The primary treatment of acute empyema is to re-expand the collapsed lung as fully as possible, perform drainage and administer antibiotics. Debridement and drainage using video-assisted thoracic surgery (VATS) with minithoracotomy were successfully performed in five patients with acute empyema that did not respond to thoracic drainage, antibiotic therapy and/or irrigation. The mean duration of preoperative symptoms was 16 days (range, 3 to 43 days), and the mean duration of preoperative drainage was 7 days (range, 1 to 14 days). Five patients underwent successful debridement, irrigation and drainage with the use of VATS. The mean operative time and intraoperative blood loss were 90 minutes and 265 g, respectively. Postoperative course was good in all patients . The mean duration of postoperative drainage was 11 days (range, 8 to 18 days) and the mean duration of postoperative hospitalization was 19 days (range, 14 to 27 days). Debridment with the use of VATS is safe and efficient for acute empyema with persistent inflammation and insufficient re-expansion of lung.

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Between January 1991 and March 2001, 84 patients with lung cancer underwent operation after induction therapy at our hospital. Twenty-one underwent broncho-vascular plastic procedures (bronchoplasty: 10, vascular reconstruction: 6, and both: 5). Postoperative complications occurred in 12 patients (57%) in the group with plastic procedures and 25 (40%) in the group without, but no significant difference was found between the two groups. Operative mortality was slightly higher in the group with plastic procedures (9.5% vs 4.8%), but no significant difference was detected. There were also no differences in the patterns of recurrence (local vs distant) between the two groups. Broncho-vascular plastic procedures were considered to be safe even after induction therapy for lung cancer.

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Clinical pathway (CP) has been introduced with the aim of the practice of standard medical treatment and the reduction of medical care expenses. The purpose of this study was to assess the efficacy and safety of CP of videoassisted lobectomy for lung cancer. CP was employed for 64 patients who underwent video-assisted lobectomy from June 2000 to December 2001. Compared with 79 patients before CP introduction, postoperative hospital stay was significantly shortened in cases with CP. Major variances were identified in 7 cases (10.9%), although postoperative complications were not relevant to CP. There were no differences in total costs of hospital treatment. However, medical costs per day tended to be increase. We concluded that employing CP for video-assisted lobectomy was safe and efficient for the shortening of hospital stay and the standardization of medical treatment.

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We treated 6 patients with spontaneous hemopneumothorax from June 1995 to May 2002, and five of these underwent emergency surgery. All patients were male, and ranged in age from 19 to 33 years. It was the first occurrence of pneumothorax for all patients. Video-assisted thoracic surgery (VATS) was performed in all cases. In four patients, active bleeding from the parietal pleura at the top of the thoracic cavity was found, and it was easy to stop the bleeding. In the remaining patient, the bleeding point was suspected to be an aberrant vessel near the bulla. In all five, the bullae at the apex of the lung were resected. From admission to the end of the operation, the amount of blood loss ranged from 1250 to 2550ml. Postoperative course was uneventful and they were discharged 3 to 9 days after the operation.
We suggest that early surgical repair should be considered for spontaneous hemopneumothorax and VATS is very useful for such surgery.

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A 25-year old man presented with an asymptomatic pulmonary nodule first detected by routine chest roentgenogram. His laboratory findings were within normal limits. Chest CT showed an approximately 2cm solitary and well-circumscribed nodule in the lingular division. Preoperative CT-guided lung biopsy revealed few inflammatory cells. He underwent lingulectomy of the left upper lobe, because the tumor histopathologically showed spindle cell proliferation and also suggested low grade malignancy on intraoperative frozen section examination. The final diagnosis was inflammatory myofibroblastic tumor of the lung. Inflammatory myofibroblastic tumor is a rare disease that most often occurs in the lung. IMT has been described by various terms due to its variable cellular components, including plasma cell granuloma, inflammatory pseudotumor, xanthogranuloma, and fibrous histiocytoma. We report this case with reference to the literature.

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We reported two resection cases of pleomorphic carcinoma of the lung . In case 1, an abnormal mass shadow was found on the chest X-ray of a 65-year-old male. After right upper lobectomy and chest wall resection, the tumor was found to measure 6 cm and was diagnosed as a pleomorphic carcinoma because imagings showed sarcomatous components consisting mainly of spindle cells and giant cells . About 4 months after surgical operation, multiple liver metastases were found. In case 2, a 46-year-old woman complained of hemosputum . An huge abnormal shadow was found on chest X-ray and we resected the right upper lobe and performed partial resection of the middle lobe. Histological findings showed numerous giant cells, thus it was diagnosed as pleomorphic carcinoma . About 2 months after surgical operation, multiple brain metastases were found . Both patients had recurrence soon after operation.

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M. szulgai, a non-tuberculous mycobacteria (NTM), usually responds well to medication.
We have encountered two patients with non-tuberculous mycobacteriosis (M. szulgai) of the lung, which revealed M. szulgai in their sputum despite long term medication. In a case 1: 70-year-old male, right upper lobectomy was performed 45 years ago under the diagnosis of pulmonary tuberculosis. Since 1989, his right residual lung had been repeatedly infected. As a result of pneumonitis, his right residual lung was destroyed and he risk of obstruction of airway by the bleeding. While a case 2: 42-year-old male, was being treated with anti-tuberculosis medication under the diagnosis of NTM (M. kansasii), the bullae of his right upper lobe often became infected by bacterium. M. szulgai is identified from tissue in the cavity after lobectomy. Those two patients underwent completion pneumonectomy and lobectomy. After surgical treatment, NTM were not detected in their sputum, and the patients have been enjoying better quality of life. The standard therapy for NTM, particularly M. szulgai, is medication with anti-tuberculosis drugs, however, we often encounter patients hard to cure by those treatments. If there are no effects of medication, we suggest it is more useful to take away the focus of M. szulgai before the spread of damage in the lung.

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Most hyperparathyroidism with chronic renal failure is secondary, and mediastinal parathyroid tumors are relatively rare (approximately 2%). We report a case of primary hyperparathyroidism due to a mediastinal parathyroid adenoma accompanied by chronic renal failure.
A 42-year-old man had been undergoing dialysis therapy, was admitted to our hospital with high serum Ca, P and intact-PTH. Chest CT and MRI showed a mass measuring 3 cm in diameter in the anterior mediastinum, and ^99mTc-MIBI scintigram demonstrated abnormal radioactivity accumulation in the anterior mediastinum. CT and ultrasonography of the neck revealed no abnormal findings. From the results of the above examinations, hypercalcemia resulted from primary hyperparathyroidism due to a mediastinal parathyroid adenoma. The mediastinal tumor was resected in thoracoscopic surgery. Histologically, it was diagnosed as a parathyroid adenoma.
In hypercalcemia with renal failure, it is important to check for primary hyperparathyroidism.

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Extensive calcification of arteries are sometimes found in patients who have been dialyzed for chronic renal failure. Some non-dialyzed patients also have aortas characterized by circumferential calcification, so called “porcelain aorta”. A porcelain aorta is too hard and brittle to clamp or even operate . For example, if a porcelain aorta must occluded by an occlusion balloon, it is difficult to anastomose the wall of the porcelain aorta. The porcelain (unclampable) aorta thus presents a challenging problem to the cardiac and/or vascular surgeon, and various operation methods had been contrived.
We report a 57-year-old man who had received hemodialysis for 32 years. It was found that the patient had a large cell carcinoma in the left upper lung that invaded to his porcelain aorta. We were unable to clamp or sideclamp the porcelain aorta because the calcified wall was brittle, and we did not resect and replace the invaded aorta with a prosthesis. Left upper lobectomy was performed, but was not a radical operation because of the leftover invaded aorta. Irradiation therapy (60Gy) was applied. The patient is alive and without local recurrence, pleural effusion, or distant metastasis (brain and/or bone) 20 months after the operation.

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A 50-year-old male was admitted to our hospital with an abnormal shadow on chest X ray film. Chest CT scan showed a tumor 2.5cm in size in the right S¹. Right upper lobectomy with ND2a lymph node dissection was performed. The histopathological examination revealed adenocarcinoma in the right S¹ and large cell carcinoma in the mediastinal lymph nodes (#3, 4). In spite of a thorough systemic examination, the primary site of the mediastinal large cell carcinoma could not been identified. The patient is alive 23 months after the operation without any evidence of recurrence.
This is the first reported case to our knowledge of synchronous primary lung cancer and mediastinal lymph node cancer from an unknown origin.

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A 42-year-old woman was admitted to our hospital because of severe hemoptysis in July 2000. There was a history of chronic sinusitis operation at age 29: She had been diagnosed with Kartagener's syndrome because of the presence of bronchiectasis and complete situs inversus in March 1997, and massive hemoptysis was controlled by bronchial artery embolization in May 1998. Chest X-ray on her latest admission showed dextrocardia and infiltration shadow in right lower lung field. Chest CT scan and bronchofiberscopic examination revealed that the right lower lobe and lingula (S⁵) were ectatic. Surgical resection was performed, and the postoperative course was uneventful with no sign of hemoptysis recurrence for 30 months. Kartagener's syndrome, which is now considered a type of primary ciliary dyskinesia, has a good long-term prognosis.

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We report a case of successful treatment of cerebro-spinal fluid fistula to the pleural cavity after en-bloc chest wall resection of lung cancer. A 56-year-old man visited our outpatient clinic and was diagnosed with lung adenocarcinoma of the right upper lobe. The tumor was located in S2, and measured 5.5cm in maximum diameter. Three ribs, the right third to fifth, were involved near the costal-vertebral joint. On October 15, 2002, thoracotomy was performed. Right upper lobectomy and chest wall resection of three ribs with hilar and mediastinal lymph-node dissection were carried out. The intervertebral foramina were opened to the pleural cavity, but no cerebro-spinal fluid leakage was seen intraoperatively. At first, the postoperative course was uneventful except for a great amount of chest drain discharge, about 500 to 600 ml per day. The discharge did not look normal, however, but had low viscidity and much clearer color. On POD 7, headache and vertigo appeared, cerebro-spinal fluid fistula to the pleural cavity was diagnosed by cistern scintigram. There was no obvious parenchymal air leakage, and we clamped the chest drain for two days. Because this complication was likely caused by the pressure difference between the pleural cavity and cerebro-spinal cavity, it was thought that clamping the chest drain would lead to increased pressure in the pleural cavity and cerebro-spinal fluid leakage would stop.rNo excessive pleural fluid collection was seen on chest X-ray thereafter, and the chest drain was removed. Seven days after clamping, the symptoms, headache and vertigo disappeared. After two months, cistern scintigram was carried out and no obvious cerebro-spinal fluid leakage was seen.
In cases of cerebro-spinal fluid fistula to the pleural cavity, if the symptoms are not severe and there is no air leakage, clamping and removing the chest drain is one of the possible treatments. If failure, reoperation should be considered.

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Videopericardioscopy was successfully performed transthoracically to clarify the resectability in a patient with pulmonary adenocarcinoma in whom the hilar metastatic lesions appeared to directly invade into the intrapericardial space on chest CT.
Recently, multimodality treatment has been attempted for stage III B non-small cell lung cancer. Videopericardioscopy is thought to be a useful diagnostic tool for staging of lung cancer patients in whom direct invasion of a huge hilar mass into intrapericardial great vessels is suspected on chest CT.

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We report a case of superior mesenteric artery (SMA) embolism 4 days after lung resection. The patient was a 57-year-old man. He underwent left upper lobectomy and systematic lymph node dissection for lung cancer. On the 4^th postoperative day, he suddenly developed an intolerable abdominal pain. Abdominal CT and angiography confirmed a diagnosis of SMA embolism 6 hours after the symptom onset. As he showed no acidosis and the SMA was occluded distal to the first jejunal branch, we chose thrombolytic therapy. A microcatheter was selectively placed at the SMA orifice, through which urokinase was administered by bolus followed by continuous 12-hour infusion. Subsequently, we decided to perform emergency laparotomy embolectomy. The postoperative course was satisfactory, and he was discharged 21 days after the laparotomy.

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A 69-year-old man visited our hospital for evaluation of an abnormal chest X-ray shadow in the right upper lung field in June 2001. Serum protein electrophoresis revealed mild monoclonal IgG gammopathy. Bone marrow biopsy showed no evidence of myeloma. He did not visit again until September 2002, when he was admitted for evaluation of an abnormal chest X-ray finding. Bone marrow biopsy showed no evidence of myeloma, and bone scintigraphy revealed abnormal accumulation only in the right second rib. The patient was diagnosed as having a solitary plasmacytoma of the rib and received chemotherapy (melphalan and prednisolone) and radiotherapy. However, the tumor size remained unchanged and the serum IgG did not normalize. He was admitted to our division for surgical resection of the lesion. CT-guided transcutaneous needle biopsy of the tumor was performed, and the biopsy specimens showed plasmacytoma. The chest wall and the first and second ribs were resected.

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A 53-year-old man was diagnosed with non-specific interstitial pneumonia typell (NSIP II) by VATS in February 1998, and was treated with steroids. A total gastrectomy for gastric cancer was performed in September 1999, and in the follow up course, a malignant lung tumor was detected by TBLB. Lung surgery was recommended, but he had already received three abdominal operations after the gastrectomy. He rejected the recommended lung operation because of suffering from abdominal disorders including adhesion ileus and stenosis. An abnormal lung shadow was pointed out to him again in the last treatment for subileus, and he was advised to consult our department for the lung disease on October 15, 2001. He recognized the growing tumor and chose to have the lung operation at that time. A right upper lobectomy and lymph node resection (ND2a) were performed on December 17, 2001. Pathological findings revealed adenocarcinoma of the lung as stageIIB (pT2N1M0) and UIP (usual interstitial pneumonia). The postoperative course was uneventful without deterioration of UIP and he was discharged. He was followed up by checking the serum KL-6 and SP-D concentration for UIP activity. He was admitted to the department of general surgery again because of appetite loss on May 30, 2002. A metastatic liver tumor was found, and he received inpatient chemotherapy and arterial infusion, but UIP gradually became worse and he died of respiratory failure on October 11, 2000, 4 years and 8 months after the first diagnosis of interstitial pneumonia.

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A 28-year-old man was admitted to our hospital with abnormal shadow on chest X-ray. A mass was detected between 1t. B⁸a and 1t. B⁸b on chest CT with a clear margin, and was evaluated as pulmonary hamartoma radiographically. During operation, the tumor was enucleated and diagnosed as mucoepidermoid carcinoma histologically. Left lower lobectomy was additionally performed. Mucoepidermoid carcinoma is a low-grade malignant tumor, usually located in the central bronchus. This case is interesting because radiographicallydiagnosed distinction from pulmonary hamartoma was needed, and because it originated in the peripheral bronchus.

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