Since 1978, we routinely performed partial parietal pleurectomy at thoracotomy for spontaneous pneumothorax to prevent postoperative recurrence. Since the introduction of the thoracoscopic procedure to our service in 1992 we have made it the first choice approach in surgery for pneumothorax. Aiming at as less recurrence, as in the case of open thoracotomy, we make it a rule to carry out a partial parietal pleurectomy through the thoracoscope in addition to wedge resection of the lung.
We have operated upon 38 patients (40 thoracic cavities) to date. Pleurectomy required only 10 minutes, and caused only negligible additional bleeding, (average bleeding per entire procedure 20 ml.) One patient (one thoracic cavity) developed a postoperative recurrence of pneumothorax (2.5%). No other complication has been noted.
We consider that a partial parietal pleurectomy is easy and useful method through the thoracoscope, in the treatment of spontaneous pneumothorax.

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A questionnaire was sent to 106 patients who had undergone conventional thoracotomy or video-assisted thoracoscopic surgery (VATS) for treatment of spontaneous pneumothorax in our hospitals from January 1989 to May 1995. We received answers from 54 patients (51%). Postoperative chest pain was compared in the two groups. Sixty-four operations (32 thoracotomies, and 32 VATS) had been performed in these 54 patients, including metachronous bilateral and recurrent pneumothorax. The degree of postoperative chest pain in VATS group was significantly less than that in the thoracotomy group. Patients in the VATS group had a more favorable impression of their operative wounds than did those in the thoracotomy group. Unexpectedly, there was no difference between the two groups in the presence of chest pain 1 month after operation. It is concluded that VATS is the method of choice for the treatment of spontaneous pneumothorax.

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A preoperative value of forced expiratory volume in one second that was less than 500 ml in the contralateral lung (FEV_1c <500 ml) has been suggested to be a lower limit value for pulmonary resection. To extend surgical treatment to the patients with FEV_1c <500 ml, we carried out 16 lobectomies and 3 segmental resections and compared the morbidity of postoperative pulmonary complications and mortality with those in patients with FEV_1c 500 ml. FEV_1c was calculated by the equation; FEV_1c= (preoperative FEV_1.0) × (proportion of pulmonary perfusion in the contralateral lung) / (body surface area). Seventeen patients discharged in very good condition. However, there were lung complications in 14 patients : atelectasis (n= 8), air leak for more than three days (n=4), bronchial asthma (n=3) -Two patients died of interstitial pneumonitis or pneumonia following bronchial fistula. The morbidity of postoperative atelectasis and mortality of patients with FEV_1c <500 ml were 42.1% and 10.5%, respectively, they were significantly higher than those of patients with FEV_1c ≥_500 ml (p <0.05). Patients with atelectasis had values significantly lower FEV_1.0%, higher %TLC, and higher PaCO₂ than those without atelectasis (p<0.05). In conclusion, we could perform pulmonary resection to patients with FEV_1c <500 ml despite the higher morbidity of atelectasis and mortality. Preoperative values of FEV_1.0%, %TLC, and PaCO₂ are predictive markers for postoperative atelectasis in patients with FEV_1c <500ml.

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Between 1985 and 1993, 109 clinical stage I lung cancers were resected in our hospital. The accuracy of preoperative staging was 59.6%. The most common inconsistent factor between clinical and pathological stage was the N factor, and pm was the second. Adenocarcinomas, larger than 3 cm in diameter showed significantly high positive rates of pN and pm factors (p<0.05). The prognosis for patients with adenocarcinomas and squamous cell carcinomas larger than 3 cm in diameter was significantly poor (p<0.01). These data suggest that in T2 lung cancers, more precise diagnosis and adequate therapy are necessary. On the other hand, pN2 cases were few in peripheral T1NO lung cancers, so minimally invasive procedure is available in these cases.

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We analyzed the immunosuppressive substance (IS) derived from malignant pleural effusion of lung cancer. This IS was different in molecular weight from any other immunosuppressive matter which has been reported, and the composition of amino acid was similar to α1-acid glycoprotein (α1-AG). The IS inhibited the blastogenesis of peripheral blood mononuclear cells from patients with lung cancer. This result suggests that IS plays a crucial role in immunosuppression in the patients with lung cancer.

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Detection and clinical results of treatment for lung cancer have not been satisfactory. Between January 1, 1987, and December 31, 1994, 220 patients were admitted to our hospital for lung cancer : in 39 it was detected by chest x-ray films taken for follow-up of other diseases (other disease group), in 83 it was found in routine screening (mass screening group), and in 98 it was suspected from the symptoms (symptom group). The mean age was 69.4 years (range 61 to 79) in the other disease group, 63.3 years (range 33 to 82) in the mass screening group and 63.7 years (range 32 to 89) in the symptom group. The mean size (longest diameter) of the tumors was 3.3 cm in the other disease group and 4.5 cm in the symptom group, a significant difference. The other diseases for which chest x-rays were taken were hypertension, myocardial infarction, arrhythmia, cardiac valvular disease, deep vein thrombosis, etc.. The 5-year survival rates were 58% for the 32 in the other disease group who had pulmonary resections, 53% for the 79 with resections in the mass screening group and 41% for the symptom group. The patients in the other disease group tended to have a better outcome. We conclude that careful reading of chest x-ray films taken during follow-up examinations of patients with other diseases must be emphasized.

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We studied the effect on postoperative pain relief of continuous epidural infusion of analgesics with an infusion balloon container. Of the 46 patients undergoing thoracotomy at our hospital 24 patients (Group A) received continuous infusions of diluted buprenorphine with saline with an infusion balloon container and 22 patients (Group B) were infused every 12 hours. The average pain score in Group B was 1.79±0.24, significantly higher than that in Group A, 1.62 ± 0.19 (p =0.01). The pain score was especially higher in Group B than in Group A from morning to evening on the 2nd post-operative-day. The frequency of administration of supplemental analgesics was higher in Group B than in Group A. We conclude that continuous epidural infusion of analgesics with an infusion balloon container is more effective than intermittent infusion for postoperative pain relief after thoracic surgery.

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A 68-year-old man was referred to our department in December, 1994, with advanced squamous cell lung carcinoma. The tumor was 6 cm in diameter, and was located mainly in the right upper lobe, invading the superior vena cava with paratracheal lymphnode metastases. The clinical stage of the cancer was diagnosed as T4N2M0 ; stage IIIb. An extended operation was performed through a right posterolateral incision and muscle sparing thoractomy. After the right pulmonary veins, arteries and bronchus had been closed and cut by autosuture and the mediastinal lymphnodes had been dissected, the superior vena cava was simply clamped, and the right lung with part of the superior vena cava was removed en bloc. The defect of the superior vena cava was reconstructed with a pericardial patch. The total clamping time was 25 minutes, and the operation time was 5 hours 20 minutes. The intraoperative hemorrhage was 2, 000 ml. Facial edema was temporarily observed during the clamping. The postoperative course was uneventful. Nine months after operation the patient died of pneumonia. There had been no sings of recurrence of the cancer or obstruction of the superior vena cava.

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A 28-year-old female had an abnormal shadow in the right mediastinum on a routine chest X-ray. We performed thoracoscopic surgery, and found a cystic tumor surrounding the SVC, azygos vein, and trachea. After aspiration of the contents, we tried total removal of the cyst, but only subtotal cystectomy was possible, because the cyst wall was densely adherent to the SVC and azygos vein. Three days after the operation the abnormal shadow on her chest X-ray reappeared, and slight fever continued. We performed reoperation with thoracotomy 14 days after the first operation, with total cystectomy and ligation of the lymphatic duct. Surgery for mediastinal lymphangioma requires adequate dissection so that the lymphatic duct can be ligated securely.

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A 61-year-old male had enlarged lymph nodes in the right middle and lower lobe, upper mediastinum and left hilum, but the primary cancer could not be found. The right paratracheal pretracheal lymph nodes were especially enlarged (8cm in diameter).The lymph nodes were resected, and the histological diagnosis was metastatic adenocarcinoma. We performed right middle and lower lobectomy and RID lymph node dissection. But the histologic result of operated spesimen of the lymph nodes from the other sites were sarcoidosis. We could find no malignant lesion in the resected lung spesimen. A primary lesion was identified 18 months after the operation.

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A 62-year-old man was admitted to our hospital because of an abnormal shadow on chest X-ray film and clubbed fingers. His serum level of growth hormone was high. His chest X-ray showed a mass shadow to the right of the heart. Chest CT scan revealed an anterior mediastinal tumor with an irregular surface and no calcification. An invasive thymoma was suspected, so the tumor was resected. The tumor had invaded the pericardium and the right lung, so partial resection of the pericardium and right lung was added. The pathological examination showed poorly-differentiated squamous cell carcinoma of the thymus. After operation, growth hormone was reduced to the normal level and finger clubbing was reduced. Thymic cancers with finger clubbing are very rare, and we found only two case reports in Japan.

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A 54-year-old man with sudden onset of chest pain was admitted to our hospital because X-ray evidence of left pleural effusion. A massive left hemothorax was drained. Left thoracotomy revealed a pulmonary arteriovenous fistula projecting into the intrapleural space from the left lower lobe. Partial resection of the left lung was performed. Pulmonary arteriovenous fistula is reported frequently, but intrapleural rupture of such a fistula, usually a fatal complication, is rare. We describe here our surgical treatment of this patient and review ten such cases previously reported in Japan.

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Primary liposarcoma is one of the common soft tissue neoplasms, occurring most commonly in the lower extremities and retroperitoneum. Primary mediastinal liposarcoma is rare. In our review of the literature in Japan we found 44 reported cases. We treated a patient with primary mediastinal liposarcoma which was diagnosed histologically as myxoid type. A-58-year-old male was admitted to our hospital for further investigation and treatment of a tumor in the left upper mediastinum. Chest CT scans demonstrated a non-enhanced mass with water density in the anterior mediastinum. Resection of the tumor was performed successfully. The pathological diagnosis was myxoid liposarcoma. The patient had no additional therapy and is free of disease one year after operation. Extended surgical removal is recommended treatment, so far. The survival of patients with mediastinal liposarcoma depends on its histologic type, location, and the adequacy of surgical removal.

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A 75-year-old man presented with pulmonary infiltrates in the right upper lobe. Computed tomography of the chest confirmed these infiltrates ; no lymphnode metastasis was detected. Bronchoscopy revealed a polypoid tumor obstructing the distal right B2b bronchus. Transbronchial tumor biopsy via fiberoptic bronchoscopy revealed squamous cell carcinoma.
Right upper lobectomy was performed, with removal of mediastinal lymphnodes seen intraoperatively. A polypoid tumor was present near the entrance of right B2b. The central part of the tumor had infiltrated the inner aspect of the bronchial cartilages but remained within the bronchial wall. Unexpectedly, pretracheal lymphnode metastasis was noted, so the pathological staging was T1N2M0 stage IIIA. Postoperatively, he received chemotherapy. Seventeen months later, the patient is well with no evidence of recurrence.
We believe that mediastinal lymphnode dissection should be done even in cases of early stage hilar type lung cancer except for carcinoma in situ.

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A 17-year-old male was admitted with hemoptysis. A chest X-ray film and CT showed a cystic lesion with an air fluid level in the left lower lung field. Arteriography did not revealed aberrant artery. On 48 hospital days after conservative treatment, CT demonstrated lung tissue surrounded by abnormal visceral pleura and the bullous lesion decreased to about 3 cm in size. The preoperative diagnosis was intralobar sequestration. At the time of surgery, sequestrated lung tissue which had the same visceral pleura as the left lower lobe was revealed. Although the arterial and venous supply were from S ¹⁰, aberrant artery was not found. The sequestrated lung was resected. Our case was considered to be due to abnormal embryonic development of a lung bud and bronchus.

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A 68-year-old man was referred to our department on Sept. 6, 1994, because his chest-X-ray film showed a mass shadow (4 cm in diameter) in the right lung suspected to be primary lung cancer. His right thorax had been deformed by thoracoplasty for pulmonary tuberculosis 34 years earlier. His preoperative lung function tests were : FVC = 1, 94 l, %FVC= 58.7%, FEU_1.0 = 0.96 l, FEV_1.0% =43.4%. Arterial blood gas analysis results were : PaCO₂= 48.1 mmHg, PaO₂= 77.0 mmHg at room air. Exercise respiratory function tests were : Vo₂max = 840 ml/mm, Vco₂= 800 ml/mm, and AT (anaerobic threshold) =15.3 ml/mm/kg. Lung perfusion scanning showed different distributions (left : right = 59.1% : 40.9%). Right lower lobectomy and mediastinal lymphnode sampling were performed. Severe adhesion of the pleura was observed and made the operation difficult. The operation time was 5 hours and intraoperative hemorrhage was 2, 300 ml. Pathological examination revealed moderately differentiated adenosquamous carcinoma and a pulmonary metastasis in the same lobe. The postoperative course was uneventful.
His postoperative lung function was examined one month and ten months after the operation. There was little change one month after the operation : FVC= 1.41 l, %FVC = 42.7%, FEV_1.0 = 0.90 l, FEV_1.0% =63.8%, PaCO₂=45.5 mmHg, PaO₂= 76.4 mmHg at room air and Vo₂max= 562 ml/min, Vco₂= 555 ml/min, and AT =10.3 ml/min/kg. However, lung perfusion scanning showed a different distribution (left : right= 91.8% : 8.2%). The results of the function tests can be divided into two group. The fist group are FEV_1.0 PaCo₂, and PaO₂, which were little changed after the operation. In the second group are FVC, VO₂max, Vco₂, AT, and lung perfusion, which changed at least 20% ; the degree of change seemed to correspond to the volume of resected lung. The patient's performance status (PS) and quality of life (QOL), which were conserved after the operation, seemed to be based on FEV_1.0, PaCo₂ and PaO₂.
In this patient lung resection on the side of impaired lung function caused little change of FEV_1.0 PaCO₂ and PaO₂, so preservation of his PS and QOL was possible.

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A 19-year-old man was admitted to our hospital for treatment of pneumothorax. Chest X-ray films and chest CT scan showed left pneumothorax and pneumopericardium. A diagnosis of left partial defect of the pericardium could be made before operation, because of pneumopericardium associated with pneumothorax. Bullae were resected without repair of the pericardial defect. He has had no complaints since the operation.
Since we will occasionally see patients with congenital pericardial defect complicated by pneumothorax treated with thoracoscopic surgery, it is desirable to make the diagnosis of pericardial defect preoperatively, and perform surgery for pneumothorax and repair the pericardium under thoracoscopy at the same time.

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A 45-year-old male had received a nephrectomy for right renal cell carcinoma 5 months ago, and a chest CT demonstrated four masses in the lungs, in right S², S⁴, left S¹⁺² and S¹⁰, indicating bilateral pulmonary metastatic tumors. One-stage partial resection of both lungs was performed via thoracoscopic assisted median sternotomy. For the tumor of S¹⁰, thoracoscopic visualization was possible ; the other tumors were removed in the usual way. It could be that our first trial will help this type of operation to be performed smoothly without inducing arrhythmia, and in a single stage. The post operative course was uneventful, and he was discharged 22 days after surgery.

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A 20-year-old woman was admitted to our hospital, complaining of recurrent massive hemoptysis which was estimated to be more than 1000 ml. Her chest X-rays and computed tomography showed a ball-like consolidation within a cavity in the left upper lobe. Digital subtraction angiography (DSA) showed abnormal feeding arteries from her thyro-cervical artery and superior intercostal artery. First we performed embolization of these feeding arteries. Before hemoptysis could recur, left upper segmentectomy was performed for a preoperative diagnosis of pulmonary aspergillosis. The histological examination demonstrated a foreign body, a fragment of a chopstick, which penetrated the chest wall. We conjectured that she had been injured more than ten years earlier. She was discharged on the 11th postoperative day.

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Recently, we treated two patients with rare thymic tumors. Case 1 was a 72-year-old female, who was diagnosed as having malignant melanoma. Although metastasis from an unknown primary melanoma could not be ruled out, we suspected that is originated in the thymus, because it was a solitary tumor, no other lesions could be found, and there was no lymph node metastasis. The resected tumor measured 6.5 × 5.5 × 3.5 cm and was encapsulated. There are only two reports of malignant melanoma originating in the thymus in Japan. She is alive with no signs of recurrence 5 months after the operation. Case 2 was a 21-year-old male diagnosed as having thymolipoma without myasthenia gravis. We resected it with surrounding fat tissue. It weighted 390 g.

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