Five cases of complete tracheobronchial transection caused by injury were examined. Patients' ages ranged from 18 to 28 years old, with 4 men and 1 woman. Four cases involved traffic injury, and one was due to a fall. The sites of injury were the left main bronchus, the carina, the right main bronchus, between the middle and inferior lobar bronchus, and the right intermediate bronchus, respectively. The former 4 cases underwent bronchoscopy before surgery, and injury sites were confirmed in all cases. The interval until surgery ranged from 8 hours to about 5 days. All cases underwent open surgery, and all underwent tracheobronchoplasty. Methods of suture were continuous and knotted suture in one case, continuous suture in two, and knotted suture in two. None of the cases showed any stenosis post operatively. Two cases developed complications such as pneumonia, but all patients survived. Early surgical procedure and adequate intensive care was important in saving the patients' lives.

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Objective: Postoperative air leakage remains a major cause of morbidity after lung resection. The aim of this study was to evaluate the optimum application technique of fibrin sealant and PGA felt for the treatment of alveolar air leakage in lung surgery. Methods: First, viscosity, osmolarity, and specific gravity of a fibrin sealant product were measured. Next, pleural defects, 20×30mm with a depth of 1.0mm, in heart-lung blocks retrieved from male swines were covered with fibrin glue and polyglycolic acid (PGA) felt using the following six different application techniques and the minimum seal-breaking airway pressure (SBP) was compared among groups: Spray of fibrinogen (F) and thrombin (T) solutions without PGA felt (Group I, Control Group, n=8); Rubbing of T solution, attachment with PGA felt soaked in F solution, and application of the other half of T and F solutions by drops (group II, Morikawa II Group, n=5); Rubbing of F solution, attachment with PGA felt soaked in T solution, and application of the other half of F and T solution by drops (group III, Reverse-Morikawa II Group, n=5); Rubbing of F solution, attachment with dry PGA felt, and spray of both solutions (group IV, rubbing and Spray Group, n=5); Spray of both solutions, attachment with dry PGA felt, and spray of the other half of both solutions (group V, Spray Sandwich Group, n=7); Attachment with dry PGA felt, and spray of both solutions (group VI, Dry felt and Spray Group, n=5). Results: The viscosity of F and T solution was 49.8±4.5 (mPa·S) and 1.43±0.04 (mPa·S). The osmolarity of F and T solution was 845±14 (mOsm) and 243±1.0 (mOsm). The specific gravity of F and T solution was 1.048 and 0.978. There was no significant difference between seal-breaking pressures (SBP) in Group I (19.23±5.05cmH₂O) and II (18.54±4.13cmH₂O). The SBP in Group III (57.14±19.9cmH₂O) was significantly higher than that in Group II, V (29.41±13.26cmH₂O), and VI (18.50±2.60cmH₂O) (P=0.006, 0.0054, 0.0006, respectively). SBP in Group IV (41.74±24.7cmH₂O) was significantly higher than that in Group II and VI (P=0.026, 0.026, respectively). Histologically, adhesion between the lung and sealant was best in Group III, with significant penetration of the fibrin gel into the lung tissue compared to other groups. Conclusion: The technique in Group III, the Reverse-Morikawa II technique, is the most effective and reasonable combination for the treatment of alveolar air leakage based upon the physical properties of the fibrin sealant.

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We reviewed 16 cases of acute empyema, which underwent video-assisted thoracoscopic surgery (VATS) from January 2003 to December 2005. The patients were 13 males and 3 females, and ranged from 25 to 82 years (mean: 61 years) of age. The duration of preoperative symptoms, postoperative drainage, and postoperative hospital stay were 10 to 50 days (median: 26 days), 9 to 62 days (median: 12.5 days), and 14 to 106 days (median: 22.5 days). All patients were discharged and there were no operative mortalities. Ten cases were operated on in the fibropurulent phase and 6 cases in the organized and chronic phase. Operations were performed through 2 ports in 9 patients and 3 ports in 6 patients. One patient with chest wall abscess needed mini-thoracotomy, but no patients required conversion to standard open thoracotomy. As for complications, empyema recurred in 3 patients and airleak persisted in 1 patient. These patients were cured by conservative treatment or second VATS debridement. VATS is a safe and effective method in the management of acute empyema, and it is favorable to perform it in the fibropurulent phase. However, it is also effective in the early organized and chronic phase. In cases of acute empyema caused by methicillin-resistant Staphylococcus aureus (MRSA), it may be recommended to add postoperative treatment such as irrigation of the pleural cavity, because empyema often recurs.

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Background: Recently, CT scans have been used broadly. More frequently, very small lung adenocarcinomas 10mm or less in diameter have been detected. However, there have been few investigations on these small lung cancers, and a treatment strategy for these tumors has not yet been clarified. Therefore, we reviewed our experience of resected lung adenocarcinoma cases 10mm or less in diameter. Method:The records of all patients were reviewed who had undergone resected peripheral lung adenocarcinoma 10mm or less in diameter at Fukuoka University Hospital from January, 1999 through October, 2006. Results:The study included 21 patients (5 men and 16 women) with a median age of 66 years (range: 49 to 82 years). Thirteen women (61.9%) had no Smoking history. All patients had Solitary tumors, and no symptoms. In 11 patients (52.4%), image pattern of tumors on CT scan showed ground-glass opacity (GGO) which occupied more than 50% of the whole area. Fifteen tumors (71.4%) were detected by CT scan. Tumor diameters ranged from 4 to 10mm. Tumors of 18 patients (85.7%) were well differentiated adenocarcinoma(G1). Twenty patients (95.2%) had a confirmed diagnosis during the operation. Fifteen patients (71.4%) had preoperative comorbidities. Lobectomy was performed in 8 patients (38.1%), and limited resection in 13 patients (61.9%). No patients had lymphnode metastasis, and all were stage IA. Follow-up ranged from 0.2 to 77.6 months (median: 16. 6 months). One patient (4.8%) developed recurrent lung cancer with metastasis, who had undergone complete resection for a tumor without GGO. Conclusion: Metastatic recurrence can occur in patients with small lung adenocarcinoma even if 10mm or less in diameter. In the treatment of such tumors, the nature of each tumor should be considered carefully.

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According to the General Rule for Clinical and Pathological Record of Lung Cancer, interlobar pleural invasion (interlobar p3) of non-small cell lung cancer (NSCLC) is categorized as T2 and parietal pleural invasion as T3. We examined whether the category is adequate concerning the prognosis and operative procedure selected for the treatment of the adjacent lobe invaded by cancer. Among 634 patients who underwent operation for primary NSCLC in our hospital between 1992 and 2001, this study was targeted for 20 patients with interlobar p3. The outcome of the 182 patients with T2 excluding interlobar p3, and 61 patients with T3 were compared. The 5-year survival rate for patients with interlobar p3 was 62.5%, T2 excluding interlobar p3 was 48.5%, and T3 was 28.7%. Whereas there was no significant differences in survival between patients with interlobar p3 and with T2 excluding interlobar p3, the survival rate for patients with interlobar p3 and with T2 excluding interlobar p3 was significantly higher than that with T3. There were no significant differences in survival rate and locoregional recurrence between the type of operative procedure selected for the treatment of the adjacent lobe invaded by cancer. It is adequate that interlobar p3 is categorized as T2 and the optical operative procedure is considered to be a partial resection of the adjacent lobe.

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This report describes two patients who underwent completion pneumonectomy about 2 years after undergoing left upper sleeve lobectomy. A 68-year-old man had received induction chemotherapy/radiothe-rapy and undergone surgery for small cell lung cancer 21 months previously. He underwent completion pneumonectomy for squamous cell lung cancer diagnosed as a second non-metastatic primary lung cancer. As of 6 years and 8 months after the second operation, he was alive and disease-free. A 70-year-old man who had been treated surgically for squamous cell lung cancer 24 months before, experienced local recurrence and underwent completion pneumonectomy. The operation was initiated by median sternotomy and accomplished by posterolateral thoracotomy. The left main pulmonary artery was dissected with an intrapericardial approach to prevent vascular injury. The patient died of the recurrent disease 20 months after the second operation. At the second operation, both patients were found to show the main pulmonary artery bending and ascending toward the apex of the lung to a greater extent compared to those undergoing upper lobectomy. Our experience in the second patient suggests that median sternotomy may facilitate intrapericardial management of lung vessels during completion pneumonectomy.

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In 3 patients with solitary fibrous tumor of pleura (SFTP), we performed video-assisted thoracic surgery (VATS) for inspection or resection and reported that the preoperative angiography was useful for the giant SFTP. In this report, we describe the cases, and effectiveness of VATS in managing SFTP. Case 1: A 75-year-old woman was found to have a right pleural tumor (3cm) on chest XP and CT. We performed VATS resection for the SFTP of the right middle lobe. Case 2: A 67-year-old woman was found to have a pleural tumor (5.7×4.7cm) on chest CT and MRI. We performed VATS for inspection of the thoracic cavity, and identified a pedunculated SFTP on the chest. The tumor was removed with a mini-thoractomy under the videoscopic view. Case 3: A 59-year-old woman with an un-diagnosed giant tumor (22×11cm) in the left side of the thoracic cavity had noticed exertional dyspnea. We performed VATS for inspection of the thoracic cavity after angiography, and identified a pedunculated SFTP on the diaphragm. We converted from VATS to postero-lateral thoractomy, and removed the tumor in combination with partial resection of the diaphragm and lung. These tumors were completely removed in all cases. After 11-29 months of follow-up, all patients are alive without recurrence.

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A 78-year-old man was admitted to our department for a routine screening chest X-ray film demonstrated a pulmonary solitary nodule. Ten years ago, he underwent left nephrectomy for renal cell carcinoma and the postoperative course was uneventful. Chest radiography and computed tomography disclosed a round-2cm mass in the right lobe (S⁹) of the lung. Transbronchial lung biopsy did not reveal malignancy, however malignant lung tumor presence could not be denied. Therefore, video-assisted thoracic surgery was performed and the tumor was completely resected by a partial resection of right lower lobe(S⁹). Intraoperative pathological examination revealed metastasis of renal cell carcinoma, clear cell type. This is a rare case of solitary metastasis of renal cell carcinoma occurring 10 years after radical nephrectomy.

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A 77-year-old male was identified as having a 4.5cm middle mediastinal tumor in the subcarinal region on chest CT by medical examination for the detection of pulmonary metastasis of caecal cancer. Gadolinium (Gd)-DTPA-enhanced MRI showed the tumor with the Target Sign, i. e., signal intensity of the mass was low on T1-weighted MRI, and the center of the mass was enhanced by Gd-DTPA. A neurogenic tumor was suspected on radiological findings. Transbronchial needle aspiration biopsy (TBNA) and endoscopic ultrasonography-guided fine needle aspiration biopsy (EUS-FNA) were performed, but did not lead to a definitive diagnosis. For the diagnostic and therapeutic modality, resection of the tumor by open thorachotomy was performed. The tumor was diagnosed as Schwannoma originating from the left vagus nerve by operative findings and on pathological examinations. In the preoperative diagnosis of the middle mediastinal tumor, it was suggested that both radiological examinations and aspiration biopsies such as TBNA and EUS-FNA were useful.

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A 58-year-old male was referred to our hospital for investigation of an abnormal chest shadow. He was receiving nasal continuous positive airway pressure (nCPAP) therapy because of obstructive sleep apnea syndrome (OSAS). Computed tomography revealed an irregular pulmonary nodule, 15 mm in diameter, between S² and S⁶ in the right lung. Because the nodule became enlarged, partial resection of the right lung was performed using an ultrasonic scalpel in April 2005. Intraoperative pathologic examination revealed that the nodule was a fibrous scar. Air leakage was not observed and the chest tube was removed on postoperative day 2. Even though he did not receive nCPAP therapy, his postoperative course was uneventful and he was discharged on day 7. At the time of re-starting nCPAP therapy at home, the patient developed right chest pain and he turned off the nCPAP apparatus. Chest X-ray and CT showed a thin-walled cavitating shadow between S² and S⁶, which suggested that nCPAP therapy triggered late-onset air leakage. The pulmonary cavity was reduced in size 3 months later and had disappeared by 6 months after the operation.

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An asymptomatic 43-year-old female was admitted to our hospital with an abnormal shadow on her chest X-ray. Close examination revealed a 35 mm right anterior chest wall tumor located in the first intercostal space and she underwent video-assisted thoracoscopic surgery. The tumor adhered to the ribs and was resected with periostea and intercostal muscles. No malignant cell was identified during intraoperative examination and the operation was completed. Pathological diagnosis after the operation was myofibroma. Six months later, she had a relapse in the right apex. The tumor extended from the 1^st to the 4^th rib, suspected to have invaded the subclavian vein. With an anterior approach (median sternotomy, right hemi-collar incision, and 4^th intercostal thoracotomy), she underwent partial resection of the 1^st to the 4^th rib, sternum, right clavicle, and the right upper lobe, and chest wall reconstruction. Histological diagnosis was inflammatory myofibroblastic tumor (IMT). She's been alive for 20 months without any recurrence.

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A 70-year-old man complained of hemosputum, and chest X-ray and computed tomographic scan of the chest showed a mass, 4cm in diameter, in the right lower lobe of lung. Transbronchial biopsy of the mass in the right S¹⁰ segment revealed pulmonary undifferentiated carcinoma. Distant metastases could not be detected (stage IB). Then a right lower lobectomy with lymph node dissection was performed. Pathological examination revealed that tumor cells are spindle cells and positive for cytokeratin and vimentin. Taken together, the tumor was diagnosed as pulmonary spindle cell carcinoma (stage IB). One month after operation, the carcinoma metastasized to liver, bilateral adrenal gland, pancreas, thoracic vertebrae (Th ^6th and 7^th), right pleura, and left lower lobe of the lung, and the patient died five months after surgery. This case suggests that lung spindle cell carcinoma has the possibility of rapid recurrence after complete resection and needs strict follow-up.

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We present herein a rare case of multiple pulmonary sclerosing hemangiomas arising in an asymptomatic 22-year-old man. He was referred to our hospital because of abnormal shadows on chest X-ray film. Chest X-ray and computed tomogramphy (CT) scans of the chest showed multiple small nodules in the lower lobe of the right lung. He underwent partial resection of the lung to confirm the histological diagnosis. During the operation, in addition to the main tumors, innumerable minute nodules were found on the surface of the lower lobe of the right lung. No such lesion was found in other lobes. The resected specimen revealed multiple sclerosing hemangiomas. He has been doing well with neither nodule growth nor new lesions for 14 months to date after the operation.

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A 48-year-old man with moderate dyspnea (Hugh-Jones III) and bilateral giant emphysematous bullae (total volume, about one half of the left thoracic cavity) underwent video-assisted thoracoscopic surgery (VATS) of the left-sided giant emphysematous bullae. In spite of pressure limiting ventilation without nitrogen oxide during surgery, the patient developed severe respiratory failure due to right-sided over-inflation and atelectasis. The respiratory failure gradually resolved with spontaneous respiration and we decided not to perform the contralateral, emergency surgery under ECMO. He was extubated on the first postoperative day, moved from the intensive care unit on the third postoperative day, and discharged in good condition on the eighteenth postoperative day. Two months later, he underwent elective VATS for the right-sided giant emphysematous bullae. Postoperatively, pulmonary function was significantly improved and his dyspnea disappeared (Hugh-Jones I).

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A 70-year-old man underwent a left upper lobectomy under the diagnosis of left squamous cell lung cancer. A high fever of 39°C developed on the 4th postoperative day. Staphylococcus aureus was detected in the pleural dischage on the 6th postoperative day. Chest CT scan on the 7th postoperative day revealed an abcess cavity, into which a 12 Fr catheter was inserted by the CT-guided procedure. Intermittent pleural irrigation was started on the same day, however pneumonia and sepsis developed. From the 11th postoperative day, continuous drip injection into the pleural cavity with a normal saline of 250ml/hr was initiated. The patient recovered from empyema on the 27th postoperative day. Continuous irrigation needs troublesome maintenance of the devices. Thus, we developed the new system using a conventional chest drainage bag connected with a suction device. Continuous pleural irrigation using this system was very effective and convenient for acute empyema.

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A 58-year-old woman was hospitalized with a persistent cough. Chest X-ray showed abnormal shadows. Chest CT showed 4 pulmonary shadows less than 3cm in diameter, three of which were in the right lung field and one of which was in the left lung field. The findings of her transbronchial lung biopsy were normal. The shadows were suspected of being metastatic tumors, but there was no neoplasm without pulmonary shadows. In her past history, she underwent mandibular tumor resection when she was 19 years old, and resection again when the mandibular tumor recurred 10 years later. She was referred to our hospital for surgery. Video-assisted right lung wedge resection was performed. The tumors were diagnosed as ameloblastoma with frozen sections. The tumors were pulmonary metastases of the mandibular tumor, which was resected 39 years before. Most ameloblastomas as odontogenic epithelial tumors are benign with a metastatic ratio of 2-5%. Some cases have been reported after a delay of more than 10 years from initial treatment. The present case is very rare as 39 years is a very long interval between the diagnosis of primary tumor and subsequent evidence of metastatic pulmonary disease.

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A 59-year-old woman presented with back pain, general fatigue, and abdominal pain. Chest X-ray and computed tomographic scan showed a severe mediastinal shift to the right with a large amount of fluid and gas collection in the left pleural cavity. Laboratory examination revealed leukocytosis (24,570/mm³) and C-reactive protein elevation (33.3mg/dl). Under the diagnosis of pyothorax with fistula, pleural drainage and curettage were performed through a left lateral thoracotomy. At the opening of the parietal pleura, gas with a stool-like odor was emitted and coffee-milk-like purulent pleural effusion was present in the left pleural cavity. Bacterial culture revealed gram-negative anaerobic bacillus. The left pleural cavity had been left open for 3 days after the first operation to control the anaerobic bacterial infection. The postoperative course was uneventful. No recurrent pyothorax was found 9 months after the operation.

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A 27-year-old man had a cough from 6 months previous. Chest CT and MRI showed a mass arising from the proximal head of the right clavicle and penetrating into the mediastinal area. The mass measured about 7 cm in diameter. Although a diagnosis of osteochondroma was made from a tumor biopsy, we suspected the tumor to be a chondrosarcoma by the findings of chest CT and MRI. We performed a wide resection of the tumor with a part of the right 1st, 2nd and 3rd ribs and sternum. The thoracic skeletal defect was reconstructed with Marlex mesh. Histological examination revealed grade 1 chondrosarcoma. This was a very interesting case in that the chondrosarcoma was of clavicular origin and the tumor was considered to be secondary chondrosarcoma because the patient had shown an abnormal shadow on a chest X-ray from 8 years previous.

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A 13-year-old boy was treated with a silicone T-tube because of post-tracheotomy tracheal stenosis. The pathologic granulation was scarcely removed when the silicone T-tube was placed in the trachea, but it reduced gradually and finally disappeared after one year. We suggest that we should not remove the pathologic granulation completely on placement of the T-tube, and that it is necessary to prolong T-tube intubation at least for one year, until the pathologic granulation disappears completely.

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A 69-year-old woman was pointed out to have a nodule in the right upper lung field by chest X-ray. Chest computed tomography (CT) reveled that the patient had a nodule with a 1 cm diameter in the right S³ segment. Immediately after CT-guided percutaneous needle biopsy, the patient lost consciousness with shock. After resuscitation, brain CT demonstrated multiple intravascular air bubbles in the right parietal lobe, resulting in left hemiplegia. Within 1 hour after onset, hyperbaric oxygen therapy was started. After the first treatment, air bubbles clearly decreased and the consciousness level improved. After 7 episodes of treatment (performed once every day), left hemiplesia recovered with slight motor disorder in the left fingers. Air embolism is a very rare complication in CT-guided percutaneous needle biopsy. However, as this complication is fatal, rapid diagnosis and treatment are necessary.

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[in Japanese]

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