In this study, the incidence, timing, and risk factors of postoperative nocturnal hypoxemic episodic A (SpO₂ below 90% for at least 10 seconds) were evaluated by arterial hemoglobin oxygen saturation monitoring using pulse oximetry in 56 patients who underwent thoracic surgery. The mean oxgen saturation was significantly better on postoperative nights than on preoperative nights, due to oxygen administration. Despite the improved better oxygenation, hypoxemic episodic A occurred in 35 patients. No risk factors were identified. Hypoxemic episode A occurred most frequently on the third postoperative night. No patient developed severe complications, but 3 aged patients who had severe hypoxemia developed delirium. A relationship between hypoxemic episode A and delirium was suspected. Furthemore, an apnea recorder in 7 patients evaluated sleep apnea, which can cause hypoxemia. Obstructive sleep apneas were more frequent and developed into more severe hypoxemia than other types. These findings suggest the patients who have undergone thoracic surgery may need treatment in order to avoid unpredictable hypoxemia.

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Air leaks after pulmonary resections may contribute to increased patient morbidity, delayed removal of chest drainage tubes, and prolonged hospitalization. The purpose of this study was to investigate the effects and safety of a new synthetic, absorbable sealant to stop air leaks after lung resection. A total of 28 patients (26 patients were primary lung cancer cases 2 were metastatic lung cancer cases) undergoing pulmonary lobectomy, segmentectomy, wedge resec tion and/or partial resection by a thoracotomy between August and December 1999 were screened for eligibility and enrolled in the study. A surgical site was defined as any site that had been manipulated and was assumed to be at risk for air leakage, including all staple lines, suture lines, areas of dissection and adhesion lysis. Each site was inflated to pressures of 20 cm H₂O and the grade of air leaks was scored and recorded. The primer was brushed onto the target tissue, then the sealant was mixed into the primer. Visible light illumination from a xenon arc lamp was used to initiate polymerization for 40 seconds. A final submersion test was performed, and a posttreatment grade for each identified site was recorded. The evaluation of the efficacy was investigated by two outcomes: the results of sealing tests during operation and the time from operation to chest tube removal. The safety profile was determined by the frequency and severity of the adverse device effects. The application sites were 38 sites of staple lines, followed by 32 areas of adhesion lysis, 17 sites of suture lines, and 10 areas of dissection. The average number of application sites per patient was 3.2. Intraoperative air leaks from staple lines and areas of adhesion lysis were sealed in 100% of treated patients. Although 5 cases had prolonged air leaks, 3 fever, 1 pneumonia and 1 liver dysfunction, no significant side-effects related to the device application were noted. A major complication included 1 case undergoing segmentectomy resulting in an late pleuropulmonary fistula five weeks after the surgery necessitating a re-thoracotomy with pleurodesis because of persistent air leak. It was demonstrated that a new synthetic, absorbable sealant had a safety profile and clinical efficacy to seal or reduce air leaks especially from stapled lines, adhesion sites, and suture lines after lung resections.

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We assessed the use of a pleural catheter (Thoracic Vent: a small device for the treatment of simple pneumothorax) to determine its effectiveness in treating spontaneous pneumothorax for outpatient management.
Sixty-three pneumothorax patients were treated using a thoracic vent in a 12 month period at our hospital. There were 54 men and 9 women with a mean age of 31.9 years (range, 16 to 76 years). Forty-two patients were first pneumothorax, and 21 were recurrent pneumothorax. Outpatient treatment was successful in 30 cases (71.4 %) of 42 first pneumothorax patients. Four patients were hospitalized on the first day because of massive air leakage in 2, and initial cases in 2. The other 8 patients were hospitalized and underwent thoracoscopic surgery because of persistent air leakage in 6, giant bulla in 1, and a history of contralateral pneumoth orax in 1. Our indication for operation is persistent air leakage (7 days or more) and recurrent pneumothorax. Eighteen of 21 recurrent pneumothorax patients underwent operation, the majority of whom were treated using thoracic vent as outpatients until admission. In the present series, outpatient management saved a total of 291 inpatient days.
Continuous suction of the thoracic vent was needed in 4 patients, 2 of whom required second drainage tubes because of obstruction by pleural effusion in one and massive air leakage in the other. No kinks in the catheter or accidental removal of the thoracic vent were encountered. No serious complications occurred, except for mild reexpansive pulmonary edema in one case.
The thoracic vent is useful in the outpatient management of spontaneous pneumothorax.

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Recently, the number of patients with lung cancer and pulmonary mycobacteriosis has been increasing. Over the last 10 years, we operated on 10 patients with lung cancer and active pulmonary mycobacteriosis, including atypical mycobacteriosis, at Toneyama National Hospital. All cases were male, with a mean age of 61 years. All of them had a history of smoking. Histological types of lung cancer were squamous cell carcinoma in 7 cases and adenocarcinoma in 3 cases. Clinical stages were stage IA in 4 cases, stage IB in 2 cases, stage IIB in 1 case and stage IIIA in 3 cases. Either before or after the operation, 4 cases had multiple primary cancers. In all cases, the operation was performed after adequate chemotherapy for pulmonary mycobacteriosis. The operative procedure was lobectomy in 7 cases, lobectomy and chest wall resection in 1 case, pneumonectomy in 1 case, and partial resection in 1 case. In the postoper ative period, no recurrence of pulmonary mycobacteriosis was found.
It is reported that lung cancer is more frequent among patients with pulmonary mycobacteriosis than healty individuals; thus, patients with pulmonary mycobacteriosis must be carefully followed up.

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We report a mediastinal germ cell tumor in a 10-year-old boy with Klinefelter's syndrome. An anterior mediastinal tumor was diagnosed in another hospital and referred to our department. Chest CT scan revealed a 10 cm-anterior mediastinal mass invading the pericardium. After percutaneous needle biopsy, a mature teratoma was diagnosed. There was no evidence of metastasis. Genetic analysis, interestingly, showed Klinefelter's syndrome (47XXY). The levels of serum AFP, hCG and hCG-β were high, 289ng/ml, 1, 150mIU/ml and hCG-β 7.90ng /ml respectively. Because the malignant component was highly suggested, three courses of preoperative chemotherapy with CDDP, VP-16 and Bleomycin (PEB) were performed. After chemotherapy, the serum levels of tumor markers fell to within normal limits . We performed a resection of the tumor with median sternotomy on September 9, 1998. There was neither invasion nor adhesion to surrounding organs and complete resection was possible . His postoperative course was uneventful. Pathological findings revealed a mature teratoma with placental site trophoblast. Therefore germ cell tumor, combined type was finally diagnosed. Additional six courses of postoperative chemotherapy were performed and he has been on follow-up in outpatient clinic. There was no sign of recurrence and metastasis . Several articles have reported that Klinefelter's syndrome is present in 20% of patients with medias tinal germ cell tumor and the reported incidence of germ cell tumor in Klinefelter's syndrome patients is 1.5/1, 000, which represents a 50-fold higher level than for the general population. The pathogenesis has been suggested to be related to the genetic abnormality and the abnormal hormonal status in Klinefelter's syndrome.

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A 46-year-old woman was admitted due to abnormal results on annual medical examination. There was no pulmonary marking observed in the left thorax and the mediastinum was deviated to the right. Surgery disclosed that a giant bulla arising from S⁶ occupied the left thorax. After the giant bulla was extirpated, the left lung re-expanded immediately . After surgery, respiration became easier and the results of respiratory function tests immproved . As the bulla had been demonstrated for ten years, it is considered that the atelectasis had been developing for long time as well. It is noteworthy that respiratory function was improved by releasing the lung from long term atelectasis.

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A 69-year-old man underwent distal gastrectomy for early gastric cancer and left upper lobectomy for adenocarcinoma of the left lung about three years ago. An abnormal shadow in the middle field of the right lung was noted on a chest X-ray. We suspected a malignant tumor, and right lower lobectomy was performed. The histological diagnosis was primary pulmonary leiomyosarcoma. Thirty-two days after the operation, he underwent total gastrectomy for cancer of the residual stomach. A case of quadruple cancer involving lung cancer and primary pulmonary leiomyosarcoma has not previously been reported. This case is rare and therefore we report it together with some comments on the literature.

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Extramedullary plasmacytomas are rare neoplasms in plasma cell tumors and occur mainly in the upper respiratory tract or oral cavity. The occurrence localized in the mediastinum is extremely rare, and no occurrences in the thymus have been reported. In this paper, we report an extramedullary plasmacytoma probably arising from the thymus.
A 63-year-old man consulted our hospital due to an anterior mediastinal tumor revealed on chest X-rays and CT scan. Histologically, a specimen taken by percutaneus needle biopsy suggested thymic carcinoid. A total resection of the thymic tumor was performed in September 1999. The tumor was almost encapusulated, occupied the whole thymus, and protruded into the left pleural cavity through the left mediastinal pleura. The chest wall, the great vessels, and the left phrenic nerve were not involved. A small amount of pleral fluid was found, and cytological examination suggested plasmacytoma.
Histpathological findings revealed plasmacytoma producting monoclonal IgG kappa in immunohistochemical staining.
Although bone marrow aspiration was not performed because of the patient's refusal postoperatively, neither M-protein in the serum nor Bence-Jones protein in the urine were found, and bone roentogenogram and scintigram showed no pathological findings.
At 10 months after the surgery, the patient remains well, and there is no evidence of recurrence and development into multiple myeloma.

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A 48-year-old man was admitted due to an abnormal chest shadow, accompanied by left adrenal tumor. Chest x-ray and chest CT revealed a peripheral large mass shadow in the right upper lobe invading the chest wall. Right-upper lobectomy combined chest-wall resection was performed, and pathological examination confirmed poorly differentiated adenocarcinoma (p-T3N0M1, Stage IV). Postoperatively, value of serum CEA decreased, but then gradually increased and four years 10 months later, the left-adrenal tumor showed necrotic change with high CEA value, and Laparoscopic It adrenalectomy was performed. The tumor was 5×3.5×2 cm in size and was similar to the previous lung cancer histologically, so it was diagnosed as metastatic adenocarcinoma. This case suggests that synchronism between lung cancer and solitary adrenal metastasis does not necessarily represent an unfavorable prognostic factor. In selected cases, resecton of metastatic adrenal tumor can obtain long-term survival.

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A surgical case of solitary fibrous tumor of the pleura (SFT) which recurred 12 years after the initial operation is herein reported. The patient was a 74-year-old man with a chief complaint of abnormal finding on chest X-ray examination. In 1988 he received resection of benign pediculate type of SFT, measuring 4.6 cm in the maximum diameter in the right lung S². Although his postoperative course was good, recurrence of SFT was found in 2000. The recurrent tumors were resected under thoracoscopy. They were two pediculate tumors, measuring 4.8 cm in the maximum diameter from the pleura of the right diaphragm, measuring 0.8 cm in the maximum diameter from the pleura of the right S¹⁰, respectively.
Histopathological examination showed that both tumors were benign SFT and similar to the findings on the previously resected specimen. Accordingly, this case was definitely diagnosed as recurrent SFT. It is concluded that even though histological examination on SFT shows no malignancy, patients should be followed up with long-term chest X-ray examination and that total resection of recurrent tumor should be performed in the early stage . In addition, dynamic CT and dynamic MRI are useful in the diagnosis and treatment of SFT.

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Two rare cases of ACTH-producing thymic carcinoid are reported. [Case 1] A 29-year old male was admitted because of an anterior mediastinal tumor in July 1991. He had undergone parathyroidectomy due to hyperparathyroidism 10 months before admission. Blood chemistry revealed high levels of ACTH, cortisol, prolactin, and parathyroid hormone and a low level of potassium. Extended thymectomy was performed and the histology of resected tumor was thymic carcinoid. Final diagnosis was ACTH-producing thymic carcinoid with multiple endocrine neoplasia. Adjuvant radiation and chemotherapy were performed. The tumor recurred in May 1997 and chemotherapy was administered. The patient is still alive as of Aug. 2000. [Case2] A 28-year old male exhibiting dyspnea and chest pain. Chest roentgenogram and CT showed a tumor shadow in the left middle mediastinum. Blood chemistry revealed a high level of ACTH and a low level of potassium. Histology of the resected tumor was thymic carcinoid. Adjuvant radiation and chemotherapy were performed. The 20 previously reported cases of ACTH-producing thymic carcinoid in Japan are discussed, together with our 2 cases.

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