We evaluated a novel urokinase-coated polyurethane slit drain (UK slim drain) equipped with 3 ditches, which contributed to a 31-33% increase of the drain surface area. Fluid volumes evacuated with 5, 10, and 15 cm of H₂O using 19Fr were 234±9.2, 391±9.5, and 527±13 ml/minute, respectively, and those using 24Fr were 407±3.6, 686±6.7, and 883±6.7 ml/minute, respectively. No thrombus was found after more than 4 hours using a coagulation test. The maximum traction strength of slit-tube transition was 16.8±0.9 and 21.3±2.6 kgf for 19Fr and 24Fr, respectively. We also performed a prospective clinical feasibility trial using the 24Fr UK slim drain with 20 patients who underwent general thoracic surgery. The postoperative drainage period was 2-7 days (median: 4 days). The maximum Prince Henry pain scale value ranged from 1-3 (median: 2). No instances of insufficient air or fluid drainage requiring additional drainage were found. In conclusion, the 24Fr UK slim drain is feasible for clinical use in general thoracic surgery.

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Normal values for the vital capacity (VC) and forced expiratory volume in 1 second (FEV_1.0) have been taken from regression equations of Baldwin and Berglund in Japan. On the other hand, newly generated equations of VC and FEV_1.0 for Japanese were developed by the Japanese Respiratory Society in 2001. In this study, we compared the equations of Baldwin and Berglund with the new equations for Japanese for evaluation of the respiratory function in practical surgical patients. The percent predicted VC and FEV_1.0 calculated with the new equations for Japanese were significantly lower than those estimated with the equation of Baldwin and Berglund. The predicted postoperative VC and FEV_1.0 also showed the same results. Considering the indication of lung resection, the surgeon should pay sufficient attention to the equation used and evaluate the indications based on the respiratory function calculated employing the new equations for Japanese.

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Objective. We previously reported the outcome of surgical treatment for malignant pleural mesothelioma (MPM) of death cases in Japan. Here, we evaluated the outcome of surgical treatment for 5 years.
Subjects. Among the 4,860 mesothelioma death cases extracted from the document “Vital Statistics of Japan” for 2003-2007. We reviewed 131 cases undergoing surgery out of 679 cases. Results. The 122 men and 9 women had a mean age of 62 years old. Histological diagnosis was as follows: 64 cases had the epithelioid type, 31 cases the biphasic type, and 24 cases the sarcomatoid type. According to staging of the International Mesothelioma Interest Group, 33 cases had stage I+II disease, 62 cases stage III, and 13 cases stage IV. The 89 cases underwent extrapleural pneumonectomy, 6 cases pleurectomy/decortication, and 36 cases tumor resection. Sixty-three cases received adjuvant therapy. The median overall survival time was 12.0 months. On multivariable analysis using the Cox proportional hazards model, the age, pathological type, and adjuvant therapy were prognostic factors. Conclusion. Adjuvant therapy may improve surgical success.

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This patient was a 37-year-old woman. An abnormal shadow was found in the hilar portion on a chest radiograph during examination. The tumor showed a lobular shape on chest CT and MRI. The tumor consisted of multiple cysts and substantial parts. Multilocular thymic cysts merging with a tumor was doubtful. A thymothymectomy with thoracoscopically assisted surgery was performed for this mediastinal tumor. A part of the tumor had invaded the middle lobe and required combined resection. The postoperative pathological diagnosis was basaloid carcinoma, which developed in the background of a multilocular thymic cyst. We added postoperative radiotherapy to the treatment of this patient, and there has been no recurrence after two postoperative years. Thymic basaloid carcinoma, including our case, is a very rare disease classified in the low-malignancy group; 37 cases have been reported to date. We discuss its diagnosis, treatment, and considerations of its biochemical characteristics from the literature.

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Bronchopleural fistula (BPF) can be difficult to treat.
The patient was an 82-year-old female. She came to our hospital complaining of fever. Chest CT showed a cavity in the right upper lobe of the lung. She was diagnosed with atypical mycobacteriosis based on the detection of Mycobacterium intracellulare. Two days after the start of drug therapy, she had a pneumothorax caused by a bronchopleural fistula in the cavity. Air leakage continued after the insertion of a chest tube, so we performed endobronchial emoblization of the draining bronchus using a polyglyconate (PGA) sheet. The air leak disappeared just after the operation, and she is now in good health without any signs of recurrence.

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A 65-year-old woman complaining of back pain and low-grade fever was admitted to a local hospital with mediastinal abscess. Because conservative treatment was ineffective, she was referred to our hospital 10 days after onset. CT scan revealed a multilocular abscess with ring enhancement on both sides of T1/T2. A T2-weighted MRI image showed a high-intensity area in the T1/T2 vertebral body and intervertebral disc, suggesting spondylitis complicating mediastinal abscess.
Considering there was neither a neurological symptom nor bone destruction, abscess drainage of the superior mediastinum was performed, and spondylitis was planned to undergo conservative medical treatment. With the combination of cervical collar incision and thoracoscopic surgery, effective drainage was conducted. Streptococcus intermedius was detected in the abscess cavity. She was discharged 37 days after surgery, and followed a favorable course for a year.
As one of the causes of mediastinal abscess, pyogenic spondylitis should be considered. MRI is useful for the diagnosis. Surgical indications were reported in such cases as neurological symptoms and abscess formation.

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Recently, medical technology has been improved, and the number of multiple primary cancers has increased. The patient was a 55-year-old woman. She came to our hospital regularly for a mammary hamartoma, and a new tumor was detected in her left breast. Aspiration cytology of the tumor revealed a ductal carcinoma. Preoperative PET-CT examination showed an abnormal shadows in the right lung and isthmus of the thyroid. The thyroid tumor was diagnosed as a papillary carcinoma, and the lung tumor was an adenocarcinoma. Breast and thyroid cancers are cancers developing on the surface of the body, so we planned a one-stage operation. First, the patient underwent complete thoracoscopic right upper lobectomy and systematic nodal dissection (ND2a-1), then thyroidectomy, and left partial mastectomy and sentinel lymph node resection. The total operation time was 5 hours and 38 minutes, and she was discharged on postoperative day 7. If the second and third cancers are on the surface of the body, we can perform one-stage operation for synchronous triple cancer involving lung cancer

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A 59-year-old man treated with peritoneal dialysis for chronic renal failure developed mediastinitis after coronary artery bypass surgery, and underwent pectoralis major muscle plombage. Postoperatively, right empyema without a pulmonary fistula was seen, and pleural cavity curettage was performed under video-assisted thoracoscopy. Infection improved temporarily, but bacterial conversion to methicillin-resistant Staphylococcus aureus (MRSA) was found. MRSA empyema proved intractable for 2 months after fenestration, so the combined systemic and pleural administration of Teicoplanin was attempted. An aseptic cavity was obtained within a week, after which a successful radical operation with muscle plombage and thoracoplasty was performed.

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We describe a case of lung cancer with severe chronic obstructive pulmonary disease (COPD) involving a 70-year-old man who had an adenocarcinoma of the left upper lung, and the forced expiratory volume in 1 second (FEV1) was 770 ml. The degree of his dyspnea was II based on the Hugh-Jones classification. Three weeks after the combination of pulmonary rehabilitation and Tiotropium, FEV1 improved to 810 ml. However, the predicted postoperative FEV1/predicted FEV1 was 33%. He underwent left upper lobectomy, resulting in a reduced lung volume, severe emphysema, and low blood perfusion. After the lobectomy, FEV1 was the same as the preoperative level.
Resection is possible for lung cancer patients who would be considered to have physiologically inoperable disease in combination with lung volume reduction. Forty-six months after the operation, the patient is alive and shows a favorable condition.

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A 54-year-old female was noted to have an abnormal shadow on a chest radiograph. Chest CT showed a low-density mass arising from the left 9th rib, and chest MRI showed a low-intensity mass in T1-weighted images, and a high-intensity mass in T2-weighted images. We suspected the tumor to be a chondrosarcoma of rib origin, and performed a wide resection of the left 8th and 9th ribs and the diaphragm. The tumor was localized at the infradiaphragmatic space, without peritoneal invasion. The defect of the chest wall was reconstructed with an polytetrafluoroethylene sheet. A histological examination revealed grade 2 chondrosarcoma.

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A 58-year-old man was diagnosed with bilateral pulmonary masses on chest radiograph in a routine medical checkup. Computed tomography-guided needle biopsy revealed bilateral lung cancer. Pathological examination revealed squamous cell carcinoma (SCC), 27 mm in diameter, in the left S1+2, with staging of cT1bN0M0, Stage IA, and adenocarcinoma, 45 mm in diameter, on the right S1, with staging of cT2aN2M0, Stage IIIA. We first performed wedge resection of the left lung to remove the left SCC. We used intravenous patient-controlled analgesia (ivPCA) with fentanyl at 1.25 mg + droperidol at 5 mg as postanesthetic analgesia. On postoperative day 8, we performed right upper lobectomy to remove the right adenocarcinoma and used the same volume of ivPCA with the addition of single-dose wound infiltration of ropivacaine. In this method, the surgeon infiltrated all surgical strata with 10 mL of a 0.75% solution of ropivacaine and waited for 5 min after thoracic closure. The numeric pain rating scale (NRS) and patient satisfaction were better with wound infiltration using ropivacaine than without it until 12 h postoperatively.

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A 75-year-old woman with a past history of breast cancer, gastric cancer, and renal cell carcinoma was found to have an abnormal shadow on chest computed tomography, and was referred to us. Chest CT revealed a nodule in right segment 8. Retrospectively, the tumor had been 3 mm in diameter three years previously and 4 mm two years previously. The tumor was surgically resected because of its gradual growth over three years, and was suspected as a metastatic pulmonary carcinoma. The intraoperative frozen section was diagnosed as metastatic carcinoma of renal cell carcinoma.
The tumor was composed of clear cells with abundant cytoplasm surrounding sinusoidal thin-walled vessels. Immunohistochemically, the tumor was positive for PAS and MelanA and negative for CD10 and HMB-45, being diagnosed postoperatively as a clear cell tumor of the lung. Clear cell tumor of the lung is rare and must be distinguished from metastatic pulmonary carcinoma of renal cell carcinoma. To our knowledge, there has been no reported patient with a past history of renal cell carcinoma. We report this case with a bibliographic review.

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We often encounter abnormal branching of the pulmonary artery on lung resection. We report a case of right lower lobectomy with mediastinal type A⁸. A 77-year-old woman with a history of surgery for facial basal cell cancer and radiation therapy for uterine cervical cancer, was noted to have an expanding abnormal lung shadow in S10 of the right lung. A right lower lobectomy(ND2a-1) was conducted following partial lung resection of S10 by employing video-assisted thoracic surgery because the histological diagnosis of the tumor was adenocarcinoma based on intraoperative pathological examination. We recognized mediastinal type A⁸ before the operation on employing MDCT. The operative findings showed the aberrant branching of A⁸ from the right main pulmonary artery, passing between the superior and inferior pulmonary vein, and along the mediastinal side of the intermediate bronchus. We needed to be careful to avoid intraoperative injury of the pulmonary artery, because mediastinal type A⁸ is very rare.

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The progress in diagnostic imaging has increased the chance of identifying small pulmonary tumors. We cannot specify them by inspection or palpation during an operation, and so we perform preoperative marking with Lipiodol. It is straightforward to perform wedge resection of a peripheral tumor near the pleura, whereas it is difficult to do so for a central tumor far from the pleura. For central tumors, regardless of the size, we often cannot help but perform segmentectomy or lobectomy thinking of pleural tension or deformity of the rest of the lung. We devised a method of wedge resection for the central tumor. We generally mark only one location of the tumor under computed tomographic fluoroscopic guidance before surgery, but, for a central tumor, we mark the place beneath the pleura in addition to the tumor. At surgery, we confirm the two markings under C-arm fluoroscopic guidance, and sew the pleura above the surface marking. We incise the pleura and parenchyma cylindrically using an electric knife towards the tumor while pulling the string, grasp the tumor and pleura with ring-shaped forceps, and perform wedge resection using staplers when the tumor rises up. This resection including the pleura decreases postoperative air leakage. Using ring-shaped forceps enables us to performed wedge resection for central pulmonary tumors just as for peripheral ones. We named this the “double-marking method”.

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An 84-year-old man was referred to our hospital due to an undiagnosed mediastinal mass. The patient had undergone prostate cancer surgery eight years before the mediastinal mass was found. The patient received extirpation of the tumor via complete VATS. According to the pathological examination, the tumor was derived from the parietal pleura and consisted of MALT lymphoma cells. Postoperatively, the patient received regional radiation therapy (30Gy). The patient is now alive without recurrence. MALT lymphoma solitarily arising in the pleura is very rare, with only 10 cases reported previously. We must accumulate additional cases to clarify the indistinct entities of this rare disease.

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Pulmonary metastasis from gastric cancer is usually detected as carcinomatous lymphangiosis or pleuritis with a poor prognosis, and reports of its pulmonary metastasectomy are thus rare. We encountered four patients who underwent resection of metastatic lung tumors from gastric cancer. Each case showed a nodular lesion on chest radiograph and computed tomography. Three patients died of relapse at 16, 26, and 56 months after resection, respectively, while one patient remained alive without relapse at 15 months. Some groups have reported long-term survival after pulmonary resection of pulmonary metastasis from gastric cancer, and further studies are therefore warranted.

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The patient was a 74-year-old female, who had a history of surgery for herniation of the diaphragm 41 years previously. A left pleural mass shadow on chest radiograph had been pointed out. She was diagnosed with chronic empyema. A few years later, severe cough and hemoptysis appeared. She presented with excertional dyspnea; moreover, she suffered from strong dyspnea at rest. Therefore, she was treated with Hot therapy. She had no swallowing difficulty at that time. A huge mass in the left cavity was growing to the right lung field and compressed the mediastinum. We performed surgery for the chronic expanding hematoma, involving pleuro-pneumonectomy and extirpation of the hematoma, measuring 24 × 15 × 15 cm and weighing 2,880 g. After the operation, shift of the mediastinum improved, Hot therapy was no longer needed, and her pulmonary function improved.

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A 65-year-old woman underwent tumor resection on the suspicion of an invasive thymoma of Masaoka stage IV. The pathological and immunohistochemical findings revealed that this tumor had components of large cell neuroendocrine carcinoma and small cell carcinoma, and it was finally diagnosed as poorly differentiated neuroendocrine carcinoma of the thymus. Although we performed complete resection, a distant relapse was detected 8 months after surgery. Poorly differentiated neuroendocrine carcinomas of the thymus are very rare. Because these tumors have a poor prognosis, it is necessary to document and study cases of this tumor to understand its pathology and suitable treatment.

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A 76-year-old male who complained of hemoptysis presented with a large tumor in his left upper lobe on computed tomography (CT). Since we did not obtain a definitive diagnosis using a bronchofiberscope or percutaneous needle aspiration biopsy, we resected the tumor because of its rapid enlargement. Pathological findings showed a pleomorphic carcinoma including poorly differentiated adenocarcinoma (pT2N0M0). He had taken tegafur-uracil (UFT) until rapidly spreading mediastinal metastasis occurred 3 months after the operation. We resected the tumor, followed by 50 Gy of irradiation and chemotherapy (carboplatin + paclitaxel). Sixteen months after the initial operation, he was diagnosed with cancer in the ascending colon and metastasis in the liver. Surgery was performed, and the final diagnosis was colon and liver metastasis of pulmonary pleomorphic carcinoma. Human chorionic gonadotropin (hCG) was expressed on immunohistochemical staining in all specimens. He died 19 months after the initial operation because of massive bleeding of the stomach wall metastasis. Pulmonary pleomorphic carcinoma producing hCG is rare and has a very poor prognosis. Improvement of the preoperative diagnosis and postoperative treatment is expected for this disease.

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Thoracolithiasis is a rare condition, with only 21 cases of surgically removed nodules reported in the literature in Japan. We report 4 additional cases of surgically removed thoracolithiasis. Case1: A 64-year-old man was referred to our department with an abnormal shadow on a chest radiograph. Chest computed tomography revealed a subpleural nodule of 10 mm in diameter in the right lower lung lobe. During video-assisted thoracoscopic surgery, a smooth-surfaced white material was identified between the hypersegmentations. Cases2-4: The other 3 cases were discovered incidentally during sugery for primary lung cancer in the right lower lung. The pathological diagnoses were all thoracolithiasis. Its core in all cases consisted of fatty necrotic tissue. We should consider thoracolithiasis in the differential diagnosis of a peripheral pulmonary nodule, especially on the surface of the diaphragm.

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A 60-year-old man was pointed out to have an abnormal shadow on chest radiograph. Chest CT showed that the 45-mm tumor with fat density was present through the right anterior chest wall. We resected the tumor with video-assisted thoracic surgery. The pathology revealed intramuscular lipoma, and we diagnosed it as an hourglass intrathoracic lipoma. We encountered an extremely rare intramuscular lipoma growing to the intra- and extra-thorax. To decide on the excision line from the intrathorax, it was very useful to achieve a field of vision through thoracoscopy.

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A 92-year-old woman consulted a doctor for dyspnea on effort. Based on the findings of chest-computed radiography, she was diagnosed with a left pneumothorax. We started continuous chest drainage, but air leakage did not resolve, so we planned an operation. When a CT scan was carried out, a nodule was detected in the left upper lobe. Because there were no findings of other lesions caused by pneumothorax, video-assisted thoracic surgery (VATS) was performed, and wedge resection of the tumor was carried out. The tumor was diagnosed as primary lung cancer, and carcinomatous pleuritis was recognized in operative findings. After the operation, the air leakage disappeared, but then relapsed on post-operative day 2. Finally, adhesion therapy was performed. Primary lung cancer complicated with a pneumothorax is rare, and carcinomatous pleuritis may have caused this intractable pneumothorax.

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Morbid obesity is one of the technical pitfalls in video-assisted thoracoscopic surgery (VATS). We used a Wound Retractor (Applied Medical, USA) to keep away the thick subcutaneous adipose tissue in VATS for a morbidly obese patient. It was useful to thin out the chest wall of the patient, and made it straightforward to apply the VATS devices to the thoracic cavity.

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