A retrospective study comparing pre-/intra-operative and postoperative antibiotic prophylaxis was performed for patients who had undergone pulmonary lobectomy and segmentectomy. The JSS group (n=72) received 2nd-generation cephem or penicillin at 1g every 12 hours after the operation for 3-4 days. The CDC group (n=82) received cefazolin at 1g at 30 minutes before the operation and 1g every 3 hours during the operation. The total administration dose was 9.3g in the JSS group and 2.9g in the CDC group. The overall rate of infection did not differ between the JSS group (12.5%) and CDC group (13.4%). The most frequent infection was pneumonia. Surgical site infection did not occur. Two sepses were noted only in the CDC group. No significant intergroup difference was found concerning the clinical characteristics, pathogens from the infection site, and the perioperative circulating white blood cell counts and C-reactive protein levels. The prophylactic effect on postoperative infection was equal in both groups. Postoperative antibiotic administration can be recommended for elderly patients with comorbidity to prevent postoperative sepsis.

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This study was aimed to estimate the safety and efficacy of covering the visceral pleura with a polyglycolic acid (PGA) sheet and autologous blood following thoracoscopic surgery for spontaneous pneumothorax. We retrospectively evaluated the results of the two different methods. Between December, 2001 and December, 2005, 32 consecutive patients (PGA and autologous blood group) with primary spontaneous pneumothorax were treated by thoracoscopic bullectomy followed by covering visceral pleuras with a PGA sheet and autologous blood. The conventional group consisted of 26 consecutive patients treated by thoracoscopic bullectomy only between March, 1995 and November, 2001. There were no significant differences between the two groups in terms of operation time, operative blood loss, drainage period, and hospital stay. Otherwise, the recurrence rate was lower in the PGA and autologous blood group. (0% vs 11.5%) The method of covering the visceral pleura with a polyglycolic acid sheet and autologous blood is safer and more effective than the conventional method.

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Although there is no standard method concerning the prophylactic use of antibiotics to prevent surgical site infection (SSI), the method based on the CDC (Center for Disease Control) guideline has recently become generally adopted. Because we have administered this method since 2004, we investigated its feasibility. We retrospectively reviewed the clinical records of patients who received antibiotics only on the day of surgery (group A: n=101), and patients who received them for two days or more (group B as a historical control: n=98). The incidence of SSI was similar between both groups (1% vs. 2%, p=0.5431). Prophylactic use of antibiotics only on the day of surgery might be feasible in pulmonary lobectomy.

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Generally, an operation for pneumothorax is performed under general anesthesia, however, we often have to consider the risks of general anesthesia for high-risk patients. We have operated on cases of intractable pneumothorax under local anesthesia in such high-risk patients. The experience consisted of 12 cases of intractable pneumothorax treated by thoracoscopic surgery under local anesthesia between April, 1996 and March, 2005. The patients consisted of 11 males and one female, with a mean age of 71 years old. All cases but one had a high risk for surgery under general anesthesia, and one patient refused an operation under general anesthesia. The mean total operation time was 50 minutes. There were no intraoperative complications, but there was one death resulting from postoperative pneumonia and empyema. Nine cases achieved surgical success, and their bullae were identified intraoperatively. If surgical indication is examined carefully and preoperative evaluation is performed sufficiently, thoracoscopic operation under local anesthesia is effective, and is thought to be one of the valuable surgical procedures.

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Atypical adenomatous hyperplasia (AAH) and bronchioloalveolar carcinoma (BAC) often occur around adenocarcinomas, showing ground-glass opacity (GGO) on high resolution CT (HRCT) scans. Here, we report three cases of multiple GGOs. Each case showed different numbers, appearances, and locations of GGO, making it difficult to establish a standard therapy. When we deal with multiple GGOs, we must formulate a suitable therapeutic strategy for each case including the type of operation. As for the residual GGOs after an operation, we must observe carefully the size, appearance, and density of GGOs on HRCT scans, and, if we recognize any change, we must consider further treatment including re-operation, radiotherapy, and chemotherapy.

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A 72-year-old man with a history of tuberculous pleuritis at the age of 19 presented with exertional dyspnea for 6 months. A right lower opacity in the chest roentgenogram had been pointed out since he was 61 years old. The mass was 19 cm at the maximum diameter and compressed the mediastinum. With a diagnosis of chronic expanding hematoma of the thorax, the patient underwent extirpation of the hematoma with the whole capsule. Since the hematoma adhered strongly to the lung and diaphragm, it was removed with the combined resection of the middle and lower lobe of the lung and the hemidiaphragm, which was reconstructed with a polypropylene mesh. The postoperative course was uneventful. Exertional dyspnea was resolved with improved pulmonary function.

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A healthy 52-year-old male presented himself in the emergency department with a 2-week history of epigastralgia. During physical examination, the patient suddenly complained of severe dyspnea and then shock ensued. Thoracoabdominal CT showed a strangulated ileus and pneumothorax in the left thoracic cavity. Dexter deviation of the mediastinal organs and insufficiency of right lung expansion were observed, and an emergency operation was performed. The stomach, small intestine, colon, greater omentum, and spleen were herniated to the left thoracic cavity through the postero-lateral diaphragmatic defect. Intraoperative findings indicated a diagnosis of congenital Bochdalek hernia. The inflammatory mass in the meso-appendix originating from the appendix was strongly adherent to the colon. The lobes of the left lung were the size of fist because of a pulmonary hypoplasia. Ileocaecal resection, splenectomy, and resection of the extensive necrotic small intestine were performed. The hernial defect was repaired in two overlapping layers with interrupted mattress sutures after restoration of the herniated organs via laparotomy. In emergency cases with multiple herniated organs and whose cardiorespiratory function is unstable, surgery with rapid and safe manipulation should be recommended through simultaneous thoracotomy and laparotomy.

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We report two cases of mature teratoma perforating the lung. Case 1: A 19-year-old woman complained of chest pain. Chest CT revealed an anterior mediastinal tumor. Surgery was performed and the tumor was strongly adhered to the right upper lobe. Extirpation was performed with a right lung partial resection. Histological findings showed a mature teratoma with many pancreatic tissue glands. Case 2: A 35-year-old women experienced right chest pain and hemosputum. Chest X-ray showed a large mass in the right middle lung field. Chest CT showed a cystic tumor in the anterior mediastinum. Chest MRI revealed that the cystic tumor contained a fatty component suggestive of mature teratoma. In the surgical findings, the tumor had perforated the right lung and extirpated the right middle lobe. There are a very variety symptoms in adult mature teratomas. In some cases, a definite diagnosis is very difficult. In our case, MRI findings were effective for an accurate diagnosis and surgical treatment.

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In a 67-year-old woman, mastectomy was performed for breast cancer, and the follow up study is currently proceeding. The serum CEA level gradually elevated. Chest X-ray and CT examination revealed a tumorous lesion. Although the histology of TBLB and cytological material showed no malignancy, the serum CEA level was elevated (40.6ng/ml). Therefore, it seemed impossible to neglect the possibility of lung cancer and a right lower lobectomy was performed. The dissected specimen was diagnosed as organized pneumonia showing squamous metaplasia. Immunohistochemical staining for CEA was positive at the region of metaplasia. The postoperative serum CEA level was reduced (8.9ng/ml). The elevated serum CEA level made it difficult to diagnose this case.

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A 57-year-old woman was admitted to our hospital for further examinations of an abnormal shadow of the left lung field on chest X-ray films. Chest CT revealed a mass shadow, measuring 1cm in diameter, in S⁸ and an infiltrative shadow in S⁵. Lung biopsy was performed for the mass of S⁸ and the infiltrative shadow of S⁵ by video-assisted thoracoscopic surgery (VATS). Pathologically, the specimens of S⁵ and S⁸ revealed pulmonary MALT lymphoma and an intrapulmonary lymph node, respectively. Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma, which shows various features on radiologic findings, is difficult to definitively diagnose. It is considered that the occurrence and growth of both pulmonary MALT lymphoma and intrapulmonary lymph node are associated with chronic inhaled antigen stimulation, and it is presumed that this association existed in our case. It was thought that careful management is necessary for cases indicating mass lesions on biopsy by VATS that are probably of intrapulmonary lymph nodes with an infiltrative shadow.

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A 61-year-old male was referred to our department due to the presence of a mediastinal tumor detected by chest X ray film and CT scan. The CT scan showed a mass lesion raised from the right middle mediastinum and a marginal dominant enhancement effect inside this lesion. The tumor compressed the superior vena cava and phrenic nerve strongly without invading the surrounding tissue, and was resected completely by the three-ports-VATS technique. The diagnosis of solitary fibrous tumor was made by pathological examination and immunohistochemical study. Solitary fibrous tumors most frequently arise in the visceral pleura and are rarely observed in the mediastinum. This technique could be one of the options to resect solitary fibrous tumors compressing the SVC and phrenic nerve.

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A 40-year-old woman who showed upon routine check-up an abnormal mass shadow in the right lung was admitted to our hospital. Chest CT scan showed a mass shadow in the right S4. Preoperative diagnosis was not obtained. As an intra-operative frozen section showed carcinoma, a right middle lobectomy with lymph node dissection was performed. A definitive histologic examination demonstrated a choriocarcinoma. The pathological classification was T1N0M0, stage IA. Although the serum HCG and beta-HCG levels were still high at 1 week after surgery, these values returned to normal limits at 3 weeks after surgery. Chemotherapy was started at 4 weeks after surgery and consisted of Methotrexate, Actinomycin D, and Cyclophosphamide. At 7-year follow-ups, the patient was alive with no recurrence.

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We report a 76-year-old man who underwent surgery for a clear cell adenocarcinoma detected on a health checkup. Chest computed tomography (CT) revealed a tumor at the S³ of the left lung. Transbronchial lung biopsy did not lead to a definitive diagnosis, and partial resection of the left lung was performed. Because rapid pathological diagnosis using a frozen specimen suggested adenocarcinoma, superior lobectomy of the left lung and mediastinal lymph node dissection were performed. Systemic diagnostic imaging before and after surgery did not reveal any tumorous lesion in other organs, and the clinical findings suggested a primary tumor of the lung. Postoperative pathological investigation showed that clear cells comprised 90% or more of the lesion, with small foci of papillary structure. Immunohistochemically, the tumor was positive for keratin, EMA, thyroid transcription factor-1, and surfactant apoprotein A, and negative for HMB45, suggesting a primary clear cell adenocarcinoma of the lung. There has been no recurrence during the 22 months of postoperative follow-up.

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A 24-year-old woman complained of pain and swelling of the left-sided cervix. Cervical echography revealed congestion of the left cervical vein. Both chest CT and MRI revealed a tumor in the anterior mediastinum, which compressed the innominate vein and showed thrombus formation. The tumor was suspected to be a mature teratoma complicated with mediastinitis and thrombophlebitis of the innominate vein. We resected the tumor and removed the thrombus through a median sternotomy. The histological diagnosis of the resected tumor was a mature teratoma. This mature teratoma associated with thrombophlebitis of the innominate vein is the first reported case as far as we know.

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A 53-year-old woman with a mass in the anterior mediastinum was admitted to our hospital. Video assisted thoracic surgery was performed for extirpation and the postoperative diagnosis was bronchogenic cyst of the thymus. Such cysts are commonly located in the middle mediastinum. Herein, we report a rare case of a bronchogenic cyst of the thymus in the anterior mediastinum.

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A 37-year-old female was admitted to our hospital for recurrent fever and neck pain. Chest radiography and CT demonstrated a multilocular cystic lesion with niveaus at the right side of the trachea in the lower neck. Symptoms reduced following antibiotic therapy. However, infection of the cervical cyst occurred twice. Thus, the patient was operated on via a transverse neck incision. Histologically, the cyst consisted of ciliated columnar epithelium and was diagnosed as a cervical bronchogenic cyst. No recurrence has occurred for 18 months. This is the 16th reported case of cervical bronchogenic cyst in the Japanese literature and, among these, only our case shows multilocular cyst.

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A 38-year-old woman was referred to our hospital with the complaint of hemoptysis. At the age of 8, she underwent right middle and lower bilobectomy due to bronchial carcinoid. Thirty years later, a mass adjacent to the bronchial stump was noted. Under the diagnosis of recurrent carcinoid, right completion pneumonectomy was performed. Postoperative pathological examination revealed lymph node recurrence of typical carcinoid. Our experience indicates that lymphadenectomy in addition to pulmonary resection and long-term follow up are necessary even for a case of typical carcinoid.

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A 20-year-old male was diagnosed with a lung abscess. He was treated with antibiotics as an outpatient. But the lung abscess showed deterioration on chest X-ray and chest CT. He was consequently admitted to our hospital. Although we changed and increased the dose of anbiotics, the lung abscess showed no improvement. So, we considered surgical treatment. At first, we performed percutaneous lung drainage. The lung abscess was improved temporarily, but the abscess cavity subsequently enlarged and the wall of the cavity became thin. Then, we performed a left upper division segmentectomy. No complications occurred during the operation. Lung abscess may still require surgical treatment on a case by case basis.

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The patient was a 63-year-old woman. An abnormal shadow on X-ray films was noted. Chest computed tomography revealed a 2 cm nodular shadow with an irregular margin and cavity, and F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) showed accumulation in the nodule. We suspected primary or metastatic lung cancer, and therefore, partial resection of the lung was performed to diagnose and treat the tumor. The pathologic sample revealed Dirofilaria immitis. It is difficult to differentiate lung cancer from pulmonary dirofilariasis because pulmonary dirofilariasis often shows CT findings similar to lung cancer and is false-positive on FDG-PET. Pulmonary dirofilariasis must be kept in mind as a probable diagnosis when an abnormal shadow is observed in the lung.

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