We reviewed 42 patients with pneumomediastinum whom we encountered at our hospital from April 1992 to June 2009. Pneumomediastinum secondary to bronchial asthma and pneumomediastinum in healthy patients without or with predisposing episodes were defined as Group A (17 cases), Group B (16 cases), and Group C (9 cases), respectively. The patients included 13 men (76.5%) in Group A, 15 men (93.8%) in Group B, and 5 men (55.6%) in Group C. The average age was 21.6, 26, and 23 years old in Groups A, B, and C, respectively. The most common presenting complaint was dyspnea in 9 patients of Group A, and pain in 16 of Group B and 7 of Group C. All patients responded well to bed rest and antibiotic therapy. No surgical treatment was necessary. We investigated the possible correlation between the occurrence of pneumomediastinum and weather conditions, but the weather changes did not significantly influence the incidence of pneumomediastinum.

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Various approaches have been described for therapeutic assessment of pericardial effusion, including anti-inflammatory or diuretic medication, pericardiocentesis, percutaneous catheter drainage, subxyphoidal pericardial drainage, and pericardial fenestration via anterior thoracotomy or by means of thoracoscopy. Specially, recurrent or loculated effusions are best managed surgically with pericardial fenestration. Video-assisted thoracoscopic surgery has demonstrated usefulness, since this technique has the advantages of a minimally invasive approach combined with excellent visualization. Our experience of a video-assisted thoracoscopic technique to create a pericardial fenestration for recurrent or loculated pericaridial effusion was retrospectively evaluated. Between 2008 and 2012, eight patients (four men, four women; mean age: 69 years) underwent video-assisted thoracoscopic pericardial fenestration for recurrent or loculated pericardial effusions. In the group studied, six patients had pericardial effusion after cardiac surgery, one patient had pericardial effusion due to heart failure, and one patient had malignant pericardial effusion. The reasons for choosing video-assisted thoracoscopic pericardial fenestration for the treatment of pericardial effusion were: loculated effusion in six patients, recurrent effusions after subxyphoidal pericardial drainage in one patient, and difficulty in peforming the others in one patient after epicardial pacemaker implantation with a transdiaphragmatic approach. A pericardial window was created of 2×2∼5×2 cm. There was no intraoperative nor postoperative complication. There was no in-hospital mortality. The mean follow-up was 3.0±1.7 years (maximum: 5.3). Recurrence occurred 3.1 years after the operation in only one patient suffering from congestive heart failure for hypertrophic cardiomyopathy. Video-assisted thoracoscopic pericardial fenestration is a safe and effective treatment for recurrent or loculated pericardial effusions.

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Diaphragm patch dehiscence is one of the frequent complications of extrapleural pneumonectomy (EPP), and is classified as a technical complication. We performed 54 EPP for malignant pleural mesothelioma, and encountered 4 diaphragm patch dehiscences. The cause of patch dehiscence was rupture of the soft tissues sutured to the diaphragm patch in all cases. The reduction of tension between the soft tissue and patch may contribute to prevent diaphragmatic dehiscence. The following 4 points are important to prevent diaphragmatic dehiscence: 1. Preserve the peritoneum. 2. Fix the patch to the chest wall with sufficient tension and reduce the tension of soft tissue fixed to the diaphragmatic patch. 3. Preserve a sufficient diaphragmatic margin. 4. Reconstruct the diaphragm with an appropriate height. Since diaphragmatic dehiscence is directly related to the surgical procedure, we have to perform diaphragmatic reconstruction more carefully.

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In our hospital, we performed surgery for 12 patients with pulmonary non-tuberculous mycobacteriosis (pNTM) from January 2008 to March 2013. Of these patients, 9 underwent totally endoscopic surgery, 8 underwent pulmonary lobectomy, 1 underwent segmentectomy, and 3 underwent partial excision. We performed bronchial lavage for 5 of the 7 female patients, and were able to achieve early diagnoses for them. We also treated all 7 female patients and 1 male patient for#8805;6 months before surgery according to the conventional surgical treatment guidelines. Thus far, all patients have demonstrated good postoperative courses without relapse, except for 1. However, we found it difficult to differentiate pNTM from lung cancer in 3 of the 5 male patients. We performed thoracoscopic partial pulmonary excision for these 3 patients, and diagnosed them with pNTM. We have been following 2 of the 3 patients who did not receive postoperative drug treatment, and have not observed any episodes of relapse. Although pulmonary lobectomy is a standard operative procedure, patients with localized cavities and no scattering shadows may be managed with partial excision. In addition, pNTM becomes difficult to treat once it spreads widely. Therefore, we recommend diagnosis as early as possible in such patients, that is, intervening during the early phase of the disease when the lesions are still localized. Further more, surgery according to the conventional surgical treatment guidelines should be actively considered.

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A 32-year-old female at 36 weeks of pregnancy developed a right lung spontaneous pneumothorax, and underwent thoracic drainage. After the drainage, she showed re-expansion pulmonary edema with resulting hypoxia. An emergency Caesarean operation was performed because the mother's hypoxia could affect the baby. The patient received ventilation support for 2 days postoperatively and was discharged 9 days after the operation. Re-expansion pulmonary edema is likely to develop and be prolonged during pregnancy due to an expanded intravascular volume and enhanced vascular permeability. The possibility of such cases should be carefully considered.

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A 42-year-old male showed tracheal deviation to the right on a chest radiograph. Preoperative CT demonstrated a 2.8×1.8-cm hypodense lesion on the left side of the trachea in the lower neck. The lesion was thought to be a benign cyst, such as a thyroid or bronchogenic cyst, and expansion was a concern. At the operation, involving a left hemicollar incision, the cyst was attached to the trachea, left carotid artery, and esophagus. Furthermore the upper portion of the cyst adjoined with the left lower pole of the thyroid, and a narrow funicular tissue bridge which connected the cyst to the superior trachea behind the thyroid. We ligated this funicular tissue and removed the cyst. Histologically, the cyst consisted of ciliated columnar epithelium, mucous glands, and smooth muscle, yielding a definitive diagnosis of bronchogenic cyst. As a complication, transient recurrent nerve paralysis developed after the operation. The symptom disappeared and no recurrence has occurred for 6 months. To date, 26 cases of cervical bronchogenic cyst have been reported in the Japanese literature, excluding infant and cutaneous cases. We examined these 26 and our case.

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There has been no report on the resection of a chest wall abscess caused by candida albicans. The patient was an 83-year-old male who had undergone hepatic resection for hepatocellular carcinoma. In the postoperative course, he developed liver abscess caused by candida albicans. After PTAD and Voriconazole administration, his condition improved. Six months later, he became aware of chest pain and an elastic, hard mass in the rt. anterior chest wall. After computed tomography, a metastatic chest wall tumor derived from hepatoceller carcinoma was suspected. He then underwent chest wall resection and reconstruction. The pathological diagnosis was abscess formation caused by Candida albicans. We encountered a patient requiring the resection of a chest wall abscess caused by Candida albicans.

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A 76-year-old man with angiosarcoma of the scalp underwent surgery for the scalp lesion in May. A thoracoscopic right lung biopsy undertaken for bilateral pneumothorax in January of the following year revealed lung metastasis of angiosarcoma, and he was transferred to our hospital for palliative care. Right air leakage persisted 3 months after admission. We performed right lung fistula closure with thoracoscopy. We closed the fistulas with continuous and automatic sutures with reinforcement using a polyglycolic acid sheet. We removed the chest tube on the fifth postoperative day. He was discharged from our hospital on the 21st day. Left pneumothorax recurred on the 36th day and necessitated readmission. He died of respiratory failure complicated by hemothorax and pulmonary hemorrhage on the 91st day. Pneumothorax secondary to lung metastasis of angiosarcoma, which is not curable with medical treatment, causes pain and limits the patient's activities. We advocate considering surgical closure of lung fistulas according to the general state, and are confident that this procedure is meaningful in the palliative care setting.

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We report a case of Paragonimus westermani infection caused by eating raw deer meat. A 49-year-old man was referred to our hospital with pneumothorax and pleural effusion, followed by abdominal discomfort. Because he had a history of eating raw deer meat 2 weeks before the abdominal discomfort developed and showed eosinophilia in the peripheral blood and pleural effusion, paragonimiasis was suspected. Video-assisted thoracoscopic surgery was performed because possible spontaneous pneumothorax with empyema was considered due to the findings of purulent pleural effusion. Many green purulent exudates on the parietal pleura, diaphragm, and visceral pleura of the lower lobe were identified under thoracoscopic view. Biopsy of the parietal pleura including the purulent exudates and partial resection of the lower lobe were performed. He was diagnosed with Paragonimus westermani infection based on immunological examinations. After the oral administration of praziquantel, the eosinophilia improved. He has not shown any clinical symptoms for 13 months since the treatment. In suspected case of paragonimiasis, early diagnosis by immunological examinations and immediate pleural drainage and medication are necessary. It was thought that the distribution of purulent exudates in the pleural space corresponded to the route by which the metacercariae had migrated from the abdominal cavity to pleural space across the diaphragm.

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We herein report the identification of a pleuroperitoneal communication by the intraoperative establishment of CO₂ pneumoperitoneum in two patients with uncontrollable hepatic hydrothorax. The patients were 44- and 79-year-old men. Both had alcoholic liver disease and were admitted because of the development of massive right pleural effusion. The diagnosis of pleuroperitoneal communication was based on the presence of exudative pleural effusion and a small amount of ascites. In both cases, we performed thoracoscopic surgery on the establishment of CO₂ pneumoperitoneum. After the peritoneal cavity had been inflated with CO₂, air leakage from the diaphragmatic defect was detected. We resected the diaphragmatic defect using a stapler and covered the staple line with a polyglycolic acid sheet and fibrin glue. The postoperative course was uneventful in both of them, and hydrothorax did not recur after the surgical treatment. This surgical method may be useful for the identification of pleuroperitoneal communications.

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An 18-year-old man was emergently admitted for the recurrence of left spontaneous pneumothorax. The patient had a history of left spontaneous pneumothorax treated by thoracoscopic surgery, and congenital factor VII deficiency. Laboratory data showed a prolonged prothrombin time, and factor VII activity was reduced to 46%. Chest CT scan revealed a recurrent bulla at the apex of the left lung and pneumothorax. Thoracoscopic surgery was performed, and we could identify the bulla in the apical lung after dissecting the adhesion between the left upper lobe and chest wall. The bulla was ligated with adequate hemostasis. One day after the operation, a chest radiograph revealed left hemothorax. After larger chest tube re-insertion, we noticed bloody effusion discharging from the chest tube. Although we administered hemostatics, bleeding remained uncontrolled and the patient developed anemia. Therefore, recombinant activated factor VII was administered, and the bleeding gradually stopped. The chest tube was removed 3 days after surgery, and the patient was discharged 7 days after the operation. Recombinant activated factor VII transfusion can be considered for post-operative hemorrhage in patients with congenital factor VII deficiency. In such cases, the potential risk of thromboembolic complications should be discussed before its use.

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We report a 28-year-old man with an initial complaint of back stiffness who was referred to our hospital with an abnormal chest shadow on plain radiography during a medical checkup. A chest computed tomography (CT) scan and magnetic resonance imaging (MRI) showed a hypervascular tumor approximately 10 cm in its longest diameter in the left posterior mediastinum. On positron emission tomography, marked accumulation of fluorodeoxyglucose was observed in the tumor. We suspected paraganglioma, and a serological endocrine examination was performed. The results indicated normal catecholamine levels. I¹²³-metaiodobenzylguanidine (MIBG) scintigraphy showed uptake in the tumor. Histopathological examination of the specimen by CT-guided needle biopsy revealed paraganglioma. The patient underwent resection of the tumor by thoracotomy. Blood transfusion was necessary owing to bleeding from the tumor. The patient was doing well 3 years post-surgery without recurrence. As paragangliomas often have endocrine functions, it is necessary to examine endocrine the function for appropriate perioperative management.

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A 64-year-old woman had received thoracoscopic partial lung resection for lung metastasis of colorectal cancer. A left chest wall tumor was noted during observation after the operation. Since it increased gradually and malignancy could not be ruled out, chest wall tumor extirpation was performed. The hemispherical tumor was covered with the parietal pleura and intercostal muscle, and existed on the scar of drain insertion during the previous thoracoscopic operation. Pathological examination revealed spindle cells with fusiform nuclei proliferating in a fascicular pattern. Immunohistochemical staining showed that spindle cells were positive for SMA and vimentin. The final pathological diagnosis was nodular fasciitis.

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We report two surgical cases of pulmonary Mycobacterium abscessus (M. abscessus) infection. Case 1, a 45-year-old male with no previous medical history, complained of a cough, persistent fever, dyspnea, and chest pain. Case 2, a 75-year-old male with a previous history of pulmonary tuberculosis and Mycobacterium intracellulare infection, showed symptoms of productive cough and hemoptysis. Both had focal infections in their right upper lobes, and underwent right upper lobectomies. They were also treated with clarithromycin (CAM), amikacin (AMK), and imipenem/cilastatin (IPM/CS) perioperatively. Their clinical symptoms improved, and they are alive with a negative sputum examination for M. abscessus. We investigated the reported thirty-two cases of pulmonary M. abscessus infection in Japan. Nine of them had a medical history of pulmonary tuberculosis, and 7 of them had malignant disease. No distinctive features were detected regarding the gender, age, and infected locations. Medication with CAM, AMK, and IPM/CS was reported to be effective in 8 cases, although various antibiotics were prescribed in 31 cases. Pulmonary resections were performed in 5 cases, and they were all discharged with no sputum excretion of M. abscessus. Pulmonary M. abscessus infection cure has been reported to be difficult, but a combination of surgical procedures and chemotherapies including CAM, AMK, and IPM/CS should be considered for tolerable patients with pulmonary resection.

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A 57-year-old male was referred to our department for an abnormal shadow on chest computed tomography (CT). A mass of approximately 3 cm in diameter was noted on the right side of the upper mediastinal trachea, and another mass had a diameter of approximately 2 cm in the right scapula associated with bone destruction. Fluorodeoxyglucose-positron emission tomography (FDG-PET) scan showed high accumulation in both masses with max standard uptake values (SUV) of 3.5 and 1.3, respectively. Thoracoscopic-assisted resection of the mediastinal tumor was first performed for diagnosis and treatment. The postoperative pathological diagnosis was benign schwannoma of Antoni A and B type. Subsequently, partial resection of the scapula was performed. The pathological diagnosis of the tumor in the scapula was ossifying fibromyxoid tumor (OFMT). The origin of this OFMT was unknown, although it was recently suggested by immunohistochemical techniques that this tumor might be of Schwann cell origin. We encountered a case of a mediastinal schwannoma, which was also considered to be of Schwann cell origin, and an OFMT of the scapula. We describe herein the findings of this very rare case.

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We encountered a surgical case of infected bronchoesophageal cyst that developed in the muscle layer of the esophagus after fine-needle aspiration biopsy. Three quarters of the cystic wall was removed but one quarter remained due to inflammatory adhesion to the esophagus. Long-term placement of a chest tube was required because of postoperative pleuroesophageal fistula. We plan to observe this case for a long period because of the possibility of recurrence due to the cyst wall remnant.

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A woman in her late 30s developed oropharyngeal muscle weakness. A tumor shadow was observed in the anterior mediastinum. She was diagnosed with myasthenia gravis (MG) and thymoma. After induction therapy using steroid hormones, she was admitted to our hospital. High levels of serum anti-acetylcholine receptor antibody and squamous cell carcinoma antigen (SCCA) were detected by peripheral blood examination. Computed tomography scans showed an anterior mediastinal tumor and right pleural lesions. The tumor was diagnosed as a WHO type B2 thymoma histologically by tumor biopsy under thoracoscopy. We performed resection of the tumor through a median sternotomy and right anterior thoracotomy. The post-operative pathological diagnosis was a WHO type B2/B3 thymoma, Masaoka stage IVa. There was no evidence of other types of malignancy. Serum SCCA levels were further increased after surgical treatment and decreased without any event. Thymoma is occasionally associated with autoimmune disease, such as MG, pure red cell aplasia, and Good syndrome. However, the elevation of serum tumor markers such as SCCA is extremely rare. In Japan, four cases of thymoma accompanied by high levels of serum SCCA have been reported to date.

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Alpha-fetoprotein (AFP) -producing lung cancer is a histologically rare type of lung cancer. We report a case of postoperative multiple liver metastasis from alpha-fetoprotein-producing pulmonary adenocarcinoma. A 64-year-old man was suspected of having a lung carcinoma in his right upper lobe. The tumor was diagnosed as primary adenocarcinoma of the lung (cT1aN0M0, Stage 1A), and right upper lobectomy and node dissection were performed. Four months after the operation, the serum AFP measurement was elevated at 2,318 ng/ml, and a CT scan of the abdomen showed multiple liver tumors. The histological/immunohistochemical diagnosis from CT-guided liver biopsy was liver metastasis from AFP-producing pulmonary adenocarcinoma, and he has been undergoing chemotherapy.

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We encountered a very rare case of sternum body posterior dislocation. A 23-year-old male had been snowboarding when he was strongly hit in the chest, causing posterior dislocation of the sternum body. Since conservative treatment of the patient did not resolve the dislocation, surgical restoration of the displaced sternum body was carried out without plate fixation. The postoperative course has been favorable, and recurrence of the dislocation has not been observed. There have been very few reported cases of posterior dislocation of the sternum body, so our experience provides valuable new information about such cases.

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Because mixed squamous cell and glandular papilloma is an extremely rare pulmonary neoplasm, little is known about its clinical entities. A man in his 70's was pointed out as showing a right lung nodule during an examination for a persistent cough. Chest computed tomography demonstrated an irregular shaped, solid nodule, 28×18 mm in diameter, with pleural indentation in the right lung S9. The nodule showed a high-level uptake of FDG. Serum levels of CEA and SCC were high. There were no swollen regional lymph nodes, and there were no distant metastases. Since TBLB and CT-guided lung biopsy did not reveal definitive diagnoses, we performed right lower lobectomy with lymphadenectomy thoracoscopically. Pathological findings of a surgically resected specimen demonstrated tumor cells with papillary growth in the bronchioli. Glandular papilloma consisted of papillary growing columnar ciliated cells with little atypia and squamous papilloma which consisted of papillary growing squamous epithelial cells with no atypia. No vascular invasion nor lymphnode metastasis was observed. We presented a very rare lung benign tumor, mimicking primary lung adenocarcinoma.

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A 70-year-old man was found to have an abnormal shadow and a right aortic arch on a chest radiograph. Computed tomography (CT) -guided biopsy revealed lung cancer in the right upper lobe. Before surgery, chest CT showed an anomalous pulmonary vein (V2) and a right aortic arch. The anomalous pulmonary vein was identified posterior to the right main bronchus, and independently drained directly into the left atrium. We were able to safely perform lobectomy and node dissection. Patients with anomalous structures such as a right aortic arch and anomalous pulmonary vein are very rare. However, we should keep in mind the possibility of such anomalous structures when we carry out pulmonary surgery.

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A 69-year-old man was referred to our hospital because of an abnormal shadow on a routine chest radiograph. Computed tomography of the chest revealed a round-shaped nodule measuring 2.2×2.0 cm in the right S2. Transbronchial biopsy suggested primary lung cancer, and right upper lobectomy and mediastinal lymphadenectomy were performed by VATS. The postoperative pathological diagnosis was amelanotic melanoma based on histopathological and immunohistochemical studies. Extensive examination of the whole body revealed no other malignant lesion. The FDG-PET scan and upper gastrointestinal tract endoscopy and colonoscopy showed no original lesion. Therefore, we made a diagnosis of primary amelanotic malignant melanoma of the lung. Follow-up in our outpatient clinic revealed no evidence of recurrent disease at 15 months after surgery. Primary malignant melanoma of the lung is very rare, and the 27 cases reported in Japan are reviewed.

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Thymoma tends to progress by invading the surrounding structures, but rarely metastasizes to extrathoracic organs. According to the World Health Organization histological classification, type B1 thymoma patients have a favorable prognosis and rarely relapse. We report a case of type B1 thymoma that metastasized only to the liver after resection. A 64-year-old woman with a history of lung cancer and thymoma was diagnosed with a liver tumor, measuring 4.0×3.0 cm, in the lateral segment. The patient had undergone left upper lobectomy for lung cancer and resection of the anterior mediastinal lesion simultaneously 3 years and 6 months previously. The mediastinal lesion mimicked the normal thymus on diagnostic imaging, and, therefore, a definite diagnosis could not be made before resection. The histological diagnosis of the resected specimen was a type B1 thymoma. The liver tumor was resected via a left lateral segmentectomy, and was diagnosed as type B1 thymoma metastasis. Multiple liver metastases occurred 1 year and 4 months after liver resection, and the patient received chemotherapy with doxorubicin, cisplatin, vincristine, and cyclophosphamide (ADOC regimen). One year and 3 months after chemotherapy, the patient was alive without disease progression. Type B1 thymoma potentially metastasizes to the liver after resection, and, therefore, careful follow-up of such cases is essential.

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