Microwave Coagulation Therapy (MCT) is increasingly used in cases of malignant liver tumors . MCT has been expected to be applied to lung cancers, yet it has never really been examined for its influence on normal lung tissues. With a purpose of investigating its clinical applicability to pulmonary diseases, we performed MCT on the normal lung tissues of a dog, in the power conditions of 20, 40, and 60W and with the treatment times of 15, 30, and 60 seconds in each power condition. We investigated the diameter of the maximum coagulation area and histopathological changes in normal tissue by H-E stain, immediately after and one week after the coagulation treatment. Coagulation area expanded with the increase of the power of output and the coagulation time . More than 10mm coagulation area was obtained under 40W-60sec or 60W-30sec coagulation. A maximum 23mm coagulation was obtained under the condition of 60W-60sec coagulation, but over-coagulation caused necrotic cavitations.
In conclusion, we have demonstrated in the present sutdy that optimum condition to obtain security more than 10mm coagulation area is 40W-60sec or 60W-30sec coagulation.

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The purpose of this study was to estimate the safety and efficacy of covering visceral pleura with polyglycolic acid (PGA) felt after thoracoscopic treatment for primary spontaneous pneumothorax. Between June 2002 and July 2003, 37 consecutive patients with primary spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery. The procedures included resection of bullae and covering visceral pleura with PGA felt. The methods of covering were as follows: 1) ligation of both ends of the staple line using polydioxanone suture (PDS), 2) threading PGA felt with PDS, and 3) advancing PGA felt, guided by PDS on the visceral pleura. The mean operation duration was 60.6 min. The mean durations of postoperative chest drainage and postoperative hospital stay were 1.1 days and 1.6 days, respectively. There was no postoperative mortality or morbidity. No recurrent pneumothorax was noted at a mean follow-up of 12 months. Covering with PGA felt is a safe and convenient procedure that may improve the outcome and reduce the rate of recurrence after thoracoscopic treatment for primary spontaneous pneumothorax.

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Resected multiple primary cancers that included lung cancer were studied clinically. Among the 496 cases of surgically resected lung cancer treated in our hospital from 1981 to 1997, 72 (14.5%) involved multiple site of primary cancer in addition to the lung cancer. In these cases, we investigated background variables and survival rates. The most common site of the other primary cancer was the stomach (38 cases), followed by the colon (13 cases), larynx (6 cases), esophagus, urinary bladder and breast (four cases each), uterus and prostate (three cases each), and other sites (8 cases). The five-year and ten-year survival rates were 78.6% and 40.6% for patients who had prior metachronous lung cancer, and 49.0%, 38.5% for patients with non-multiple primary lung cancer, respectively. No significant difference in survival rates was found between the patients with non-multiple multiple primary lung cancer and patients with prior metachronous lung cancer. The effect on survival of prior metachronous lung cancer was equivalent to the effect of non-multiple multiple primary lung cancer.

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A 67-year-old woman complaining of bronchial asthma attack was admitted to Seikeikai hospital for further evaluation of mediastinal mass detected incidentally on a screening chest roentgenogram. On chest computed tomography scan, a soft tissue density, unhomogenious, 35-mm spherical mass containing calcifications was located in the superior mediastinum in contact with the superior vena cava (SVC). Enhanced T1-weighted magnetic resonance images (MRI) showed staining in part of the mass and the same part of the mass demonstrated extremely higher intensity on the T2-weighted images, indicating the mass might have been a teratoma or hemangioma.
We first attempted video assisted thoracic surgery (VATS), but the tumor adhered strongly to the SVC and also involved the right phrenic nerve. We thus performed thoracotomoy via the 5th intercostal space, and a frozen section of the mass involving the phrenic nerve was histologically examined intraoperatively. The histological diagnosis was benign hemangiopericytoma. The phrenic nerve was conserved, even though some of the tumor around it remained, but the right brachiocephalic vein and the part of the SVC showing strong adhesion to the tumor were excised to resect it. Histological examination revealed that the tumor was composed of clusters of well formed capillary vessels with focal areas consisting of sheets of epithelioid cells with poorly formed vascular channels. Endothelial cells had large cytoplasmic vacuoles containing intact or fragmented red blood cells.
No necrosis or mitosis was found in the tumor cells. The tumor cells stained strongly positive for factor VIIIassociated antigen and vimentin and negative for epithelial membrane antigen (EMA), Desmin and Cytokeratin (data not shown), leading to the diagnosis of benign hemangioendothelioma. Hemangioendotheliomas are uncommon lesions of the mediastinum and 35 case reports from 1963 are listed in this paper, including our case.

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Leiomyoma in the anterior mediastinum is very rare. In this report, we describe a case of leiomyoma in the anterior mediastinum in a 53-year-old man with an abnormal shadow on chest radiogragh who was referred to our hospital for further investigation and treatment. Chest CT scan and MRI showed a solid mass in the anterior mediastinum. We suspected the tumor to be a thymoma and decided to remove it operatively. We removed the tumor along with the thymus. The resected mass was 4.0 ×3.0×2.5cm in size and 20g in weight, covered with a thin capsule. The operative findings and histology allowed diagnosis of leiomyoma from unknown origin. The patient is in good health with no recurrence four months postoperatively. This is the second case to our knowledge of leiomyoma in the anterior mediastinum in Japan.

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Because it has been difficult to make accurate diagnosis of aortic invasion in lung tumors, we have performed intravascular ultrasound imaging (IVUS) to obtain more accurate diagnosis of aortic invasion, in 11 patients with lung cancers suspected of invasion to the aorta. No complications associated with IVUS were found in this series. Eight of 11 cases were treated by surgery. In one case the tumor bordered on the aortic arch (AP window) and we could not obtain sufficient imaging to evaluate invasion. Three patients were diagnosed as having aortic invasion by IVUS, and one was followed by operation, confirming invasion by the tumor. In the other 7 cases no invasion was detected by IVUS, and all were found to be without invasion at surgery. The accuracy of IVUS for aortic invasion was 100%, while CT and MRI rates were 29% and 17%, respectively. We concluded that IVUS may be a useful and safe method for making diagnosis of invasion to the aorta.

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A 69-year-old man was diagnosed as having pulmonary fibrosis in 2000 and was admitted with a left-sided pneumothorax on January 20, 2003. A chest tube was inserted for drainage and he recovered. After discharge from hospital, he received home oxygen therapy, but he was admitted with recurrent left pneumothorax on February 7. Although a chest tube was inserted again, prolonged air leakage occurred, so partial resection of the left lung was performed twice. The site of air leakage was different at the first and second operations. After the second operation, the lung collapsed again on POD 2. Because his blood Factor XIII activity was low, we administered coagulation Factor XIII from POD 6 to POD 11, and lung expansion improved on POD 14. The chest tube was removed on POD 17 and he was discharged on POD 22. Treatment of recurrent pneumothorax with Factor XIII seems to be a safe therapeutic option for patients with interstitial pneumonia.

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A 46-year-old male patient with active pulmonary tuberculosis suffered tension pneumothorax due to perforation of the focus, resulting in respiratory failure and acute empyema. In addition to administration of antituberculosis agents, continuous closed chest drainage followed by fenestration were performed. In spite of these treatments, high fever continued and the disease worsened. Administration of steroids was required to reduce his fever . Excretion of tubercle bacillus in the sputum occurred and management of his condition became difficult . Therefore, radical pedicled omentoplasty was adapted for surgical intervention of a large fistula and active tuberculosis. To avoid a deterioration of respiratory function, pedicled omentoplasty using laparoscope was performed . His postoperative course was good and he left the hospital without oxygen support. From this case, we concluded that pedicled omentoplasty using laparoscope is potentially useful for the management of perforation of an active pulmonary tuberculosis lesion.

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A 71-year-old male had received a left nephrectomy for renal cell carcinoma in October 1987 and bilateral partial resection of the lung for metastases of renal cell carcinoma in January 1998. He admitted to our hospital for abnormal shadow on chest X-ray in February 2001. He underwent video-assisted thoracoscopic biopsy. Intraoperative histological examination revealed adenocarcinoma that originated in the lung. Right upper lobectomy was performed and the patient is doing well with no sign of recurrence two years.

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Postpneumonectomy empyema is a very serious complication. We herein report a case of postpneumonectomy empyema caused by anaerobe successfully treated by decortications followed by antibiotic irrigation using clindamycin. A 60-year old man underwent left pneumonectomy under the diagnosis of squamous cell carcinoma associated with lung abscess. The chest tube was removed on the 7th postoperative day. The patient developed acute empyema and subcutaneous infection caused by Bacteroides, which was detected in the lung abscess, and tube thoracostomy with suction drainage was performed again on the 11th postoperative day. On the 36th postoperative day, a reoperation for decortication using a thoracoscope was performed, followed by closed drainage with irrigation using clindamycin for two weeks and also systemic administration for 5 days. Under this management, empyema was successfully controlled. We proposed that decortication followed by continuous thoracic irrigation may be an effective management strategy for postpneumonectomy empyema without bronchopleural fistula.

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A 20-year-old male who collided with a car while driving a motorcycle showed deep cervical emphysem, mediastinal emphysema and bilateral pulmonary contusion on X-ray and CT upon admission . Bronchofiberscopy revealed airway hemorrhage which seemed to be due to pulmonary contusion, rupture of the tracheal membranous portion extending into the right upper lobe bronchus, and fractured cartilage of the lower trachea protruding into the tracheal lumen. Operation was not performed on the day of injury to avoid the perioperative risks arising from the hypoxemia and intrapulmonary hemorrhage due to pulmonary contusion . It was performed through posterolateral thoracotomy on the fifth hospital day, after improvement of respiratory condition . Wedge resection of the tracheal cartilage two and three rings oral to the tracheal carina and suture of the ruptured membranous portion was performed. The postoperative course was uneventful with good result.

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We performed right lower lobectomy on a 60-year-old woman suffering from right lung cancer . As her condition was complicated by diabetes mellitus, we covered the stump of the bronchus with a pedicled intercostal muscle flap to guard against development of a bronchopleural fistula. On postoperative day 11, she developed right pyothorax, and drainage and intrathoracic lavage were done. She was diagnosed with esophagopleural fistula by esophageal imaging, but bronchopleural fistula did not appear. The fistula did not close under conservative therapy, and operation to close the fistula and fill in the space from pyothorax with a pedicled latissimus dorsi muscle flap was performed 25 days after the development of the symptom. After the operation, endoscopic injection of fibrin glue into the fistula was performed. Subsequent esophageal imaging revealed that the fistula was closed 20 days after the injection, and oral intake was resumed. Then the pyothorax was cured, and she was discharged 136 days after the development of the symptom.

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A 78-year-old man complaining of dyspnea was admitted to our hospital because of left pneumothrax . Videoassisted thoracoscopic surgery was performed for air leakage.
Abdominal free air was detected in the right subphrenic space on chest X-ray on the first day after the operation. On CT the gas shadows were recognized at the portal fissure, right subphrenic space and right perinephrium. The free air was absorbed gradually over two weeks without symptoms or remarkable radiological findings . Accordingly, after the thoracoscopic surgery pneumoperitoneum was diagnosed.

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Case 1. A 68-year-old woman was admitted due to myasthenia gravis . The patient was on a respirator and received immunoadsorption before surgical treatment . After stabilization her respiratory condition was established, and the patient underwent transsternal thymectomy . She was dependent, however, on the respirator for 11 days following the surgery. On the 11th day she received a surgical tracheostomy . On postoperative day 22, high fever and peri-tracheostomal and wound infection were noted . Continuous suction drainage from the tracheostomy and the peri-sternal area and intermittent lavage were performed for 10 days . The infection was controlled and the patient was freed from the ventilator. Five years after the thymectomy, she has only mild ptosis.
Case 2. A 60-year-old man was admitted to our intensive care unit due to a myasthenia gravis crisis in August 2002 . The patient received surgical tracheostomy due to prolonged respiratory disturbance . After preoperative stabilization of his condition using immunoadsorption, he received extended thymo-thymectomy through median sternotomy. On postoperative day 18 surgical wound infections were noted . Open drainage and debridement were performed. For 4 months after surgery the infection was treated by removal of the sternal sutures . Nine months after surgery, the patient recovered from dysphagia.
Tracheostomy in myasthenic patients with thymectomy may result in wound infection . Careful management should be performed after an unavoidable tracheostomy.

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Tracheobronchial rupture by blunt thoracic trauma is relatively rare and especially right upper bronchial disruption is very rare. Here we report two cases of bronchial disruption following blunt chest trauma. The first case was a 20-year-old male. A car jacked up for repair, suddenly dropped and compressed his chest. Chest X-ray demonstrated right pneumothorax. Bronchoscopic examination revealed complete disruption of the right upper lobar bronchus. He had no critical injuries to other organs.
The contusion of the right upper lobe found in the thoracotomy was so severe that we abandoned the preservation of the injured area and performed right upper lobectomy. He is doing well without any symptoms 65 months after surgery. The second case was also a 20-year-old male. A large iron box weighing approximately 10 tons compressed his chest. When admitted to our hospital, traumatic pneumothorax was apparent. Chest tube drainage was performed, but it was not effective because of massive air leakage. Bronchoscopic examination showed complete disruption of the right upper lobar bronchus. He had no critical injuries in other organs, either. As the contusion of the right lung was not so severe in the operation, we performed end to end anastomosis of the right upper lobar bronchus and main bronchus. He was doing well without any complications 6 months postoperatively.

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We encountered a case of tracheal rupture associated with the use of a double-lumen tube during operation for lung cancer. The patient was a 48-year-old woman, 156cm in height and 48kg in weigh. She underwent right middle lobectomy and intra-thoracic hyperthermia therapy after 4 courses of chemotherapy. Intratracheal intubation was easily performed with a 35Fr left-sided double-lumen tube (Blue line endobronchial tube, Portex). However, it was difficult to fix the tube at the proper position for unilateral ventilation, so we fixed it in a squeezed position. The ventilation and operation were uneventful and chest roentgenogram just after the operation showed no abnormalities. She was returned to the ward after extubation. On day 1, subcutaneous empyema was appeared in her chest. On day 2, the empyema increased and we performed chest CT and bronchoscopy. Air-density area spread around the trachea, and laceration of the membranous portion of the trachea was diagnosed. She underwent suture repairing of the trachea on day 2, and discharged on day 14. We discuss and report this case with some reference literatures.

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A 71-year-old diabetic man, who underwent left extrapleural Lucite ball plombage for pulmonary tuberculosis 52 years before, presented to our hospital complaining of left axillary swelling and tenderness. He was febrile and also had two other chest wall protrusions. Chest x-ray and contrast-enhanced CT scan films revealed empyema in the dead spaces made by the Lucite balls and chest wall abscesses communicating through intercostal spaces. No tuberculous lesions were detected in either lung field. Incision and drainage were performed, but the thin, yellowish, creamy pus revealed no organisms at first. Extirpation of the plombs and fenestration with removal of the dorsal part of his left 7^th and 8^th ribs was performed through left thoracotomy, and eighteen hollow Lucite balls of three different sizes, 3 to 5 cm in diameter and weighing 350 g altogether, were removed. Most of them contained creamy pus inside, and some of them were partially fractured or divided at midline seams. We inserted sterilized gauze pads immersed in povidone iodine in the dead spaces of his left thoracic cavity. Based on the positive acid-fast bacilli culture and polymerase chain reaction (PCR) confirming this organism as Mycobacterium tuberculosis, which had become evident after the first surgery, we diagnosed this case as tuberculous empyema with chest wall abscesses, and antituberculous multi-drug regimen was initiated. At the second surgery a month later, curettage of the left thoracic cavity and decortication of the left lung surface was carried out. The previously removed and preserved left 7^th and 8^th ribs were autologously re-implanted, but later showed minor complication of periosteal tissue necrosis and sterile effusion.
Before the advent of antituberculous drugs in the 1950s, surgical treatment for pulmonary tuberculosis played a very important role, especially the collapse therapies, like thoracoplasty or plombage. Extrapleural Lucite ball plombage was one of them, but soon disappeared because of its various life-threatening complications. Survivors, as seen here, are also annoyed by its late complications such as empyema or hemothorax. However, it is also true that this patient had been free of tuberculosis and asymptomatic for about a half century. It is of interest to discuss the bright and dark side of this histological technique and therapeutic options for its late complications, and we found this successfully treated case worth reporting.

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