were 5 air-leaks in 73 sutured cases (lobectomy, 5; bilobectomy, 0; and pneumonectomy, 0). The incidence of intraoperative air-leaks of stapled cases was significantly higher than that of sutured cases (p<0.05). There were no postoperative bronchopleural fistulas in cases of intraoperative air-leaks when the air-leaks of bronchial stumps were repaired.

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We report two cases of thoracoscopic surgery under local and epidural anesthesia for the treatment of intractable pneumothorax, in which they consisted of a case of severe emphysema and one lung ventilation under general anesthesia was felt to be risky. Operation was undertaken after identifying the location of the air leakage by pleurogram.
Pain was minimal and the cough reflex was well controlled during the operation, allowing us to perform thoracoscopic surgery in a well exposed operation field. The blood pressure, pulse, and O₂ saturation during the operation were stable.

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A 72-year-old man underwent a right upper lobectomy for squamous cell carcinoma on December 5, 1991.
In November, 1994, a chest X-ray revealed a mass shadow in the right lower lung field, and bronchoscopy revealed a polypoid tumor in the right lower bronchus. Right lower lobectomy was performed. Histopathological examination showed tubular adenocarcinoma with intraluminal polypoid growth origination in the right lower bronchus.
This is a rare case of metachronous double lung cancer : a peripheral squamous cell cancer in the right upper lobe and adenocarcinoma with intraluminal polypoid growth in the right lower bronchus.

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A 62-year-old male, who had had left upper lobectomy for lung cancer 15 years ago, was admitted to our hospital for diagnosis and treatment of hemoptysis. His chest roentgenogram and computed tomography showed an irregular sclerosed shadow in the left S⁸. Bronchoscopy revealed bending of the left main bronchus and stenosis of the left lower lobe bronchus. There was no evidence of recurrence of lung cancer. Percutaneous transarterial embolization of the bronchial artery was attempted six times, but it could not stop the hemoptysis because of the development of collateral circulation. The remainder of the left lung was removed. His postoperative clinical course was uneventful. Histopathological examination revealed that the hemoptysis was caused by aspergillus infection.

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A 43-year-old man developed chest pain about one year after traumatic fractures of the left clavicle and the left fourth rib. Chest X-rays showed abnormal extrapleural shadows in the left lung field. The preoperative diagnosis was pleural tumor. An intraoperative frozen section revealed no malignancy. The final pathological diagnosis was fibromatosis. The postoperative course was uneventful until recurrence after five months. Further operative excision was not attempted because total removal of the tumor wound probably cause severe dysfunction of the left arm. Megavoltage radiation therapy with a total dose of 60 Gy was administered. He is doing well without symptoms six months after radiation. The tumor in this case was thought to be related to the previous trauma.

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A 38-year-old woman visited our hospital for further examination of infiltration with cystic components seen in the right middle lung field on chest X-ray. CT scan revealed an isolated area contiguous to normal lung tissue. Bronchographic examination showed a defect of the bronchial trees in the right middle lung field and deviation of the upper and middle bronchi. Arteriography did not show an aberrant artery, but the preoperative diagnosis was intralobar pulmonary sequestration. An operation was performed. Part of S⁴ was emphysematous and was supplied by an aberrant artery (3 mm in diameter) from the thoracic aorta.
The operative diagnosis was rare intralobar pulmonary sequestration in the right middle lobe. The right middle lobe was resected.

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Hemangiopericytoma, arising from capillary pericytes, rarely occurs in the chest wall. We described here a hemangiopericytoma in the right chest wall of an 18-year-old asymptomatic woman, noted as an abnormal shadow in an X-ray film. The tumor was resected with video assisted thoracic surgery (VATS). Since pathological examinations strongly suggested hemangiopericytoma, we did a partial resection of the chest wall including the 7th and 8th ribs. There were no residual tumors in the resected chest wall. The same abnormal shadow had been seen 2 years earlier. Since the tumor had been present for 2 years without any symptoms or growth, we first considered it to be benign. This is the ninth case of hemangiopericytoma in the chest wall to be reported in Japan. Because of its rarity in the chest wall, no satisfactory analysis of this tumor has been possible. A review of the nine cases, including ours, showed that hemangiopericytoma in the chest wall occurs more often in women (8 cases), and on the right side (8 cases). Four patients were 20 years of age or younger. Chest wall hemangiopericytoma differ from those in the extremities and retroperitoneum, but because of their malignancy and frequent recurrence, extensive surgery is required.

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We report a case of intralobar pulmonary sequestration (ILS), associated with a diaphragmatic hernia, which was fed by aberrant arteries from the celiac artery. A 39-year-old female was admitted to our hospital because of an abnormal shadow in her chest X-ray film. Chest CT scan revealed a wedge-shaped shadow in the left S¹⁰ and a right diaphragmatic hernia through Morgagni's foramen. Angiography revealed an abnormal artery entering the mass in left S¹⁰ from the celiac artery. The diagnosis was pulmonary sequestration, and a left lower lobectomy was performed. Pulmonary sequestration is a congenital anomaly with a portion of the lung supplied by an anomalous systemic artery. In ILS, the arterial supply almost always originates from the thoracic aorta. ILS receiving its blood supply from the celiac artery is rare.

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A 37-year-old man was admitted to our department because of a chest X-ray showing a mass shadow about 30 mm in diameter in the right hilar area. Chest CT scan revealed enlargement of the right hilar lymphnodes. No other metastases and no primary tumor were found. Right thoracotomy was performed, and the tumor was found between the right middle and lower lobes. It was tightly adherent to both lobes, so we removed both the right middle and lower lobes with the tumor.
Histopathological diagnosis of the resected specimen was metastatic adenocarcinoma of lymphnodes #11i and #3. No primary lesion could be found. This is a very rare case of T₀N₂ M₀ lung cancer. The postoperative course has been good with no evidence of recurrence 6 months after the operation.

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A chest X-ray film of a 70-year-old male with hypertension showed a smooth round tumor shadow in the right lower lung field. The preoperative diagnosis was pericardial cyst in the midmediastinum. It was resected in April, 1991. The tumor, 5 × 4 × 3 cm in diameter and 30 gm in weight, originated from the right phrenic nerve. The histopathologic diagnosis was mediastinal neurilemmoma originating in the right phrenic nerve. Such tumors are rare, and only 13 cases have been reported in the Japanese literature.

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A 75-year-old female, who had undergone right lower lobectomy for stage I lung cancer 2 years before, developed tracheal cancer. Although the histological type was the same as the lung cancer (squamous cell carcinoma), we clinically diagnosed the tracheal tumor as a primary cancer.
The tumor was located 3 cm above the carina and extended 3.5 cm in length in the cranial direction. Because the pleural adhesion due to the previous operation was presumed, median sternotomy with a neck collar incision was employed instead of right thoracotomy. Montgomery's suprahyoid release was added to peritracheal dissection. Tracheal resection of 8 cartilage rings and end-to-end anastomosis were performed and omentopexy around the anastomotic site was added.
Although the patient died 9 months after the operation, probably due to local recurrence, tracheoplasty with resection of 8 cartilage rings was feasible for this patient with previous right lower lobectomy by utilizing the median sternotomy approach with suprahyoid release.

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Tubular resection of the aorta with vascular graft replacement was performed, under temporary bypass, in two patients with advanced lung cancer invading the thoracic aorta after neoadjuvant chemotherapy. Extended excision is discussed from the aspect of surgical technique, including shunting procedure during aortic clamping.
Case 1 : A 50-year-old male had squamous cell lung carcinoma with invasion of the trunk of the left pulmonary artery and descending aorta. Left pneumonectomy was combined with tubular excision of the descending aorta and reconstruction with a Dacron graft, during temporary bypass between the central and peripheral sides of the invasion site. Thoracotomy through the 5th intercostal space with an antero-axillary incision provided an adequate operative field. Histopathological examination showed infiltration to the adventitia of the aorta. The postoperative course was good, but the patient died from cerebral metastasis 13 months after surgery.
Case 2 : A 45-year-old male with squamous cell lung carcinoma was found to have marked invasion of the distal aortic arch at the time of thoracotomy at another hospital. Combined tubular excision of the aorta and left pneumonectomy were performed during left heart bypass with a Bio-pump an effective between the left atrium and the descending aorta. This was way to assure circulation. Although invasion of the aortic wall was strongly suspected intraoperatively, the histopathological examination revealed no invasion. This unexpected finding was attributed to the down staging following preoperative chemotherapy. The postoperative course was uneventful, and at present, 25 months postoperatively, the patient is doing well.
Safe and radical resection may be performed, with a temporary bypass, for lung cancer with marked invasion and infiltration of the aorta. The procedured described herein should be actively undertaken in suitable cases.

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