Objectives: We devised a needle VATS laser ablation. We think this is lesssugical stress than bullectomy . We report this procedure's results and evaluate its efficacy. Subjects and Methods: We evaluate our results with needle VATS laser ablation in 58 patients (needle VATS group) from January 1997 to March 2001. And for reference, we report our result with VATS bullectomy + laser ablution in 32 patients (VATS group) in same period . Results: The needle VATS laser ablation is as effectual as conventional method.

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Bronchial fistula is one of the severe complications associated with pulmonary lobectomy, and according to various reports, has an incidence of about 2%. The Sweet method, the Overholt method and simple ligation method are some of the published techniques for closure of the bronchial stump following pulmonary lobectomy. In recent years, automatic suture instruments are being utilized more often. We have mainly utilized the simple ligation method because: 1) it is a simple procedure and is cost effective; 2) sputum does not enter the thoracic cavity; and 3) since sutures are not exposed in the bronchial stump cavity, infections are less likely to occur. The subjects were 174 patients who underwent surgery utilizing the simple ligation method. The results of the present study showed that there were no complications such as postoperative bronchial fistula in any patients, including those who received pre-or post-operativechemotherapy or radiation therapy, thereby suggesting the usefulness of the simple ligation method.

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Paraganglioma of the mediastinum is a relatively rare disease. We present here a patient with primary mediastinal paraganglioma who received combination treatments. The patient was a 56-year-old women who consulted aphysician for a feeling of stiffness in the chest and cough. The physician suspected mediastinal tumor and referred her to our hospital. Chest CT revealed the presence of a hypervascular lesion, extending from the middle to the anterior mediastinum, about 7× 6 cm in size. Tumor biopsy revealed that the lesion was a paraganglioma . In view of the anatomical position, radiotherapy was selected in order to reduce the size of the tumor . When the tumor shrank in size, tumor artery embolization with insertion of platinum coils was performed . Subsequently, surgical resection was attempted, but it was found difficult to remove the lesion because of its highly vascular wall. Notwithstanding the fact that the possibility of malignancy could not be excluded based on the clinical findings and complete resection was attempted, completeresection of the tumor was unsuccessful . However, histopathological examination revealed no evidence of malignancy, and a final diagnosis of paraganglioma was made . Since surgical removal is the only established method of treatment for a paraganglioma, we propose to increased tumor and metastasis follow up this patient.

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The patient was a 42-year-old woman. On an annual medical check-up in 1991, an abnormal shadow was detected in the right pulmonary hilum on chest X-ray film. Though the shadow did not change between 1991 and 1993, it gradually developed over the next eight years. Chest CT showed a 2.5×3.5× 3.0 cm tumor as a well-defined and homogeneous mass in the border between the right middle and inferior lobe bronchus. Chest MRI showed a hypointensive mass on T1-weighted image, a hyperintensive mass on T2-weighted image. The mass is strongly enhanced on contrast-enhanced CT and T1-weighted image. Tumor resection by video-assisted thoracoscopic surgery allowed diagnosis and treatment of the rare disease. Histopathological examination demonstrated hyaline vascular type of Castleman's disease. The developmental course of the disease over long-term observation is described.

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A 46-year-old man with occupational exposure to asbestos presented with a pulmonary mass with pleural thickness in the left lung. After 4 months observation at another hospital, computed tomography revealed enlargement of the mass. Transbronchial lung biopsy and fine-needle biopsy did not disclose any evidence of malignancy. Although rounded atelectasis was mostly suspected, malignant disease including mesothelioma could not be excluded because of the occupational history. An exploratory thoracotomy was performed. The histopathological findings by the needle-biopsy at surgery showed no malignancy and diagnosed the mass as rounded atelectasis. In the case of enlarging rounded atelectasis, an exploratory thoracotomy would be required.

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A 54-year-old woman was admitted due to dyspnea, hemosputum and cough when drinking carbonated water. She had had frequent episodes of hemosputum and hemoptysis from age 40, and had been diagnosed with esophagobronchial fistula. After bronchial embolization with fibrin glue 12 years ago, hemosputum and hemoptysis disappeared but hemosputum relapsed in 2000. Resection of the fistula by video-assisted thoracoscopic surgery (VATS) was performed. There was no evidence of adhesion around the fistula in operative findings. Microscopic findings of the resected material revealed a squamous epithelium with an underlying muscle layer in the wall and no evidence of inflammatory changes or fibrosis. This case was therefore diagnosed as Braimbridge I type esophagobronchial fistula. VATS is the first choice of treatment for patients with Braimbridge I and II type esophagobronchial fistula.

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A 46-year-old male was diagnosed with Mycobacterium szulgai pulmonary disease by his chest X-ray appearance and a culture test of his sputum. He was treated with isoniazid (INH), rifampicin (RFP) and ethambutol (EB) for six months. Two years later, because M. szulgai was detected again, treatment with RFP, ethionamide (TH) and clarithromycin (CAM) was done for six months. On March 2001, the infiltrative shadow became worse, and a thin - walled cavity appeared on his chest X-ray. M. szulgai was detected again. So we considered that surgical resection was indicated for his disease, and right upper lobectomy was performed. His clinical course was uneventful, and culture tests were negative for mycobacteria after surgery. Pulmonary diseases due to M. szulgai are rare and usually well controlled by treatment with antimycobacterial drugs. But for some uncontrollable cases, surgical resection must be considered.

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We reported a case of fibrous dysplasia of the left sixth rib in a 31-year-old man . In this case, the disease was detected from an abnormal shadow on a plain X-ray film at medical check-up.rChest CT suggested tumor of the rib bone. We observed that the lesion was localized in the sixth rib without pleural invasion by video monitoring through a thoracoscope. Total extirpation of the left sixth rib was performed under an axillar skin incision with the thoracoscope. The pathological diagnosis was fibrous dysplasia. Video-assisted thoracoscopic surgery is useful for detection of the extension and pleural invasion of the rib tumors.

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This is a case report of a 64-year old man with small bowel solitary metastasis from large cell carcinoma of the lung. The first symptom was abdominal pain after contusion. Abdominal CT revealed wall thickning of small intestine and high CT density of peripheral fat tissue. Chest X-ray study on admission, CT and cytological examination revealed lung cancer of the left upper lobe of lung. Laparotomy was performed, and a solitary tumor about 6cm in diameter was found in the jejunum 70cm distal to the ligament of Treitz . Partial resection of small intestine was done . The tumor was suspected to be a mesenchymal tumor initially. 18 days after that operation, left upper lobectomy of lung was performed. Histological examination revealed a large cell carcinoma of the lung and its metastasis to the small intestine. He survived 172 days after the abdominal operation.

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A case of juvenile malignant pleural mesothelioma detected by pneumothorax is presented.
A 29-year-old male was hospitalized in October 2001, after detection of left pneumothorax during a medical checkup.rLeft pneumothorax had also been detected during a medical check up in October 2000, but during a follow-up consultation at this hospital, chest X ray did not demonstrate pneumothorax. The chest X ray showed slight left pneumothorax and chest CT showed left pneumothorax along with a small nodular shadow, but not a bullous lesion.
Thoracoscopic surgery was performed on the left pneumothorax on November 9. A tumor was demonstrated in the visceral pleura of the left lower lobe and the visceral pleura near the hilum of the left upper lobe. Numerous small nodules, measuring 1 to 2 mm in diameter were diffusely scattered over the visceral, parietal and diaphragmatic pleura
Malignant pleural mesothelioma was suspected on frozen section, tumors in the upper lobe and lower lobe were excised for pathological examination andthe surgery was completed.
On postoperative permanent pathological finding, malignant pleural mesothelioma was diagnosed. Mediastinoscopy and right thoracoscopy were performed for staging, and the case was diagnosed as clinical stage lb (based on IMMG).
Left extrapleural pneumonectomy was performed on the malignant pleural mesothelioma on December 5. Postoperative adjuvant chemotherapy and radiotherapy were performed.

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A 13-year-old Japanese boy complaining of exertional chest pain was admitted to Kyoto University hospital . On chest CT, a fat density tumor waslocated in the left anterior chest wall with extension to the left pleural space . Chest MM revealed infiltration of the tumor into the muscular layers of the chest wall . Preoperative diagnosis was intrathoraciclipoma with possible malignant potential. The patient underwent en-bloc resection of the tumor and chest wall. Histological diagnosis was infiltrating intramuscular lipoma of the chest wall . The patient is alive and well with no evidence of recurrence one year after surgery.

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A 58-year-old man complaining right chest pain and dysphagia was pointed out a mass shadow in the right upper field on chest X-ray. Further examinations revealed lung carcinoma of the right upper lobe . And upper gastrointestinal examination showed esophageal carcinoma. It was pathologically revealed to be squamous cell carcinoma. They were diagnosed as synchronous double carcinoma of the lung and esophageal carcinoma. Because of his good performance status and resectabilities of the tumors, simultaneous operation was performed. Right upper lobectomy and esophagectomy were done using right posterolateral thoracotomy . And poststernal esophageal reconstruction using a gastric tube was performed. Pathological diagnosis was poorly differentiated adenocarcinoma of the lung, and moderately differentiated squamous cell carcinoma of the esophagus respectively. Prophylactic irradiation and postoperative radiation was added to bilateral supraclavian field and mediastinum postoperatively. The postoperative course is satisfactory. Synchronous double carcinoma of lung and esophagus is rare. Our case indicates that simultaneous resection of both cancer and esophageal reconstruction can be safely performed.

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A 62-year-old male had received a right upper and middle lobectomy for pseudolymphoma at another hospital 14 years before. During his post-operative follow up, a shaggy shadow was found in his lower left lung. This shadow progressed gradually, repeated chest CTs and transbronchial lung biopsies did not yield a definitive diagnosis. He was referred to our hospital for diagnosis and treatment.
We performed VATS for biopsy and obtained several specimens from the left lung. We extracted the DNA and amplified with PCR these surgical specimens and the specimen resected and paraffined 14 years before. We analyzed the genes by Southern blot hybridization, and detected a rearrangement of the immunoglobulin (Ig H) gene but no T cell receptor (TCR γ) gene, leading to a diagnosis of bronchus-associated lymphoid tissue (BALToma). After obtaining a definitive diagnosis, we administered chemotherapy twice consisting of purine analogue, fludarabine (regimen for chronic leukemia) and achieved a marked effect.

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We reported two cases of bilateral bullous emphysema with giant bullae successfully treated with video-assisted thoracoscopic surgery (VATS) simultaneously for bilateral lungs. In case 1, a 53-year-old man complained of dyspnea on effort. In case 2, a 47-year-old man consulted our hospital with a chief complaint of right chest pain and dyspnea, and chest X-ray films at that time showed a right spontaneous pneumothorax. Chest CT of both patients revealed bilateral bullous emphysema with giant bullae, and thus we performed VATS in both patients simultaneously for bilateral lungs. Both patients recovered well, and there was no air leakage. In case 1, the bilateral chest drain tubes were removed on postoperative day (POD) 2, and the patient was discharged on POD 24. In case 2, the bilateral chest drain tubes were removed on POD 3, and the patient was discharged on POD 9.
Recently, developments and improvements in thoracoscopic surgical instruments and adjunctive materials have extended the operative indications for VATS. Use of VATS techniques for bilateral bullous emphysema make these cases possible to operate simultaneously for both sides and is minimally invasive to patients thereby reducing the length of their hospitalization.

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We report a case of gastrobronchial fistula resulting from a gastriculcer. A 60-year-old man, who complained of dyspnea, fever, and abdominal pain, was diagnosed with a gastrobronchial fistula by upper gastrointestinal contrast study and referred to our hospital. Because of poor improvement of his condition by conservative treatment, simultaneous left lower lobectomy, proximal gastrectomy, covering of bronchial stump with pedicled omental flap, and suture of the diaphragm defect were performed successfully. Gastrobronchial fistula is a rare condition, and in most reported cases, occurred within the thoracic space as a postoperative complication of esophagogastric surgery. Our case developing through the diaphragm is extremely rare.

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