From January 2002 to July 2011, among 1,864 general thoracic surgeries, 53 (2.8%) operations were carried out collaboratively with cardiovascular surgeons in our department. Among patients who received a collaborative operation, 40 were men and 13 were women. Ages of the patients ranged from 18 to 77 years, with a mean of 57 years. In 34 patients, collaborative operations were planned from the preoperative assessments. On the other hand, the remaining 19 patients required the urgent contribution of cardiovascular surgeons due to unpredictable tumor invasion to the great vessels or uncontrollable bleeding. There was no mortality. It is very important to maintain a close relationship with cardiovascular surgeons for safe operations and education in the area of general thoracic surgery.

View full abstract

From February 1993 to December 2011, 35 patients with silicosis underwent surgery to treat secondary spontaneous pneumothorax. These patients were compared to 62 patients who underwent surgery to treat other types of secondary spontaneous pneumothorax in the same period. There were no significant differences in patient characteristics of age, sex, affected side, Hugh-Jones classification, indication for surgery, and the surgical techniques. However, there was a significant difference in the smoking index. Postoperative outcomes revealed no significant differences in the surgical duration, bleeding, duration of drainage, additional treatment, hospital stay, and complications. However, postoperative recurrence occurred in 7 patients with silicosis (20%) but only in 3 patients with other types of pneumothorax (4.8%). This difference was significant. Although the recurrence rate was high, we advocate surgery to treat pneumothorax complicating silicosis, because it can be performed about as safely as surgery to treat other types of secondary pneumothorax. The covering technique involves thickening of the visceral pleura surface. Viewed from the pathological features of silicosis, covering of the visceral pleura may be an important operative procedure for the purpose of preventing postoperative recurrence of pneumothorax complicating silicosis. Further studies of this operative procedure are expected in the future.

View full abstract

Surgical reconstruction of the chest wall is generally performed. When the defect size of the chest wall is wide, we have to select artificial material for reconstruction. A composix mesh sheet is created for abdominal hernia repair, and composed of polyproppylene mesh and an ePTFE sheet layer. We reviewed 6 cases of chest wall reconstruction using composix mesh sheets at our hospital between August 2005 and March 2008. Primary diseases were chest wall invasion of lung cancer in 2 cases, chest wall invasion of thymoma in 1 case, chest wall invasion of breast cancer in 1 case, and fibrous dysplasia in 1 case. Two ribs were resected in 2 cases. Three and four ribs were resected in 2 cases, respectively. The defect size of the chest wall was between 6×6 and 20×6 cm. The operation time was between 245 and 470 minutes. Intraoperative bleeding was between 100 and 1,600 mL. The postoperative period of hospitalization was between 11 and 21 days. There were no complications or sheet-associated problems. Composix mesh for reconstruction of the chest wall is considered to be a suitable material for its natural strength, easy fabrication for various defect shapes, and low incidence of infection.

View full abstract

We herein report the efficacy of silastic drains (BLAKE drains) as a primary treatment for secondary pneumothorax complicated with chronic obstructive pulmonary disease (COPD) in elderly patients.
With the increasing number of patients with COPD, the number of elderly patients with pneumothorax has also recently been increasing. Efficient chest drainage is required as the primary treatment; however, its management is difficult because of localized pneumothorax, pleural adhesion, and nonuniform compliance, all of which complicate chest tube insertion and occlude the tube orifice.
The BLAKE drain has recently begun to be used as a chest drain after pulmonary resection. This drain is soft and equipped with four longitudinal grooves that provide a wide suction area. These characteristics may be useful for the treatment of pneumothorax with COPD.
Between January 2009 and April 2011, we used the BLAKE drain as a chest drain in 21 elderly patients with pneumothorax (mean age, 74.3 years; range, 57-87 years).
The underlying diseases were pulmonary emphysema in 17 patients, multiple cysts in four patients, and interstitial pneumonitis in two patients.
Six patients needed not only chest drainage, but also additional treatments such as bronchial occlusion, pleurodesis, and surgery.
Complications included subcutaneous emphysema in seven patients, insufficient drainage in three, and drain obstruction in one.
We conclude that the BLAKE drain is suitable for the treatment of pneumothorax in elderly patients, but the insertion procedure and development of the introducing apparatus still require improvement.

View full abstract

In our hospital, Karayahesive^TM, which is a hydrocolloid dressing, is used on the skin over the site of chest tube removal. The use of this dressing is a simple, noninvasive, and effective method for wound healing. Karayahesive^TM was used for 181 patients who underwent an operation with insertion of a chest tube in the Department of Thoracic Surgery in our hospital during the period from January 2010 to October 2011. Nine patients required exchange of Karayahesive^TM after chest tube removal, and one patient required suturing of the wound due to excess discharge. Although two patients required reinsertion of the tube, it was thought that there was no problem in the technique of removal. Since there were no problems accompanying tube removal in almost all cases, our method of chest tube removal is considered to be useful.

View full abstract

A 32-year-old man was admitted to the emergency unit of our hospital for a ureteral stone. A chest radiograph showed an abnormal shadow in the right lower lung field, and he was referred to our unit. Chest CT showed a mass-like shadow and cystic change with a fluid level in the right lower lobe and Mycobacterium avium was detected on sputum culture. We diagnosed him with pulmonary sequestration with non-tuberculous mycobacteriosis. After 12 weeks of chemotherapy, the patient underwent right lower lobectomy. Pulmonary sequestration with non-tuberculous mycobacteriosis is a relatively rare disease. In this case, preoperative chemotherapy could control infection of the area of sequestration and adjacent lung tissue, so we were able to reduce the surgical risk. It is suggested as a safe and effective treatment strategy.

View full abstract

The following describes a surgical case of specific acquired bronchial atresia. A 75-year-old woman sought medical attention after complaining of hemosputum and cough. Chest CT showed segmental bronchial obstruction and a significantly reduced left lower lobe capacity, as well as a marked dilatation of the left bronchial artery. Bronchofiberscopy identified obstructions in the left B⁸, B⁹, and B¹⁰ segmental bronchi, and acquired bronchial atresia was diagnosed. Due to an aggravated respiratory infection, the patient underwent thoracoscopic left lower lobectomy, and pathological examination revealed a case of bronchial atresia caused by hamartoma with unusual extension. In light of the benignancy of bronchial atresia, we recommend that adequate consideration be given regarding indications and the method of surgery for treatment of the disease.

View full abstract

Skeletal muscle metastasis of cancer is very rare, and no cure has been established. We report a patient with an excised pectoralis minor muscle lesion that showed abnormal uptake on FDG-PET before surgery. The lesion was a metastasis of lung cancer. The case was a 72-year-old man. An unusual shadow was pointed out in the right lower lung field on a radiograph of the chest during a lung cancer medical checkup in June 2010, and FDG-PET revealed abnormal uptake in the right lower lobe and left pectoralis minor muscle. The lesion of the pectoralis minor muscle was diagnosed as inflammatory, and then thoracoscopic right lower lobectomy, systematic nodal dissection, and resection of the lesion of the left pectoralis minor muscle by cT2aN0M0 IB were performed. The tumor of the right lower lobe was squamous cell carcinoma, and the tumor of the pectoralis minor muscle was also squamous cell carcinoma, and it was diagnosed as metastasis of lung cancer. We performed pT2aN0M1b IV, postoperative chemotherapy (CBDCA+PTX), and radiotherapy (50 Gy).

View full abstract

A 51-year-old woman, who was suffering from dyspnea, was pointed out as showing multiple pulmonary nodules and cysts. Thoracoscopic resection of a nodule was performed, and the histological diagnosis was amyloidosis which was positive for Congo red staining. We should recognize the fact that pulmonary amyloidosis may show multiple nodules and cysts on chest CT.

View full abstract

A 54-year-old woman was referred to our hospital for an abnormal shadow on a chest radiograph. Computed tomography showed an aberrant artery arising from the descending aorta to the basal segment of the left lung. Dilatation of the pulmonary vessels was minimal on chest CT, and both the pulmonary artery and bronchus to the left basal segment were normal on 3D-CT. These findings led us to the diagnosis of an anomalous systemic arterial supply to the left pulmonary basal segment.
Preservation of the lung parenchyma seemed to be possible because the change in the pulmonary parenchyma was minimal. Therefore, we performed thoracoscopic aberrant artery stapling using a no-knife stapler without lung resection.
The postoperative course was uneventful. We reported a very rare case of anomalous systemic arterial supply to the left basal segment, treated only with aberrant artery stapling.

View full abstract

The patient was a 53-year-old male, who received right ureteronephrectomy for a right renal pelvic carcinoma. Then, he underwent two partial pulmonary resections and left upper segmentectomy for metastatic lung tumors, which recurred loccally twice. He also underwent three systemic chemotherapies with different regimens during treatment. After that, while he attended our hospital as an outpatient, he had a persistent cough and aqueous sputa; furthermore, he was emergently admitted to our hospital due to a high temperature. His symptoms did not improve despite antibiotic treatment, and we performed chest drainage because we considered the possibility of pleural empyema. A culture test of the pleural effusion revealed positivity for Aspergillus flavus; moreover, we deteceted many fungal granules by thoracoscopy, leading to a diagnosis of Aspergillus empyema. The efficacy of the systemic anti-fungal therapy of micafungin and voriconazole was insufficient, and so we combined it with bronchial occlusion using the endobronchial Watanabe spigot^®. This led to the successful management of Aspergillus empyema.

View full abstract

We report a case of systemic air embolism that occurred during a double sleeve left upper lobectomy of the lung for cT2aN1M0 pulmonary adenocarcinoma. The patient was a 72-year-old male with severe emphysema. Immediately after an air leak test following bronchoplasty and pulmonary angioplasty, cardiac deterioration occurred. Transesophageal echocardiography revealed numerous microbubbles in his left atrium after resuscitation, and then we recognized massive air emboli. He could recover with cardio-pulmonary support and was discharged 2.5 months after the surgery. The cause of the air embolism was suspected to be systematic air entry at the peripheral lung induced during the air leak test under clamping of the pulmonary artery following bronchoplasty, and so we should be aware of the risk of such a fatal complication in patients with severe emphysema who undergo double sleeve resection.

View full abstract

Intralobar pulmonary sequestration is a relatively uncommon disease. We report a case of intralobar pulmonary sequestration treated by video-assisted thoracic lobectomy. The case was a 32-year-old female. She consulted the hospital for a high fever and back pain. She was diagnosed with pulmonary suppuration based on a radiograph and CT, and introduced to us for treatment. Chest radiograph showed an infiltrative shadow with an air-fluid level in the right lower lung field. Chest CT showed inflammation with a cavity in the right S10 and abnormal arterial inflow from the right diaphragm. We suspected pulmonary sequestration. Angiography revealed the right subphrenic artery flowing into the aberrant artery. We diagnosed her with intralobar pulmonary sequestration. No aberrant pulmonary venous return was observed. We performed a video-assisted right lower lobectomy. Along with improvement of the diagnostic technique, the accuracy of the preoperative diagnosis of pulmonary sequestration has been improved. It is possible to perform minimally invasive surgery in selected cases.

View full abstract

A case of bilateral malignant pleural mesothelioma diagnosed after FDG PET/CT and bilateral thoracoscopy is reported. A 59-year-old man who had a history of asbestos exposure was admitted to another hospital because of pleural effusion on the left side on a plain chest radiograph. Computed tomography revealed pleural effusion on the left side, and pleural thickening of the visceral pleura on the right side. FDG PET/CT demonstrated uptake in the pleura on the right side. There was no accumulation at other sites. After a diagnosis of malignant pleural mesothelioma based on cytological examination, he was referred to our center. Thoracoscopic findings revealed multiple small nodules on the left side. Biopsy was performed, leading to a diagnosis of epithelial mesothelioma. Thoracoscopic findings showed pleural thickening like plaque on the right side. Biopsy was performed, leading to a diagnosis of epithelial mesothelioma. We considered that there was no indication for surgery because it was bilateral malignant pleural mesothelioma stage I. Chemotherapy is now being performed.
Conclusion: We encountered a patient with bilateral malignant pleural mesothelioma with bilateral stage I. Therefore, we considered the importance of FDG PET/CT and bilateral thoracoscopy before deciding on surgical treatment.

View full abstract

An 80-year-old woman was found to have an abnormal shadow on a routine chest radiograph. Subsequent chest CT demonstrated a round-shaped, 57×46-mm mass in the superior portion of the mediastinum and middle mediastinum, surrounded by the great vessels and trachea. FDG positron emission tomography (FDG-PET) revealed high-level FDG uptake by the tumor; malignant mediastinal tumor was suspected. She was referred to our hospital for diagnosis and treatment. Surgery using a limited upper sternotomy approach revealed a sessile tumor originating from the mediastinal soft tissue around the right brachiocephalic artery. We were unable to perform a combined resection of the brachiocephalic artery; thus, tumor resection was incomplete. Histopathologically, the tumor was diagnosed as benign SFT. Immunohistochemical examination revealed negativity for CD34, loss of bcl-2 expression, a high MIB-1 index, and positive p53 staining, and also suggested signs of malignancy. The patient elected not to receive any further surgery, and was simply followed up. The residual tumor had re-progressed 6 months postoperatively, and was then treated with conventional radiotherapy (60 Gy). The patient remains alive with disease 2 years postoperatively. SFT originating from the mediastinum is extremely rare, but may be more aggressive and malignant than SFT of the pleura. We report this case and provide a bibliographic review on the biological behavior and treatment of SFT originating from the mediastinum.

View full abstract

A 75-year-old woman nearly suffocated due to massive airway bleeding from a lesion of the right upper bronchus during transbronchial biopsy for a tumor-like aneurysm. Because immediate endotracheal intubation was blocked by blood clots and ventilation failure was worsening, percutaneous cardiopulmonary support (PCPS) was introduced, using nafamostat mesilate as an anticoagulant. After that, the respiratory and circulatory status of the patient was markedly improved, and then thoracotomy was performed. The clots in the airway were evacuated through the bronchial stump as far as possible after removing the right upper lobe. The patient could be weaned off PCPS immediately after surgery, and respiratory support was not necessary on the 5th postoperative day (POD). The patient was discharged with a favorable clinical condition on POD 13.

View full abstract

Cases of solitary pulmonary metastasis derived from intrahepatic cholangiocarcinoma (ICC) are rare, because they are usually discovered as bilateral and multiple lesions or with metastases of multiple organs. The following describes an extremely rare case of resected pulmonary metastasis derived from ICC which was difficult to differentiate from primary lung carcinoma. A 70-year-old male, having undergone hepatectomy for ICC 48 months prior, was referred to our department due to a nodular shadow on chest computed tomography, but a definitive diagnosis could not be made. Assuming that the pulmonary nodule was primary lung cancer because of the rarity of solitary pulmonary metastasis derived from ICC, a thoracoscopic right upper lobectomy with lymph node dissection was performed. Histological examination and immunohistochemical staining of the resected pulmonary nodule revealed a metastatic lesion derived from ICC. In cases where the pulmonary nodule cannot be distinguished between primary lung cancer and pulmonary metastases, we recommend that careful consideration be given at the time of determining surgical treatment for the pulmonary nodule.

View full abstract

An 81-year-old male had an abnormal shadow detected on a screening chest radiograph. Chest radiographs revealed a mass in the anterior mediastinum. Chest CT revealed a heterogeneous lesion in the anterior mediastinum. The MRI revealed an isointense lesion on both T1WI and T2WI, and partially high intensity on DWI. The lesion was suspected to be a thymoma based on these findings, and we resected it using a VATS technique. A histopathological examination revealed the mass to have cystic walls lined by multilayered squamous or cuboidal epithelium and inflammatory changes within the walls. Furthermore, a portion of the mass was type A thymoma. Therefore, the lesion was finally diagnosed as a multilocular thymic cyst with thymoma.

View full abstract

We report a case of giant mediastinal goiter with acromegaly. A 59-year-old woman was admitted to our hospital because of an abnormal chest shadow. She had a history of acromegaly and resection of a pituitary tumor at age 34. Chest radiography and chest computed tomography on admission showed an upper left mediastinal tumor compressing the trachea, and serum growth hormone and insulin like growth factor I were elevated to 74.2 and 451 ng/ml, respectively. Cranial MRI showed recurrence of the pituitary tumor. Resection of the mediastinal tumor was performed with a neck hemi-collar incision and median sternotomy. The tumor had developed from the left lobe of the thyroid and its pathological diagnosis was follicular adenoma. Due to the high incidence of goiter in acromegalic patients, the thyroid function and morphology should be carefully monitored in patients with acromegaly.

View full abstract

An 80-year-old man was admitted to our hospital for palpitation and chest discomfort. A chest radiograph showed a left lung pneumothorax, and chest CT showed a left lung pneumothorax and bullae of the left upper lobe. A chest tube thoracostomy was placed immediately.
This was the fourth left spontaneous pneumothorax he had experienced. This time, we performed adhesion therapy for the pneumothorax, because he was 80 years old and was complicated by myelodysplastic syndrome. However, persistent air leak continued for 7 days following chest tube insertion. We performed thoracograpic studies, and bubbles were produced from one of the bullae of the upper lobe.
Considering his age, condition, respiratory function, myelodysplastic syndrome, and performance status, we carried out the ligation of bullae in the upper lobe by video-assisted thoracic surgery under local anesthesia only.
The patient's postoperative course was uneventful, and he was discharged from the hospital on the 5th postoperative day.

View full abstract

An 85-year-old asymptomatic male was found to have an abnormal shadow on a routine chest radiograph. Chest CT and MRI demonstrated a cystic tumor, of 6 cm, with an internal solid mass at the anterior mediastinum. The FDG-PET revealed an abnormally low uptake in the marginal region of the tumor. A cystic thymoma was diagnosed, and then an operation was perfomed. The cystic tumor underwent en bloc removal with right thymic tissue under video-assisted thoracic surgery. It consisted of a unilocular cyst and multiple yellow solid masses on its inner wall. Histopathologic examination revealed that the thymoma (Masaoka stage I, WHO Type A) was surrounded by a unilocular cyst whose wall was lined by stratified epithelial cells, leading to the diagnosis of a thymic cyst with thymoma. A thymoma arising inside a thymic cyst is rare, and this is the 19^th reported case in Japan.

View full abstract

A 30-year-old man was admitted for examination of a mediastinal mass identified on a chest radiograph. He had no complaint related to intrathoracic lesions and no disease history of note. A chest computed tomographic scan revealed a mass with cystic and solid components on the right side of the superior mediastinum. Since malignancy could not be ruled out, surgery was performed. The mass contained glandular cavities covered with ciliated columnar epithelium, cartilage, and bronchial glands. Additionally, it showed an abnormal blood vessel, and he was diagnosed with extralobar pulmonary sequestration.

View full abstract

A 33-year-old male was pointed out as showing a right giant pulmonary bulla on a chest radiograph in a medical examination 4 years ago. He did not undergo treatment until dyspnea on exertion, edema, and cyanosis of the hands presented. He was diagnosed with systemic scleroderma (SSc), and administered NSAIDs and a PGI2 analogue. After the therapy for SSc started, resection of the pulmonary giant bulla was performed by video-assisted thoracic surgery (VATS). Postoperatively, the respiratory symptoms and pulmonary function were improved, and the administration of prednisolone was started for SSc. Sjogren's syndrome is well known as a collagen disease often accompanied with pulmonary bullae; however, SSc with a giant pulmonary bulla is extremely rare. Although the cause of a giant pulmonary bulla with SSc is not clear, damage to the alveolar wall by SSc was thought to be one of the reasons for pulmonary bulla formation.

View full abstract