Background: We reviewed our experiences using Video-assisted Thoracic Surgery (VATS) to resect primary lung carcinomas. In our VATS approach, the position of a card-sized access thoracotomy was selected based on the location of the tumor.
Patients and methods: Between January 1998 and December 2001, 543 patients underwent pulmonary resections at our institution. The VATS procedure was used to perform a lobectomy or extended segmentectomy in 225 of these patients.
Rssults: Two hundred and one clinical stage I patients, 9 clinical stage II patients, and 15 clinical stage III patients underwent VATS lobectomy or segmentectomy. A comparison of operating times, blood loss, and pulmonary function between the VATS group and the conventional procedure group showed that the VATS procedure was less invasive than the conventional procedure.
Conclusions: The VATS technique is less invasive and superior to conventional pulmonary resection procedures; VATS may be useful for performing most standard lobectomy and segmentectomy procedures.

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We retrospectively studied the treatment for 14 patients of spontaneous hemopneumothorax. The mean age was 31.2 years, ranging from 21 to 63 years, and only one female patient was included in this study. For most patients it was the first episode of pneumothorax, and grade III collapse was most common. The site of bleeding was an interrupted stump of the funicular structure from the parietal pleura in 10 patients and from a ruptured bulla in 2 patients. Conversion from VATS to thoracotomy was needed for patients with a long delay between onset and operation, because it was difficult to remove massive blood clots from the trocar port by suction. Reoperation was needed for one patient who had VATS 15 days after onset, because of the prolonged air leakage. The results of VATS were better than those for open thoracotomy with respect to duration of drainage, postoperative stay and duration of analgesic use. We conclude that prompt decision for the surgical treatment is desirable considering blood loss, persistent air leakage and pulmonary re-expansion. VATS may be considered as feasible treatment for patients with spontaneous hemopneumothorax in their early stage.

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The outcome of surgery for lung cancer was assessed in 27 patients 80 years old or over. As to histological types, there were 13 adenocarcinomas, 12 squamous cell carcinomas, and 2 other types. Operative procedures were 22 lobectomies, 3 segmentectomies, and 2 partial resections. Postoperative complications occurred in 44% of the cases and operative mortality was 7.4%. Five-year survival rates were 47.8% in all cases and 66.8% in stage IA cases. There were no significant differences in the survival rates of patients between those 80 years old or over and those aged 70 to 79 years. Thus, we concluded that aged patients can undergo surgical treatement with an expectation of operative outcome similar to younger patients, and limited operation should be considered in patients 80 years old or over with stage I cancer.

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(Objectives) The aim of the present study was to investigate both the benefits and adverse effects of prophylactic administration of methylprednisolone for interstitial pneumonia (IP) after pulmonary resection.
(Methods) We reviewed 41 patients with primary lung cancer who underwent complete resection. Of these, 24 patients who had two or more risk factors for postoperative IP were given 125mg of methylprednisolone intravenously just before the thoracotomy. The risk factors included male gender, Brinkmann index >600, and the presence of interstitial changes on chest CT.
(Results) The serum CRP on the third postoperative day (POD) was significantly lower in the steroid group than in control (8.5±5.2mg/dlvs. 13.3±4.2mg/dl, p=0.011) while it was not different between those two groups on the seventh POD (1.9±1.3 vs. 2.0±2.0, p=0.942). Both the mean days of postoperative hospital stay and the disease-free survival were not different between the two groups.
(Conclusion) Prophylactic administration of methylprednisolone suppressed the inflammatory response during the early postoperative days, and no adverse effect on wound healing or disease-progression was identified.

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(Objective) Without oxygen (O₂) administration, we streamlined our postoperative management for pulmonary resection.
(Methods) We reviewed 35 patients, who underwent a pulmonary lobectomy for primary lung cancer from August 2000 to February 2002. Our guideline of the perioperative care is as follows: (Preoperative) prohibit smoking for longer than a week before surgery. Clean the respiratory tract by nebulizers with bronchodilators (Intraoperative) Postero-lateral thoracotomy through the 5th or 6th rib bed. Cut the 5th or 6th intercostal nerve before closure of the wound. (1 POD) O₂ off. Respiratory nebulizers at sitting. (2 POD) Discontinue both epidural and urinary catheter. Ambulation by him- or herself. Continue monitoring O₂ saturation.
(Results) The mean O₂ saturation after operation was 96.7 % on 1POD, 96.5 % on 2 POD, 97.2 % on 3 POD, and 97.9 % on 7 POD. Of these 35, only one patient needed O₂ inhalation after 1 POD, due to asthma attack. Twenty-nine patients did not need oral analgesics on 14 POD.
(Conclusion) The postoperative care without O₂ administration makes early ambulation easy.

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The case of a 70-year-old woman with a pulmonary glomus tumor is reported. The patient underwent chest roentgenogram examination for post-operative follow-up of rectal cancer and an abnormal shadow was detected. Chest CT scan revealed a round mass 1.0cm in diameter in the S³ of the right lung. Diagnosis was not obtained in lung biopsy under a bronchoscope. We could not rule out pulmonary metastasis of rectal cancer and a partial resection by video asssisted thoracoscopic surgery was perfomed. The tumor was white and wrapped in capsula. Histological findings of the resected specimen showed small round cells, compact and arranged circumferentially in the vascular cavity, crossing like a pair of swords.
Immunohistologic examination showed α-smooth muscle actin and vimentin in the tumor cells, and negativity for CAM5.2, desmin, chromogranin and synaptophysin. The diagnosis was pulmonary glomus tumor. Generally the prognosis of glomus tumor is good, but malignancy, postoperative recurrence and multiple metastasis can occur, and careful follow-up is necessary. To our knowledge, this pulmonary glomus tumor is the 13th reported case in the literature and the 5th reported case in the Japanese literature.

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Empyema with bronchial fistula developed in a 42-year-old man about 4 months after right panpleuropneumonectomy for diffuse malignant mesothelioma. A fenestration was performed and 82 days later, closure of the fistula and the fenestra was carried out.
After curetting the thoracic cavity, a right rectus abdominis muscle (RAM) flap based on the right inferior epigastric vessels and a pedicled omental flap supplied by the right gastroepiploic vessels were prepared. The omental flap was transposed to the thoracic cavity and the fistula was sealed with this flap.rThen the RAM flap with pedicle of inferior epigastric vessels was made free, and microscopic anastomosis was established between these vessels and left gastroepiploic vessels of the omental flap.rThe revasculized RAM flap was fixed over the omenal flap to reinforce the bronchial stump and these flaps decreased the residual cavity.
Clinical course after the reoperation was satisfactory and there was no evidence of recurrence of empyema during 4 years of follow-up observation.
Simultaneous use of free RAM flap and pedicled omental flap could be of great help in treatment of broncial fistulas and empyema.

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A 71-year-old male underwent left upper lobectomy for lung cancer (large cell carcinoma) at another hospital in November 1997. He developed left anterior chest skin redness in June 2002, diagnosed as intractable phlegmon. A needle biopsy histologically demonstrated large cell carcinoma, and the patient was referred to our hospital for treatment of chest wall metastasis in August 2002. Chest CT showed a mass lesion (60×60×42mm) in the left anterior chest wall invading to the pericardium. Induction therapy (radiotherapy and chemotherapy) was performed to reduce the tumor size, then chest wall resection and reconstruction was performed with Marlex mesh and rectus abdominis myocutaneous flap.rOn postoperative day 7, pyothorax occurred surrounding the Marlex mesh. Removing the mesh improved the pyothorax, the patient recovered well and was discharged. Complete resection of chest wall recurrence was successful by multimodal-therapy.

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Schwannoma of the chest wall is rare and 58 cases were reported in the Japanese literature. Case 1 was 15-years old female. She visited our hospital because of abnormal shadow on chest X-ray film. Tumor located at posterior chest wall. It seemed that tumor originating from second or third intercostal nerve. Case 2 was 39-years old male. He visited our hospital because of abnormal shadow on chest X-ray film. Tumor located at posterior chest wall. It seemed that tumor originating from tenth intercostal nerve. Tumors were resected easily by thoracoscopic surgery. Pathological findings were benign schwannoma. It is difficult to differentiaing benin tumor from malignant tumor by needle biopsy and perioperative histological examination on the chest wall tumor. So active surgecal resection should be performed on the chest wall tumor.

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A 12-year-old female was admitted to our hospital because of right pleural effusion. Right thoracotomy was performed, and it was diagnosed with mature teratoma with rupture into the pleural cavity. Teratoma is one of the most common mediastinal tumors, but rarely causes adherent rupture to adjacent organs. Prompt diagnosis can be difficult when pleural effusion covers the tumor on chest X-rays. It is important to consider the possibility of tumor when pleural effusion is not improved by standard treatment. Mediastinal teratoma should be resected as soon as possible, even though it is a benign tumor, because it could cause adherent rupture to adjacent organs with a potentially fatal outcome.

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A 43-year-old man was admitted to our hospital for medical evaluation of right side pneumonia and pleural effusion, which was pointed out at another hospital. Chest CT revealed pneumonia of right middle lobe, and localized pleural effusion with slightly pleural thickening. WhenA a thoracoscopic surgery was performed for drainage of right thoracic cavity, parietal pleura, thickened like abscess wall, was biopsied. Histological examination of the biopsied material led to the diagnosis of desmoplastic malignant mesothelioma. The patient then underwent right pleuro-pneumonectomy. After 16 months, he is alive without recurrence.

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A 17-year-old female complained of dyspnea and left chest pain. Chest film revealed complete atelectasis of the left lung. The bronchofiberscopic examination revealed an endobronchial lesion causing a massive obstruction of the left main bronchus, and based on biopsy results, we made a diagnosis of mucoepidermoid carcinoma. Prior to the operation, bronchofiberscopic electrosurgery was performed under general anesthesia, and partial resection of the tumor took place using an electrosurgical snare. This procedure enables observation of the distal part of the left main bronchus. Observation of the distal side of the tumor showed that the tumor originated from the mediastinal side of the left main bronchus and the tumor base was limited to the left main bronchus. Thus, it was possible to perform a sleeve resection of the left main bronchus along with the surrounding healthy bronchial tissue without losing lung parenchyma. We reconstructed the left main bronchus with end to end anastomosis after the resected edges were proven to be tumor-free by frozen section. The resected specimen originating in the left main bronchus and the tissue protruding to the endobronchial lumen were diagnosed as mucoepidermoid carcinoma grade II, according to Conlan's classification.

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Lung cancer metastasis to the small bowel indicates a poor prognosis, and long-term survival is extremely rare. We report a case of long-term survival after surgical resection of small bowel metastasis from bronchogenic carcinoma. A 72-year-old male was diagnosed with ileus by intussusception of the small intestine. He had been operated on for lung cancer seven months before, and we suspected metastasis to the small bowel of lung cancer. Laparotomy was performed, and release of the intussusception and resection of the ileum, including the tumor on the mucosal surface, was performed. The tumor was pathologically diagnosed as metastasis to the small bowel of lung cancer. The postoperative course was uneventful, and the patient is still alive without recurrence 6 years, 4 months after resection.

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A 69-year-old male who had received extraperiosteal paraffin plombage 38 years ago suddenly expectorated a paraffin fragment with cough in May, 2002. He was diagnosed with bronchopleural fistula due to perforation of plombage cavity into his lung, and underwent operation. Plombaged paraffin was removed and the bronchopleural fistula was sutured. The space was closed by transpositon of pedicle muscle flaps obtained from his pectoralis major and minor. Long-term postoperative follow up should be carried out for patients who had received extraperiosteal paraffin plombage.

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We report a case of successful two stage operation, omentopexy following cavernostomy for lung abscess arising in the residual lung after bilobectomy.
A 66-year-old woman underwent right middle and lower lobectomy on July 29, 1997, and the postoperative course was uneventful. However around 3 years after the operation, the superior segment of the right lower lobe was destroyed by an abscess infected with M. kansasii and Aspergillus fumigatus. Despite medication, her general condition deteriorated with respiratory symptoms of caehexia. To clean the abscess, cavernostomy was performed on December 21, 2000. During 6 months open drainage, the cavity was cleaned up to aseptic. On June 28, 2001, we obliterated the cavity with the omentum and a muscle flap.rThe multiple bronchopleural fistulas in the cavity were closed with the omental flap easily. Her postoperative course was uneventful and she was discharged on the 68 th postoperative day. The loss of respiratory function was slight, and she was doing well 3 months after operation.

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A 43 year-old-man with dyspnea and chest pain was hospitalized on an emergency basis. Chest X-ray and chest computed tomography showed a right emphysematous giant bulla which occupied 1/2 of the thoracic cavity and atelectasis of the right middle lobe. The bulla enlarged rapidly on the next day, occupying 2/3 of the thoracic cavity, and the lower lobe also showed atelectasis. Emergency intracavitary suction with a balloon catheter was applied to the expanding giant bulla under local anesthesia. Following the procedure, the patient recovered from severe dyspnea and the giant bulla reduced to about 1/3 of the thoracic cavity and the right middle and lower lobes were reexpanded. Next, bullectomy by video-assisted thoracoscopic surgery (VATS) was performed safely and successfully. We considered that intracavitary suction of the expanding emphysematous giant bulla with atelectasis was a safe and effective procedure before bullectomy by VATS.

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A 28-year-old woman who complained of general fatigue and left ptosis was diagnosed with anterior mediastinal tumor. Mass shadows were seen in the right chest wall with pleural effusion on her chest X-ray and CT scan, and she was referred to our hospital on December 8, 2000. Eight days after admission, she required tracheal intubation and respiratory support for respiratory crisis.
For myasthenic crisis, she was administered anbenonium 20mg/day and double filtration plasmapheresis (DFPP). However, her respiration could not be improved. Pathological examination of the tumor on the diaphragm was performed by aspiration biopsy, revealing thymoma. Thus, we diagnosed thymoma, Masaoka's Clinical Stage Na. After chemotherapy, she underwent extended complete thymectomy on February 14, 2001, but steroid therapy and immunoadsorption could not improve her myasthenia. From April 26, 2001, she received FK-506, her respiratory insufficiency was markedly reduced, and she was disconnected from the artificial ventilator. She has been well with no evidence of reccurence for two years and one month following post-operative radiation therapy (total 50Gy) to the mediastinum.

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