Although video-assisted thoracic surgery (VATS) for primary spontaneous pneumothorax is a very common procedure, the incidence of recurrence is reported to be higher with the use of VATS than for thoracotomy. The reason for the higher rate of recurrence remains to be elucidated and some adjunctive procedures such as parietal pleurectomy, apical covering with absorbable material sheet and the use of fibrin glue spray have been recommended.
Previously, when bullectomy was performed via thoracotomy, suturing was commonly used without staplers. However, recently VATS bullectomies are generally performed with staplers. In this study we investigated the outcome of VATS bullectomy without staplers, with suturing only or with suturing and abrasion.
From 1997 to 2000, 28 VATS with suturing of absorbable material suture without staplers (group A) and 36 VATS with staplers (group B) were performed for primary spontaneous pneumothoraces in patients aged under 50 years old. Operation time, postoperative drainage period, postoperative hospital stay, postoperative recurrence (over one year or more) were retrospectively compared. Since group A and B were not randomized, group A tended to include a smaller number of small bullae compared to group B, which tended to include a larger number of bullae or large bulla.
In 28 patients in group A, no recurrence was noted after 1 year. Suturing only without the use of other adjunctive techniques, drugs, materials, or staplers provided good results. In conclusion, we recommend VATS bullectomy without staplers with suturing in patients with a small number of small bullae in consideration of surgical quality and costeffectiveness.

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Indications of video-assisted thoracoscopic surgery were investigated in 67 patients with thymoma who were treated by thoracotomy procedures. Thirty of 34 patients whose disease was localized in the thymus had non -invasive thymoma pathologically. Four of 33 patients who underwent combined resection of other organs had lymph node metastases. One of 10 patients who were treated by thymomectomy had local recurrence. Two of four patients who had disseminations are alive 5 years and more after total resection of the disseminations. We concluded that video-assisted thoracoscopic thymo-thymectomy could be considered in cases of noninvasive thymoma diagnosed clinically and thoracoscopically, and enbloc resection of the thymus without exposure of the tumor is essential. When evidence of invasive thymoma or dissemination intraoperatively is clearly presented, video-assisted thoracoscopic surgery should be converted to open-thoracotomy.

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We performed pleural lavage cytology (PLC) during thoracotomy in 156 patients assessed as D0E0 among patients undergoing resection of primary non-small cell lung cancer to determine the clinical significance of cytological findings of lavage fluid. Eleven patients (7.1%) were found to be PLC-positive. The histological type of the PLC-positive cases was most often adenocarcinoma, in 8 of 11 positive patients (72.7%). Six of the 11 patients were in stage I and 5 were in stage II or higher. There were significantly more PLC-positive cases among patients with pleural infiltration and those with vascular invasion, but there was no correlation between PLC-positivity and lymphatic invasion or lymph node metastasis. The five-year survival rate was 22.7% for PLC-positive cases and 55.8% for PLC-negative cases, exhibiting a significant difference. The five-year survival rate was significantly different between the positive group, at 33.3% and the negative group, at 72.4%, in stage I, but there was no significant difference observed between the positive and negative groups in stage II or above. Pleural recurrence was found in 2 of 8 PLC-positive cases and 20 of 52 negative cases. These results suggest that PLC-positivity indicates a poor prognosis and is an important prognostic factor, particularly in stage I. PLC-positivity suggests systemic microscopic metastases rather than local infiltration of cancer.

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Surgical management of patients with concomitant resectable lung lesions and critical ischemic heart disease is controversial . From 1987 to 1998, 22 lung cancer patients with severe ischemic heart disease underwent combined resections or PTCA before lung resection at our department. Some of these patients were difficult to treat by coronary intervention and we investigated the usefulness of intra-aortic balloon pumping (IABP) for these patients. In lung cancer patients who undergo surgical resection, left main trunk (LMT) disease, unstable angina pectoris and low ejection fraction (less than 30-40%) are indications for scheduled IABP, and of our 4 patients, 4 men with a mean age of 61 years (range 55-68) matched this criteria. Histologically, the diagnosis was adenocarcinoma in 2 patients and squamous cell carcinoma in 2 patients. Pulmonary resection included lobectomy in 2 patients and partial resection in the other 2. There was no procedure-related morbidity. We consider that scheduled IABP is useful for lung cancer patients with severe ischemic heart disease.

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The purpose of present study was to evaluate the usefulness of Hand-Assisted Thoracoscopic Surgery (HATS), an endoscopic surgical technique with palpation in which an operator inserts one hand from the subxyphoid portion to mediastinum or thoracic cavity. We used HATS to avoid standard sternotomy or thoracotomy in converting an approach from conventional endoscopic surgery in which only forceps are used. HATS was attempted in 26 patients, 12 males and 14 females. The mean age was 58.1 years old (range 37-76). HATS was used in 12 patients undergoing lung and 10 patients undergoing mediastinal surgery. The mean operation times for 11 cases of partial resection of the lung and 6 cases of mediastinal cystectomy were 88 and 137 minutes, respectively. A case of right middle lobectomy and 4 cases of extended thymectomy could be completed with HATS. Surgical manipulation was safer and more stable in HATS than in conventional endoscopic surgery. Based on these results, we considered that HATS was a useful option to which a surgical approach was converted from conventional endoscopic surgery. An appropriate indication for HATS includes a partial resection of the lung for peripheral pulmonary lesions and a resection of mediastinal tumor and cyst. On the other hand, careful preoperative evaluation is necessary when considering HATS, because a further conversion from HATS to standard sternotomy or thoracotomy was required in some cases due to complications such as pleural adhesion or bleeding from the left innominate vein.

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We report two patients with severe pneumonia and empyema due to penicillin resistant Spreptococcus pneumoniae (PRSP). Both patients had been previously healthy, were not immune compromised, had normal life styles, and were not hospitalized at the time of infection. The first patient was a 34-year-old man with right pyothorax due to PRSP infection. We performed surgical debridement and closed chest tube drainage under video-assisted technique. Using the two tubes placed in the empyema cavity, we continuously irrigated this space with saline containing vancomycin (VCM). We also administered VCM intravenously. After 7 days, pleural discharge reduced to less than 20ml, and the drainage tube was removed 14 days later. The second patient was a 62-year-old man, who was treated using the same protocol described above, however, further empyema developed, and the open-window-thoracotomy was required for complete cure.

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A solitary, sharply defined, 1.5cm diameter nodular shadow in the upper lobe was detected on the chest X-ray film of a 62-year-old woman who had undergone a thyroidectomy for a papillary thyroid cancer 12 years earlier. The tumor was suspectd to be a benign tumor or inflamatory nodule because it was a well defined round nodule on the chest-CT films. Open thoracotomy was performed. Intraoperative aspiration cytologic examination showed a papillary carcinoma with nuclear cytoplsmic inclusions and then a right upper lobectomy was performed. Immunoperoxidase stain for thyroglobulin was positive in the tumor cells. The tumor was histologically diagnosed as a solitary pulmonary metastasis from thyroid cancer. We report this unique case of surgical treatment for a solitary pulmonary metastasis from thyroid cancer with a review of literatures.

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A 19-year-old woman, with a past history of blood sputum, was admitted to our hospital with hemoptysis. Bronchoscopic examination revealed blood clot and endobronchial protrusion with pulsation in the orifice of the middle lobe bronchus. Arteriography showed dilated and convoluted right bronchial artery deriving from the thoracic aorta. Racemous hemangioma of bronchial artery was diagnosed and open thoracic ligation of the bronchial artery was performed. However, hemoptysis recurred three and half years postoperatively. At recurrence, arterio-graphy revealed the remaining right bronchial artery deriving from the thoracic aorta and another dilated and convoluted right bronchial artery deriving from the right subclavicular artery. Embolization using metallic coils was performed in each of the bronchial arteries. Hemoptysis has not recurred for three years after the embolization.

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A 29-year-old female was admitted to our hospital to investigate recurrent respiratory infection. Chest radiography and CT revealed multiple cystic lesions in the left lower lobe. Bronchofiberscopic findings demonstrated a normal bronchial tree. Although the cystic lesions seemed clinically connected to the normal bronchial tree, she was diagnosed with pulmonary sequestration due to an aberrant artery originating from the celiac artery. Left lower lobectomy was performed through anterolateral thoracotomy, as we anticipated pleural adhesions and difficulties separating the sequestrated segment from normal lung. The postoperative course was uncomplicated. Examination of the surgical specimen revealed that blood flow from the aberrant artery was returned to the pulmonary vein, and there were no obstructions or deficiencies in the bronchial and pulmonary arterial systems. We concluded that this case was a type III intralobar pulmonary sequestration originating from an accessory lung bud, and the sequestrated segment became connected to the normal bronchial tree through the activity of severe infection.

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Two cases of small cell lung cancer in which the effect of preoperative chemotherapy was difficult to evaluate, are reported.
(Case 1) A 70-year old male was admitted because of an abnormal shadow. Chest X-ray and CT scan showed right hilar enlargement and a peripheral round mass. Bronchoscopy revealed that right B² orifice was obstruct-ed, and a small cell carcinoma was diagnosed. After chemotherapy, the hilar mass was reduced in size, but the size of the round lesion was unchanged. Right upper lobectomy was performed, and the peripheral tumor was identified as adenocarcinoma according to the pathological findings. Final diagnosis was synchronous primary lung cancer presenting with small cell carcinoma and adenocarcinoma.
(Case 2) A 66-year old male was admitted because of an abnormal shadow. Chest X-ray and CT scan showed a left hilar mass and a round shadow in left S⁶. Transbronchial needle biopsy of #11 lymph node was performed, and a small cell lung cancer was diagnosed. After chemotherapy, #11 lymph node was reduced in size but the round lesion showed no change. At operation peripheral tumor in left lower lobe was identified as small cell carcinoma by fine needle biopsy, and then left lower lobectomy was performed.

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We report a case of delayed diagnosis of tracheoesophageal fistula after a motor vehicular accident 12 years previously and describe the subsequent surgical repair. A 31-year-old man sustained a blunt trauma to the right chest during traffic accident in 1987, and was treated for unconsciousness and bilateral pneumothorax. In April, 1999, the patient consulted our hospital for coughing after swallowing. A giant tracheoesophageal fistula measuring about 33 mm in diameter was detected at the membranous wall just above the carina and surgery. was performed. The tracheoesophageal fistula was closed through all esophageal layers using autosuture device. A pedicled fifth intercostal muscle was interposed between the tracheal and esophageal suture lines. The postoperative course was uneventful and he has returned to work without recurrence.

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Radical thymectomy using median sternotomy is the standard operation for thymoma associated with myasthenia gravis. If tracheotomy is already performed in such a case, mediastinitis may easily occur from possible communication between the tracheotomy and mediastinum. We encountered such a tracheotomy case of thymoma associated with myasthenia gravis in which a T-shaped sternotomy was selected instead of the usual median sternotomy to avoid postoperative mediastinitis. Postoperatively, the patient had good clinical course without mediastinitis. Although a T-shaped sternotomy can not provide an adequate view for radical operations, in this case it was useful to avoid postoperative mediastinitis.

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A case of collision lung cancer is reported. An abnormal shadow was discovered in right S1 in a 51-year-old man. Right upper lobectomy with mediastinal lymph node dissection was performed for diagnosis. From the features of post-operative histology, this tumor was considered to be a case of collision cancer of adenocarcinoma and squamous cell carcinoma. Each distribution was distinguished clearly. By the collision part, the place where two cancers touched in a line, and the place where both cancer vesicle nests were intermingled mutually were confirmed. Furthermore, the adenocarcinoma had accumulation of p53 protein, but the squamous cell carcinoma did not have accumulation of p53. Despite p-stage IB, the patient died 15 months after operation from recurrence of squamous cell carcinoma.
Collision cancer has a lot of poor prognostic cases, and needs to take into consideration the postoperative treatment which suited the diameter of a tumor, the degree of proceeding, and the histlogical type.

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A 52-year old man presenting with hoarseness was diagnosed with adenocarcinoma of the lung in the upper mediastinum surrounding the left common carotid artery and subclavian artery. Thoracotomy was performed via median incision of sternum and collar incision of the left neck. A Y-graft was utilized by first suturing the end of the graft to the lateral ascending aorta, next suturing the end of the left common carotid artery and finally suturing to the end of the subclavian artery. The left brachioceplalic vein was ligatured and amputated. Then, together with a part of the brachial plexus of nerves and thoracic vertebra periosteum, the area of the lung containing the tumor was removed. Radiation therapy was performesd and the patient was discharged 44 days postoperatively. At present, two and a half years after the operation, no recurrence has been noted. In this patient with no metastasis to lymph nodes, the removal of the area of the lung containing the tumor with reconstruction of both common carotid artery and subclavian artery was effective.

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A 29-year-old man presented with a cough. A chest X-ray demonstrated a mass lesion in the right hilum, and computed tomography (CT) showed this mass was located in the anterior mediastinum. CT-guided needle biopsy was performed and histopathological examination of the tumor allowed an invasive thymoma Masaoka stage III. Complete curative surgical resection was not possible because the tumor had already invaded the surrounding tissues giving rise to pericarditis carcinomatosa. Pathological examination of the surgical specimen demonstrated anaplastic thymic carcinoma. After surgery, the patient received systemic chemotherapy followed by radiotherapy of 50Gy to the anterior mediastinum. Patients with anaplastic thymic cancer usually have a poor prognosis; however, this patient has remained well since surgery with no distal metastasis.

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A rare case of solitary squamous cell papilloma was reported and the literature was reviewed for similar cases.
A 52-year-old woman, with no history of smoking, consulted our hospital due to an abnormal shadow in the right middle lobe on a routine chest X-ray and CT film. Although the tumor was not diagnosed under bronchofiberscopy or CT-guided biopsy, partial resection under VATS was performed because lung cancer was suspected. The tumor was confirmed to be squamous cell papilloma pathologically, and was elastic soft, 14×11mm, gray-white, and had relatively smooth borders.

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A 16-year-old woman was admitted to our hospital because of an abnormal shadow in the left upper lung field. The specimen of needle biopsy showed sarcoma like findings. The chest wall tumor was completely resected including the second to fifth ribs. We paid attention to avoiding dysfunction and cosmetic considerations after the operation. The resected specimen showed a dedifferentiated liposarcoma. The patient has received no additional therapy and remains free of disease one year after the operation.

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We encountered a case of fibrothorax caused by hemopneumothorax. The patient was a 28-year-old male admitted to our hospital because of left pleuritis. He had complained of chest pain and fever two months before admission. Chest roentgenogram showed left pleural effusion and deflation of the left lung. No expansion of the lung was noted after tube drainage, which suggested fibrothorax, and empyema developed. Thracoscope-assisted debridment and drainage were performed. However, despite negative findings for bacterial culture in the pleural effusion, the patient's fever continued and we performed decortication of the left lung. Subsequently the left lung expanded immediately after the operation, the empyema disappeard and the patient was discharged one month after the final operation.
For the treatment of fibrothorax caused by hemopneumothorax, early decortication seems to be a good choice instead of prolonged chest drainage.

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A 77-year-old woman presented with the chief complaint of fever. Chest X-ray and chest CT demonstrated a pneumonia-like infiltrative shadow in the left lower lobe. Cytological examination of bronchial brushing materials demonstrated class IV adenocarcinoma. She was referred to our hospital and was subjected to left lower lobectomy with hilar lymph node dissection (ND1) in May 2000.
Histological findings of the surgical specimens showed mucin-producing adenocarcinoma with concomitant organized lesions with multinucleated giant cells, in which cryptococcal microorganisms were observed in the cytoplasm. These findings led to a diagnosis of pulmonary cryptococcosis classified as granulomatous pneumonia pattern. These microorganisms were not observed in regions other than the adenocarcinoma lesion; therefore, this case seemed to be a pulmonary cryptococcal infection of the area containing mucin produced by adenocarcinoma. There was no evidence of postoperative recurrence of lung carcinoma or cryptococcosis, although neither adjuvant anticancer chemotheraphy nor an antifungal drug was administered. It is suggested that complete resection of pulmonary cryptococcosis, the histological classification of which is granulomatous pneumonia, does not necessarily require postoperative antifungal therapy.

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A 53-year-old female presented in end-stage renal failure. She had been receiving continuous ambulatory peritoneal dialysis from August 1999. She developed acute hydrothorax in the right pleural cavity on January 2000. She was admitted to our hospital for the surgical treatment of pleuroperitoneal communication. We performed video-assisted thoracoscopic surgery. Using a dialysis solution with indigo carmine dye through CAPD catheter, we found three blebs on the diaphragm that expanded gradually. We diagnosed these lesions as pleuroperitoneal communication. The defects of the diaphragm were directly ligated with the instrument for endoscopic knot tying. Post-operative course was very favorable. She could restart CAPD on POD (postoperative days) 7 and was discharged from our hospital on POD 16. No recurrence of hydrothorax has been detected in the year after surgical treatment.

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