We analyzed intraoperative troubles associated with 834 patients who underwent thoracoscopic/video-assisted thoracic surgery (TS/VATS) in our institution from January, 1995 to January, 2006. The causes of 17 of the 25 intraoperative troubles were operators' errors, followed by 4 trouble shootings of stapling instruments. Including the 3 miss-choice of the stapling instruments and one assistant's error, the causes of 21 (84%) of the intraoperative troubles were surgeons' errors. However, almost of them were considered to be derived from the specific TS/VATS-related surgical handicaps. Conversion to open thoracotomy was needed in 4 (1.0%) of 416 TS-patients and in 3 (0.7%) of 418 VATS-patients. Two cases of life-threatening major vascular injuries were encountered, which might have been fatal without a small thoracotomy routinely placed in our VATS. There were no operative deaths in our TS/VATS patients. It is therefore recommended to place an access thoracotomy in VATS so that surgeons can safely manage unexpected events, resulting in successful completion of the anatomical pulmonary resection associated with vascular dissection. In conclusion, it is essential to build up a system of reporting intraoperative troubles in TS/VATS in order to share information and provide a data base to aid risk management.

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In 299 cases of VATS (Video Assited Thoracic Surgery) for spontaneous pneumothorax, a recurrent rate of 40 cases, which had operations for the ipsilateral parts before, was 35.0%. This rate was significantly higher than that of other 259 cases, which did not have operations before, 4.6%. We analyzed the cases by two types of operations. One is a excision bullae with autosuturing divice, which we called type A, the other is suturing bullae with hand or looping ligation, which we called type B. In 259 cases, which did not have operations before, a recurrent rate of 236 cases operated by type A, was 5.1%. This rate was higher than that of other 23 cases operated by type B, 0%. In the 40 cases, which had operations before, a recurrent rate of 26 cases operated by type A, was 34.6%. This rate was similar to that of other 14 cases operated by type B, 35.7%. We divided the 40 cases into two groups. One is a group of 27 cases with additional reinforcement of visceral pleura, and the other is that of 13 cases without them. A recurrent rate of former group was 22.2%. This rate was lower than that of other group, 61.5%. Based on the analysis, it is considered that in cases not had operations before, a suturing bullae with hand or looping ligation is effective to prevent post operative recurrence, and in cases had operaions before, additional reinforcement of visceral pleura is effective.

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Pleural lavage cytology (PLC) at thoracotomy was performed in 359 patients with non-small cell lung cancer who underwent a curative resection. Twenty patients (5.6%) were found to be positive for PLC. The clinicopathological factors of the patients identified most frequently were 12 stage III (60.0%), 15 adenocarcinoma (75.0%), and 17 vascular invasion (85.0%). Furthermore, visceral pleural invasion (p0 and p1) was absent in 10 (50.0%) of the positive PLC 20 patients. Positive cytologic findings were more frequently observed in the patients with T3/T4, p2/p3, vascular invasion. The 5-year survival rate was 33.0% in the positive PLC patients and 61.2% in the negative PLC patients. A significant difference was observed between the two groups (p=0.003). Fourteen (77.8%) of 18 positive PLC patients with an observable post-operative course showed some form of recurrence. Regarding the recurrence patterns in the positive PLC findings, distant metastasis (10/14 [71.4%]) was observed more frequently than local recurrence (4/14 [28.6%]). Systemic recurrence was more common in the positive PLC patients. In conclusion, PLC was therefore found to provide useful information in the detection of a subgroup with a high-risk of recurrence. These findings suggest that additional therapies for local and systemic recurrences are thus necessary for patients with postive PLC findings.

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We developed a Critical Pathway (CP) for patients with video-assisted thoracoscopic surgery for spontaneous pneumothorax in April, 2003 for the purpose of shortening the length of hospital stay and reduction of the hospital charges. We reviewed 73 cases where the CP was applied. When we set the outcome to be discharge on the day after surgery, there were 13 variances(17.8%). Under the same national insurance system, the hospital charges were significantly reduced after the introduction of the CP(after: 64,303±3,843 points; n=35, compared with before: 69,354±12,052 points; n=44, p=0.026). Thus, the introduction of the CP was considered very useful in cost performance, but it was thought that an allowance for the discharge day was necessary.

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We report a resected case of pulmonary infection caused by Mycobacterium gordonae (M. gordonae) in a 70-year-old man. The patient has been treated for primary biliary cirrhosis with prednisolone (5mg/day) and for diabetes mellitus for years. He visited a clinic because of right chest pain, and abnormality on chest radiograph was first noted in February, 2004. He was referred to our hospital for further examination. Chest X-ray and CTrevealed a cavitary lesion in the upper lobe of the right lung. Culture of a bronchial washing specimen revealed acid-fast bacilli identified as M. gordonae by DNA-DNA hybridization. He was then observed with no medication for mycobacterium; however, he complained of hemosputum several times since March, 2005 and chest CT revealed infiltration around the cavity. After treatment with INH, RFP and EB, the radiographic findings showed improvement of the infiltrates and a right upper lobectomy was performed with a satisfactory result.

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The patient was a 38-year-old male. Chest CT showed an approximately 1 cm nodule shadow in S8 of the left lung. The margin of the nodule was relatively clear but a ground glass area surrounded it. Sputum cytology and CT guided needle aspiration cytology did not reveal malignancy but malignancy could not be ruled out absolutely on CT findings. Therefore, partial resection with video assisted surgery (VATS) was performed. As the location of the lesion was not identified under VATS, small thoracotomy was added. The lesion was identified by finger and partial resection was performed. The specimen was examined pathologically during the operation, and it was highly suspected as pulmonary infarction. We did not add further resection and finished the operation. This patient had polycythemia. It was possible that pulmonary infarction was due to this disease.

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The number of newly registered tuberculosis in 1997 increased compared to the previous year, making it the first rise in the last 38 years. We describe here one case of tuberculosis that occurred with mediastinal and abdominal abscess. A 65-year-old male visited our hospital with a swelling at the midline of his abdomen. CT revealed an encapsulated mass tracking from the anterior mediastinum to the abdomen. An incision was performed for diagnosis and treatment. The mass was found to be an abscess and its contents were of positive acid-fast bacilli by bacterial examination. Antituberculous therapy was initiated postoperatively.

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We report a case of a mediastinal lymphangioma accompanied with bilateral refractory chylothorax. A 53-year-old woman was admitted to our hospital for progressive dyspnea. Computed tomography (CT) of the chest revealed a mass measuring 4 cm in diameter in the right lower anterior mediastinum. Because of progressive dyspnea and a cough, thoracentesis was performed and the presence of a milky fluid was confirmed. The chylothorax was drained with a catheter, and daily drainage persisted at over 500ml. Complete resection of the anterior mediastinum mass and thoracic duct ligation were performed through a right thoracotomy. Histological examination diagnosed the tumor as benign lymphangioma. Postoperatively, with the persistence of chyle drainage greater than 1000ml per day, a second surgical intervention was undertaken on the 16th day after the first operation. After the second surgery, however, the patient continued to drain chylous discharge, and needed further chemical pleurodosis. On the 40th day after the first surgery, the patient developed left chylothorax too, and needed drainage tube insertion and chemical pleurodosis. The right and left chest tubes were removed on the 54th and 96th day after the first surgery, respectively. A 14-month follow-up period showed the patient to be in excellent health with no detectable signs of pleural effusion on chest roentgenogram.

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We report a case of 7 ring (3.5cm)-circumferential resection and end-to-end anastomosis of the trachea with suprahyoid release for adenoid cystic carcinoma. A 54-year-old man who had complained of dyspnea for over 6 months was referred to our hospital. Chest X ray, CT scan and respiratory examination revealed a midtracheal tumor, which was diagnosed as adenoid cystic carcinoma of the trachea. We performed 7 ring (3.5cm)-circumferential resection and end-to-end anastomosis of the trachea with suprahyoid release. Post-operative bronchofiberscopic findings showed good healing of the anastomotic site, and the post-operative course was uneventful. Suprahyoid release is a technically simple and useful procedure for extended upper and mid tracheal resection.

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A resected case of pulmonary atypical mycobacterial disease associated with acute myeloid leukemia with severe neutropenia is reported. A 55-year-old man was admitted because of acute myeloid leukemia. An abnormal shadow on chest X-ray was pointed out. The definite diagnosis did not be achieved by a bronchoscopy. By chest CT findings, the diagnosis of lung cancer or infectious disease such as pulmonary tuberculosis, pulmonary mycosis was suspected. Because a treatment of leukemia should be started as soon as possible, an operation was performed. The diagnosis of pulmonary atypical mycobacterial disease was made by an operative needle aspiration examination and segmentectomy of the left upper division was performed. In preoperative blood examination, white blood cell counts were 1460/μl, neutrophil counts were 226/μl, neutropenia were severe. We did not use G-CSF because it may promote the proliferation of blast cells. As an antimicrobial prophylaxis, panipenem betamipron and amikacin sulfate were administered according to IDSA guideline for febrile neutropenia. Postoperative course was uneventful and he had no complications such as postoperative pneumonia or wound dehiscence. It might be thought that a neutropenia did not always disturb an enforcement of pulmonary resection.

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A 57-year-old male had undergone a right sleeve pneumonectomy combined resection of SVC after induction chemotherapy for lung cancer. On the 8th postoperative day, dehiscence occurred. Re-closure and omentopexy was performed on the 10th postoperative day. Bronchoscopy revealed that dehiscence occurred 7 days after reoperation, but it spontaneously healed, because the omentum had an anti-infection effect and vascular growth effect. Because sleeve pneumonectomy combined with resection of other organs after induction chemotherapy has a very high risk of dehiscence, it may be advantageous to perform omentopexy at the same time.

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We report a case of solitary fibrous tumor originated from the pleura of the diaphragm. A 76-year-old woman was admitted because of an abnormal shadow on chest X-ray. CT scan revealed a solid giant mass in the right thoracic cavity and she was diagnosed as SFT by needle biopsy. After embolization of the right inferior phrenic artery, which was the main feeding artery to the tumor, operation was performed. The tumor was 21×17×10cm in size and weighed 2070g. Histologically, the tumor was diagnosed as SFT without malignancy. The postoperative course was uneventful, and she was discharged on the 11th day after surgery. The patient has been followed up for 1 year and 9 months with no evidence of reccurence. We experienced a rare case of SFT originated from the pleura of the diaphragm. The tumor is apt to be discovered after becoming giant. MRI was useful for close inspection of the area surrounding the diaphragm.

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A 56-year-old man, whose serum carcinoembryonic antigen (CEA) level had been 7.3ng/ml (nomal <5.0) in 1990 and increased gradually to as high as 237.9ng/ml in 1997, was referred to our hospital to investigate the causative malignancy. Chest computed tomography (CT) revealed a small irregular opacity 1cm in diameter in the right S3, and pretracheal (#3) lymphadenopathy. Exploratory thoracotomy was performed and the diagnosis of lymph node metastasis of adenocarcinoma was obtained by frozen sectioning. Subsequently, right upper lobectomy and mediastinal lymph node dissection were performed (pT1N2M0). The serum CEA level, which once dropped to 6.5ng/ml postoperatively, began to increase again, but repeated whole body screening, including F-18 fluorodeoxyglucose-positoron emission tomography (FDG-PET), couldn't reveal any recurrence or distant metastasis. In 2004, the serum CEA level reached up to 874ng/ml, and finally FDG-PET detected a minute abnormal uptake at the right sacroiliac joint, which was diagnosed as bone metastasis. Here, we report a case of latent lung cancer with elevated serum CEA whose primary site and metastasis could not be confirmed for many years in spite of repeated whole body screening.

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A 73-year-old female was admitted with an abnormal shadow on chest XP. Her chest CT showed the presence of a 3×3cm tumor with calcification in the left anterior mediastinum. Video-assisted thoracoscopic surgery was performed. The resected tumor measured 4.5×2.7cm, and it had a hard capsule due to calcification. This cystic tumor was filled with a soft brown tissue. Pathological examination revealed the presence of a mediastinal cyst of unknown origin because epithelial cells were not present on the inner surface of the cystic wall. Based on tumor localization and pathological findings, we suspected that this tumor was a thymic cyst with dystrophic calcification resulting from chronic inflammation.

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Hemangioma in the chest wall is a very rare entity. We report the case of a 16-year-old boy who presented with intercostal hemangioma of the right chest wall. Computed tomography and magnetic resonance imaging revealed a soft tissue mass arising from the 2nd intercostal space, which was rich in vasculature. The patient underwent surgery. Under thoracoscopical observation, the hemangioma-like tumor was localized under the parietal pleura and was removed with an internal layer of intercostal muscle, without removing any bone. Histopathological examination confirmed the diagnosis of intramuscular hemangioma. The patient has had no recurrence of the tumor in the 6 months since the surgery.

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A 5-year-old girl was referred to our hospital with a fever and cough. Radiological and laboratory studies revealed a lung abscess in the right upper lobe due to compression of the right upper bronchus by a mediastinal cystic tumor. The tumor was extirpated and diagnosed pathologically as a congenital esophageal cyst. However, the lung abscess did not improve and a right upper lobectomy was performed 14 days after the first operation. The postoperative course was uneventful. We analyzed 165 cases of esophageal cysts reported in the Japanese literature, including the present case. Of 137 cases with information regarding age and symptoms available, 80 (58.4%) had a total of 101 symptoms. Twenty four pediatric patients (64.9%) had a total of 32 symptoms and 56 adult patients (56%) had 69 symptoms. The main symptoms were respiratory related in pediatric patients (87.5%), while gastroenteric symptoms were predominant (73.2%) in adult patients. In contrast, lung abscess was a rare complication being reported in only 3 patients.

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A 59-year-old man presented with a subcutaneous mass (3cm in diameter) adjacent to the processus xiphoideus. Computed tomography (CT) demonstrated an anterior mediastinal tumor (10cm in diameter), continuous with the subcutaneous mass in the anterior chest wall. Preoperative diagnosis was chondrosarcoma (grade 2) based on percutaneous incision biopsy. We inspected the thoracic cavity using a thoracoscope and judged that the tumor was resectable. The line for isolating the chest wall (sternum and ribs) was based on tumor location under a videoscopic view. The tumor (8×7×4 cm in diameter) was completely removed surgically, and the chest wall was reconstructed using mesh. Histological diagnosis was chondrosarcoma arising from the sternum. The patient is currently well and has had no recurrence for one year.

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We encountered a case of thymoma, which showed spontaneous regression after rapid growth. A 25-year-old male was admitted to our hospital because of fever and sudden severe pain in his chest and back. Chest radiograph, CT and MRI showed an anterior mediastinal tumor measuring 9.0×5.5×10.0cm. The histological findings of a CT-guided needle biopsy suggested that the tumor was a thymoma. One week after admission, the fever and pain disappeared and the tumor spontaneously decreased by 30% in maximum diameter. Total thymectomy was performed to confirm the diagnosis. Histopathologically, the tumor was composed of hemorrhagic and necrotic foci and a few viable tumor cells were found in the sub-capsular region which was diagnosed as thymoma, WHO classification type B1. Thymoma should be noted as a differential diagnosis when an anterior mediastinal tumor shows spontaneous regression.

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We describe a case of left lung cancer in a 65-year-old male with a right aortic arch and an aberrant left subclavian artery. The tumor was of the non-small cell type in the left upper lobe, with upper mediastinal lymph node metastases. After induction chemotherapy, we performed a left upper lobectomy accompanied by lymph node dissection. Mediastinal lymph nodes could be dissected easily because the aortic arch was positioned on the right side. On the other hand, we had to pay attention to the pathway of the left recurrent laryngeal nerve and identify lymph node stations in the mediastinum. For safe surgery, preoperative assessment of the pathway of arteries and nerves is very important. In this case, CT scans were applied to anticipate the anatomical position of the left recurrent laryngeal nerve from an embryological point of view. As a result, we were able to perform the surgical operation without difficulty.

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The patient was a 39-year-old female in whom an abnormal shadow was found in the thoracic region on a medical check-up, and chest CT detected shadows of multiple nodules in the bilateral lung fields on thorough examination. A tumor shadow measuring 40mm in diameter near S⁶ in the left lung was difficult to differentiate from tumors of the chest wall. Thoracoscopic biopsy was performed for diagnosis. Histopathologically, homogenous spindle-shaped tumor cells proliferated in a complicated arrangement. The tumor was diagnosed as a benign metastasizing leiomyoma based on immunostaining, hormone receptor positivity, and a medical history of uterine leiomyoma.

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