The aim of this study was to evaluate the comparability of simple lateral thoracotomy with video-assisted thoracoscopic surgery (VATS) in lobectomy for clinical T1N0 lung carcinoma. Between June 1997 and September 1998, 52 patients with lung carcinoma underwent lobectomy and systemic mediastinal lymph node dissection ; 22 by VATS without rib spreading (VATS group) and remaining 30 through a simple lateral thoracotomy with rib spreading (lateral thoracotomy group). Although the length of minithoracotomy was significantly longer in the lateral thoracotomy group (VATS group, 6.2 cm ; lateral thoracotomy group, 9.7 cm ; p<0. 0001), no significant differences were found between the two groups in terms of the intraoperative blood loss (VATS group, 35.2 g ; lateral thoracotomy group, 32.5 g ; n. s.) or the operative time (VATS group, 177.3 min ; lateral thoracotomy group, 166.6 min ; n. s.). There were no differences between the two groups in duration of chest tube drainage (VATS group, 3.7 days ; lateral thoracotomy group, 4.1 days ; n. s.) and length of postoperative hospitalization (VATS group, 9.1 days ; lateral thoracotomy group, 9.7 days ; n. s.). Lobectomy via a simple lateral thoracotomy with rib spreading had no disadvantages in increased length of postoperative hospitalization and so on, when compared with thoracoscopic lobectomy. Simple lateral thoracotomy should be considered as a minimally invasive approach, because it is comparable with VATS.

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Between January 1996 and August 1998, bilateral one-stage procedure under video-assisted thoracoscopic surgery was performed for 16 patients with unilateral spontaneous pneumothorax, because bullae and blebs of the lung, the cause of this disease, are frequently present bilaterally. We compared patients (Bilateral group ; 16 cases) undergoing bilateral one-stage procedure and patients (Unilateral group ; 30 cases) undergoing unilateral procedure for unilateral spontaneous pneumothorax.
(1) Surgical stress : Duration of operation time and postoperative chest drainage of the Bilateral group were significantly longer than the Unilateral group, but duration of postoperative hospital stay and postoperative max CRP in the blood in the two groups were equal.
(2) Recurrence : There have been two recurrences of pneumothorax in the Unilateral group, but 5 cases of lung recollapse without drainage treatment in the early postoperative phase.
(3) Cost : These total costs of all treatment for pneumothorax in the Bilateral group were higher than those in the Unilateral group, but increasing costs in the Bilateral group were equal to the cost of operation in the contralateral side. Therefore, it has been concluded that bilateral simultaneous operation for unilateral spontaneous pneumothorax should be applied to these younger patients, with roentgenographic evidence of contralateral bullae.

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This is a report on 9 patients who underwent thoracoscopic resection of paravertebral neurogenic tumor between January 1993 and December 1997. There were 5 males and 4 females ; the average age was 39.8 years. Four of nine tumors were located in upper paravertebral, five in lower vertebral. One tumor was dumbbell type. The resected tumors averaged 4.4 cm in their greatest diameter. The average operative time was 141 minutes. Three or four trocars were needed in each case. Blood loss during operation was a little except for the dumbbell type tumor. The thoracic drains were removed after an average of 4.6 days and the average hospital stay was 10.2 days. A complication developed in two patients. one with pleural effusion and one with postoperative transient sensory disturbance of forearm. Blood loss during thoracoscopic operation was significantly less than standard thoracotomy and postoperative hospital stay was significantly shorter.
Thoracoscopic resection of paravertebral benign neurogenic tumor is safe and minimally invasive. We can operate under good visualization, even in such cases which are usually difficult to approach.

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The present study was undertaken to clarify the effectiveness of new ET-Kyoto (nET) solution developed for long-term lung preservation by investigating ultrastructural damage in lungs preserved for 30 hours.
Pairs of size-matched adult mongrel dogs were assigned randomly to three groups. In group A (n = 7) lungs were flushed with nET, in group B (n=6) with University of Wisconsin (UW) solution, and in group C (n=6) with Low-Potassium-Dextran-Glucose (LPDG) solution. Lungs were flushed with each solution after vascular dilation with PGE₁ and stored at 4°C for 30 hours.
Ultrastructural damage of endothelial cells in small pulmonary artery (PA), namely protrusion of endothelial cells into vascular cavity, vacuolization, cellular destruction, detachment of endothelial cells from the basal lamina, rupture of the basal lamina, villi formation of the cell surface, and subendothelial structure destruction, were examined. For examination of alveolus, ultrastructural damage of the capillary endothelial cells (vacuolization, cellular destruction, detachment of the endothelial cells and villi formation), that of type I pneumocytes (vacuolization, cellular destruction, detachment and villi formation), and destruction of alveolar interstitium, were examined. Presence of blood cells and the debris of destroyed cells in the capillary space were also examined.
Left single lung transplantation was performed, and arterial blood gas analysis was recorded every one hour until 6 hours after reperfusion. After sacrifice, transplanted lungs were excised and dried for evaluation of the wet to dry ratio (W/D).
The frequency of cellular vacuolization in small PA evaluated as severe or moderate in group A (5.71±3.1%) tended to be lower than that in group B (24.4±7.4%) (p=0.053). The frequency of villi formation in small PA endothelial cells evaluated as severe in group A and B (2.85±2.0%, 3.33±2.3% respectively) was significant lower than that in group C (12.2 ±2.1%) (p = 0.0072, 0.016 respectively). The frequency of subendothelial structure destruction in small PA evaluated as moderate or severe in group B (52.2±6.1%) was significantly lower that in group A (80.0±6.0%) (p = 0.0088). The frequency of cellular destruction of capillary endothelial cells evaluated mild or severe in group C (22.2±2.8%) was significantly lower, and that in group A (34.2±6.9%) tended to be lower than that in group B (53.3±4.2%) (p= 0.0088, 0.063 respectively). The frequency of villi formation of capillary endothelial cells evaluated severe in group B (2.22±1.4%) was significantly lower than that in group C (14.4±3.2%) and tended to be lower than that in group A (10.5±3.5%) (p=0.0098, 0.086 respectively). The frequency of cellular vacuolization of type I pneumocytes evaluated as mild or severe in group A and C (20.0±2.9%, 27.8±4.0% respectively) was significantly lower that in group B (47.8±6.8%) (p =0.0069, 0.034 respectively). The frequency of existence of debris in the capillary space in group A (25.7±3.1%) was significantly lower than that in group C (47.7±6.5%) (p=0.019).
All animals in group A survived until the final assessment. In group B, four animals died by 6 hours after reperfusion and one animal in group C. Survival rate in group A was significantly higher than that in group B, and that in group C tended to be higher than that in group B. Pao₂ values in group A were significantly higher than those in group B until 3 hour-reperfusion and significantly higher than those in group B until 6 hour-reperfusion. The W/D of the transplanted lung in group A was significantly lower than those in groups B and C. These physiological results after reperfusion were compatible with the results of the examination of ultrastructural damage.

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A 75-year-old female with postoperative multiple recurrence of pulmonary sclerosing hemangioma was reported. Enucleation was performed for pulmonary sclerosing hemangioma of the left lower lobe in 1992. About 4 years after the operation, chest X-ray showed multiple nodular lesions in the left lung field. Bronchoscopic cytology revealed the diagnosis of sclerosing hemangioma from one of the nodules, and we made a diagnosis of intrathoracic multiple recurrence of the sclerosing hemangioma. In general, the operative procedure for pulmonary sclerosing hemangioma is thought to be sufficient by the enucleation of the tumor. However, considering reports of local recurrence and our case, further resection such as partial resection with secure margin or segmentectomy and lymph node sampling may be necessary for this condition.

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A-63-year-old man had enlarged lymph nodes (3.5 cm in diameter) in the right hilum, but no primary carcinoma could be found. We performed R2 lymph node dissection and bullectomy. The histological diagnosis was metastatic squamous cell carcinoma. However no primary lesion was identified. Thirty-four months after the operation, the mass was appeared in the middle lung field in the chest x-ray. Tumor was appeared B² bronchus by the bronchoscopy. It was suspected that the mass was invaded the basal bronchus and pulmonary artery. We performed right pneumonectomy. The postoperative course has been good with no evidence of recurrence 12 months after the second operation.

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We report a case of pulmonary blastoma treated by tracheo-bronchoplasty using PCPS. A 69-year-old female was hospitalized because of cough and dyspnea. A polypoid tumor projecting from the right main stem bronchus was revealed. Before surgery the tumor was pulled down to the trachea, which resulted in obstruction of the airway. A Dumon stent was placed to maintain the airway temporarily. Thereafter, right sleeve pneumonectomy was performed as radical surgery. Because of PCPS the procedure could be done safely. The pathological diagnosis was pulmonary blastoma. We consider PCPS to be an effective respiratory support system for tracheo-bronchoplasty.

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We report a rare case of cavernous hemangioma of the lung. A 36-year-old woman was admitted to our hospital for an abnormal shadow on chest roentgenogram. She had no symptoms. Chest roentgenogram showed a small nodular shadow in the left lower lung field. Computed tomogram of the chest demonstrated a nodular shadow in contact with the chest wall at the lingula. Pulmonary arteriogram showed no abnormal findings. Operation was performed with thoracoscopic techniques. An elastic soft mass was found in the lingula. It bulged under the visceral pleura. The tumor was round and had no definite capsules. Microscopic examination revealed a cavernous hemangiomatous pattern. Most cells lining the lumens of the cavernous structure stained positively for anti-CD 34 antigen.

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The case was a 62-year-old male, whose chief complaint was pain in his back behind his chest which gradually worsened from August 1996. Introduction to this hospital was on October 1st, of the following year. A large tumor shadow was recognized in the left middle to lower area of the lung by a chest X-ray. Also by a CT scan of the chest, in the same location as with the X-ray, a sharp shadow of a large tumor was recognized. Although it was suspected as being a worsening case of pyothorax or a tumor within the thorax, diagnosis was not confirmed, but on October 20, 1997, the extra-pleural pneumonectomy was made to diagnose as well as treat the case. According to the postoperative pathologic diagnosis, it was a case of psoriasis pyothorax caused by tuberculous pleurisy. This case had taken 42 years, an extremely long time to manifest with symptoms, as well as having had tuberculous pleurisy in his medical history. It is also similar with results obtained for CEH tests. When CEH becomes chronical, symptoms become noticeable. Pathologically, bleeding lesions were not recognized in this case, but clinical indications were that it was a special type of CEH.

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We operated on two patients with pneumothorax and collected bulla specimens. The resected specimens were histopathologically examined and Aspergillus was detected in the thickened walls of the bullae. These two cases are discussed in the present study.
Case 1 : The patient was a 48-year-old male who was hospitalized because of left pneumothorax. Continuous drainage failed to improve the symptoms and surgery was indicated. Bullae at the apex of the lung were resected, and Aspergillus was detected inside the wall.
Case 2 : The patient was a 46-year-old male. He presented to this department with a complaint of right chest pain. A film of the chest revealed right pneumothorax and bilateral cysts, and the removal of the right cysts was indicated. The resected specimen was histopathologically examined and the presence of Aspergillus in the subpleural space was confirmed.
Pulmonary aspergillosis is generally a problem in patients with pulmonary tuberculosis and suppuration and immunocompromised hosts who have been placed on anticancer or steroid therapy. In the present study, however, Aspergillus was detected in two cases of pneumothorax without underlying disease.
We experienced two cases of pneumothorax complicated with Aspergillus infection. During surgery for pneumothorax, the bulla specimens were collected for the histopathological examination. We reported these two rare cases because Aspergillus was detected inside the walls of the bullae.

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A patient is described in whom a right -sided cardiac herniation occurred through a pericardial defect following right radical pneumonectomy. A 64-year-old man was referred to our institute in 1997 because of dry cough and low grade fever. An intrapericardial right pneumonectomy for a moderately differentiated squamous cell carcinoma was performed. The pericardial defect was closed directly with interrupted sutures. Postoperative course was stable and no clinical symptoms were noted, but 15 hours after the operation, cardiac herniation occurred suddenly with hypotension, arrhythmia and cardiac arrest. Chest X-ray revealed cardiac herniation into the right hemithorax and was repaired with a Marlex-mesh patch immediately. Electrocardiogram and 20iT1 myocardial scintigram revealed inferior myocardial infarction caused by right coronary artery torsion. Cardiac herniation after pneumonectomy is a fatal complications. In our patient, immediate thoracotomy before irreversible myocardial damage resulted in a successful outcome.

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Malignant lymphoma developing from chest wall is believed to be closely related to chronic tuberculosis pyothorax or EB virus infection. Furthermore, this tumor believed to have a poor prognosis compared to other lymphomas. We experienced a case of B cell malignant lymphoma on the left side chest-wall without history of tuberculosis or empyema. EBNA antibody and IgG-type VCA antibody were negative. The tumor invaded the abdominal wall and diaphragma but riot the parietal pleura. Then surgical dissection encompassing the thoraco-abdominal wall and partial diaphragma was performed. Tumor dissected completely at pathological examination. The patient is alive, and there was no evidence of recurrence in the thirty-month follow-up examination. We report a rare case without pyothorax and EB virus infection and good outcome.

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A 1-year, 9-month-old boy was admitted to the hospital because of kerosene ingestion. He developed a left-sided empyema following focal pneumonia. Thoracoscope-assisted debridement with 6 cm mini-thoracotomy was successfully performed under general anesthesia. Fibrinopurulent space with loculations was resolved through adhesiolysis, debridement and irrigation of all inflammatory debris. Furthermore, use of the Ultrasonic Surgical Unit (USU, Olympus) facilitate more effective thoracoscopic debridement. Postoperative pleural drainage was continued with two chest tubes, and lung expansion promptly recovered. Thoracoscope-assisted debridement for acute empyema in children is safe and efficient treatment like in adult cases.

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We presented a case of aneurysmal bone cyst arising from the rib. A 41-year-old man consulted our hospital because of an abnormal shadow on chest X ray. Chest X-ray on bone image revealed a balloon-like expansion of the 4th rib. Chest CT revealed a low density tumor surrounded by a thin bony shell. We performed a posterolateral thoracotomy and removed the tumor and the adjacent segments of 3rd, 4th and 5th ribs en bloc. Histological findings showed multiple cysts filled with blood and fibrous trabeculae, confirming the diagnosis of aneurysmal bone cyst.
There has been no evidence of recurrence during the 3 months since operation.

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A 58-year old woman was admitted to our hospital with right chest wall swelling. She had a history of extra pleural plombage for pulmonary tuberculosis at age 34 years. Chest roentgenography showed a huge mass shadow in the right superior pleural space. Chest computed tomography and magnetic resonance imaging revealed that the mass occupied the right superior pleural space to the axillary subcutaneous region, and #1-#5th rib erosion. Angiography showed extravasation of the contrast material. Ligation and embolization of the hemorrhagic artery were performed. Hematoma dissection and open window thoracostomy were also performed. Pathological diagnosis was not a malignancy but a chronic hemorrhagic pyothorax. Omentopexy for broncho pleural fistula was performed after open window thoracostomy and drainage. Surgery alone can improve symptoms of chronic hemorrhagic pyothorax, despite potential complications such as massive bleeding. Ligation or embolization of the hemorrhagic artery was effective, therefore it is an essential procedure for chronic hemorrhagic pyothorax.

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We report a successful case of bilateral thoracoscopic sympathectomy on a 46-year-old man suffering from severe coldness and numbness on his upper extremities caused by Buerger's disease. Under general anaesthesia, three ports were inserted through the third to fifth intercostal space, and sympathectomy was completed by resection of the second to fourth thoracic sympathetic ganglia. Immediately after the operation, his complaints markedly diminished ; six weeks after the operation, he obtained complete relief of the numbness and coldness, and the finger ulceration of fingers healed. Increase of the peripheral circulation of each finger assessed with a laser Doppler velocimeter (LDV) was well associated with the relief from his complaints. We concluded that LDV is a useful tool for the assessment of surgical treatment in patients with Buerger's disease.

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A 66-year-old woman was admitted for further examination of cough and a tumorous shadow on her chest X-ray film. Her chest X-ray and CT films showed a tumorous lesion in S3 segment of the right upper lobe. Right upper lobectomy was carried out because the intraoperative pathological diagnosis was carcinoma. Final pathological diagnosis was acinic cell tumor of the lung. Furthermore we found a tumor locating near the right parotid gland. The tumor was resected and its pathological findings showed the same histology as the tumor of the lung. We considered that the tumor of the lung was metastatic acinic cell tumor from the one which originated from an ectopic parotid gland. The patient is free of tumor 3 years after resection of both tumors. Acinic cell tumor clinically behaves as a low-grade malignancy, showing indolent growth pattern, but occasionally metastasize to other organs after several years. Diligent long-term follow-up is important to the patient with acinic cell tumors in multiple sites.

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The patient, a fifty-nine year old female, was hit in the right hypochondorium by a traffic accident and transported to our hospital. The initial chest X-ray and CT scans revealed right multiple rib fractures and traumatic pneumohemothorax. After the chest tube drainage, clinical and radiological findings were improved, but on the next day they were worsened again. Though an additional drainage tube was inserted, her condition did not improve. Operation was performed with a diagnosis of right traumatic pneumohemothorax on the fourth day after the accident. On thoracotomy, the right diaphragm was torn about 10 cm in diameter and the liver was lifted up into the thoracic cavity. After the liver restored, the tear of the diaphragm was sutured. Postoperative course was uneventful. Diaphragmatic hernia by blunt trauma is occasionally seen as one of multiple life-threaten injuries. We should consider the possibility of delayed presentation like our case, and careful observation of the clinical course is needed. The thoracoscope might be helpful in the cases which diaphragmatic hernia is suspected and a radiological diagnosis is difficult to make.

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A case of benign Schwannoma arising in the brachial plexus with intrathoracic extension was presented. The patient was a 43-year-old man, who was pointed out an abnormal shadow in the right apical region on routine chest X-ray examination. MRI showed that the mass extended to the lowest trunk of the brachial plexus. He had no complaint. A benign mediastinal tumor was suspected, but we could not make a final diagnosis. Therefore, a diagnostic operation was performed. The tumor was round and composed of many cysts. Histopathological examination revealed a schwannoma (Antoni type A).

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A 56-year-old woman, who had been followed up for an abnormal shadow in the hilar region of the right lung since the age of 51 years, was admitted for glaucoma caused by ocular sarcoidosis. Blood chemistry data were unremarkable except for elevated levels of angiotensine converting enzyme (26.0 IU/L) and lysozyme (14.3 μg/ml). CT scan showed a well-defined mass about 3 cm in diameter in the right S⁵ region, a nodule with pleural indentation about 1.5 cm in diameter in the peripheral region of the left S³, and multiple mediastinal lymph node swellings. Positron emission tomography showed a high uptake in the left nodule, but not in the right mass. Since a definite diagnosis could not be obtained by fiberoptic bronchoscopy and needle biopsy under CT scan, open chest biopsy was performed and the diagnoses of adenocarcinoma in the left S3 and sclerosing hemangioma in the right S⁵ were made by frozen sections. And then tumor resection of the right lung and left upper lobectomy were performed. Multiple nodules about 2 3 mm in diameter on the surface of the bilateral lungs, which were diagnosed as sarcoid-nodules by frozen section, were also found. We finally made a pathological diagnosis of adenocarcinoma (T1N0M0) with sclerosing hemangioma and pulmonary sarcoidosis. The postoperative course was uneventful with hospital discharge on day 15.

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