The usefulness of Tissue-Link^TM (TL) for 419 operative cases of primary spontaneous pneumothorax between November 1999 and July 2013 was examined. The study population consisted of 369 males and 50 females, with an age of 32.7±17.6 years (mean±SD), height of 169.4±7.5 (cm), body weight of 55.7±8.1 (kg), BMI of 19.4±2.3, and smoking index of 180.9±345.6 (pack・years). Operation was performed on the right side in 211 cases and left side in 208 cases, and involved thoracoscopic surgery in 393 cases and thoracotomy in 26 cases, with the TL ablation group (TL+group) containing 251 cases and non-TL ablation group (TL- group) containing 168 cases. The mean operation time, exicision number, and exicision volume (conic approximation) were 69.2±33.6 (min), 1.21±0.49 (units), and 22.2±47.0 (cm³), respectively. In the lung bullae group of more than 3 cm in diameter, there was no significant difference in sex, age, BMI, or smoking index, while the surgical time, exicision number, and exicision volume of the TL+group were lower than those of the TL- group, with a significant difference.

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Postoperative pain after thoracotomy and thoracoscopic surgery is often prolonged because of the occurrence of neuropathic pain due to intercostal nerve injury. The aim of this study was to examine whether the combination therapy of pregabalin with NSAID for postoperative pain with a neuropathic component is effective. The present study demonstrated that, in patients with neuropathic pain treated by combination therapy of pregabalin in conjunction with NSAID, the mean visual analogue scale (VAS) and numeric rate scale (NRS) reduction rate were significantly reduced compared to NSAID-only therapy in both the thoracotomy group and thoracosopic surgery group. This pain is thought to be composed of both nociceptive and neuropathic components and linked with late convalescence after an operation. The novel analgestic drug, pregabalin, may attenuate a patient's symptoms including neuropathic pain after thoracotomy combined with NSAID.

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Objective. To evaluate the outcome of surgical treatment for malignant pleural mesothelioma (MPM). Subjects. A total of 264 cases of MPM from 2007 through 2013 from Rosai Hospital were reported. Of these, I examined 60 patients treated surgically. Results. The 56 men and 4 women had a mean age of 65 years old. Histological diagnoses were as follows: 41 had the epithelioid type, 6 the sarcomatoid type, and 11 had the biphasic type. Seventeen had stage I disease, 20 had stage II, 22 had stage III, and 1 had stage IV. Fifty-five patients underwent extrapleural pneumonectomy (EPP), 1 pleurectomy/decortication, and 4 tumor resection. Thirty patients received adjuvant therapy. The median overall survival period was 17.0 months. On multivariable analysis using the Cox proportional hazards model, surgery was a prognostic factor for all patients. Concerning EPP, the performance of adjuvant therapy and combination of pemetrexed were prognostic factors. Conclusion. There was no problem in the choice of the surgical treatment for the I+II stage.

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Objective: The objective of this study was to analyze the feasibility and efficacy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) in the staging and treatment of resectable non-small cell lung cancer (NSCLC). Methods: Between October 2009 and December 2013, 60 consecutive patients underwent mediastinoscopic lymph node biopsy/dissection for preoperative staging of resectable NSCLC. A total of 22 underwent conventional video-mediastinoscopy (CM group) and 38 patients received VAMLA (VAMLA group). The patients who had negative mediastinoscopy/VAMLA results underwent video-assisted thoracoscopic (VATS) lobectomy and systematic lymph node dissection. Results: Both groups had no complications. The operation time and numbers of dissected lymph node stations showed no significant differences between the groups. The total numbers of obtained lymph nodes per mediastinoscopy/VAMLA in the VAMLA group (55.4±24.1) were significantly higher than those in the CM group (25.4±12.6) (P<0.0001). There was no significant difference in the total numbers of dissected lymph nodes in VATS between the VAMLA group (47.6±20.8) and the CM group (43.1±15.9). The total numbers of obtained lymph nodes in both mediastinoscopy and VATS in the VAMLA group (104.2±38.0) were significantly higher than those in the CM group (68.3±22.6) (P=0.0002) (MEAN±SD). Both the accuracy and negative predictive value in the VAMLA group (89.5, 89.2, respectively) were higher than in the CM group (86.4, 85.7, respectively). Conclusion: VAMLA enabled significantly more LNs to be dissected than conventional mediastinoscopy, and is a safe and clinically feasible procedure for more accurate mediastinal staging and radical mediastinal dissection in NSCLC.

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We report a 62-year-old male with carcinosarcoma occupying a preceding lung bulla, who successfully underwent video-assisted thoracoscopic surgery (VATS). He had an abnormal shadow pointed out in his left apical region at a regular check, and was referred to our hospital. On examination, chest CT showed a round mass of 65 mm in diameter in his left apical region of the lung which occupied the preceding lung bulla, which had been followed for ten years. The mass showed positive accumulation of FDG by PET. He underwent a successful left upper lobectomy under thoracoscopy, and the postoperative course was uneventful. The patients has been well without evidence of recurrence for 12 months. Carcinosarcoma of the lung is a rare disease. To our knowledge, this is the first report of carcinosarcoma occupying a preceding lung bulla, and successfully resected by thoracoscopic surgery.

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A 71-year-old man, with a history of right middle lobectomy of the lung for the treatment of an infectious pulmonary cyst, had a right pulmonary nodule on the staple line with a hot spot on positron emission tomography (PET). Since the size of the nodule had increased during follow-up, the patient underwent partial resection of the right lung to remove the nodule. Histopathologically, the nodule was diagnosed as an inflammatory granuloma caused by a foreign body reaction to the staple. In addition to lung cancer, the possibility of suture/stapler granuloma should be considered in cases in which pulmonary nodules are detected on the staple line after pulmonary resection.

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A man in his 60s underwent right upper sleeve lobectomy after neoadjuvant chemoradiotherapy for pulmonary adenocarcinoma (Bu cT2aN2M0, cStage III). He had undergone a total of seven balloon dilations and a metallic stent placement for bronchial anastomotic stenosis, and developed repeated lung abscess. So, he was referred to our hospital for radical surgery for the lung abscess. Although the pulmonary great vessels were easily ligated at the intrapericardial proximal site during the operation, severe bleeding was noted from the dissected pulmonary surface after ligating the pulmonary veins. In addition, since the right main bronchus could not be identified as close to the tracheal bifurcation due to the inflammatory adhesion of the hilum, completion pneumonectomy was conducted, retaining metallic stent pieces in the right main bronchus. The postoperative course was uneventful, and the patient is currently alive without recurrence at 25 months after the initial surgery and 9 months after the completion pneumonectomy.

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An 80-year old man was referred to our department because of an extra-pleural tumor. CT revealed a mass in the fourth ventral intercostal space. CT-guided biopsy was conducted and the tumor was diagnosed as alpha SMA-positive, and suspected to be borderline-malignant. An operation was conducted, and we resected the ribs, costal cartilages, and sternum, including the tumor. To preserve the rigidity of the thorax, we reconstructed the chest wall using polypropylene mesh, and also reconstructed the sternum with Kirschner wire and bone cement. After the surgery, the tumor was diagnosed as a desmoid tumor. Our procedure of sternal reconstruction is effective to preserve the rigidity of the thorax, especially in front of the heart.

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A 30-year-old woman was admitted complaining of right chest pain during menses. Chest radiograph revealed pneumothorax, leading to the suspicion of catamenial pneumothorax because pulmonary bullae could not be confirmed using chest computed tomography. However, during the following 7 months, pneumothorax recurred four times during menstruation, leading to video-assisted thoracic surgery for further diagnosis. Several fistulas were found in the central tendon of the diaphragm, along with bloody pleural effusion; there were no remarkable changes in the visceral pleura. The diaphragm was partially resected, including all fistulas. After surgery, we observed a blueberry spot on the abdominal side of the diaphragm that could not be observed using a thoracic approach. This spot was confirmed to be endometrial tissue on the abdominal side of the diaphragm. The patient did not receive post-surgical hormone therapy; pneumothorax recurred 9 months postoperatively. Surgical treatment, via a thoracic approach, could not detect an abdominal cavity lesion, which is a reason why catamenial pneumothorax often recurs after surgery.

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Spinal cord infarction is a rare perioperative complication of nonaortic surgery. We report a case of spinal cord infarction following left upper lobectomy for lung cancer. A 79-year-old man with lung cancer, which was diagnosed as clinical Stage III A (cT2aN2M0), underwent left upper lobectomy, plasty of the pulmonary artery, and combined resection of the mediastinal invasive region. An epidural catheter was introduced directly after the surgery in the operating room because there was possibility of heparin administration intraoperatively. When the patient returned to the ward, muscle weakness of both legs and sensory disturbance inferior to the nipples were observed. Although a complication related to epidural anesthesia was suspected at first, there was no abnormal finding around the spine on CT. On postoperative day 7, dissociated sensory disturbance became clear, and MRI showed spinal cord infarction widely ranging from Th1 to Th10. As the symptom improved with the administration of prostaglandin E1 and rehabilitation, the patient transferred hospitals for rehabilitation on postoperative day 52. Spinal cord infarction is a rare disease that is difficult to predict; however, it is necessary to keep the possibility of spinal cord infarction in mind when postoperative neuropathy is observed.

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A 17-year-old male consulted a doctor with a chief complaint of chest discomfort. He was diagnosed with left pneumothorax and a chest drain was inserted. As the air leak did not stop, he was transferred to our hospital to undergo an operation. We performed video-assisted thoracic surgery the next day. We found the air leak point at the top of the lung and resected that part with a surgical stapler. We also detected a mass or tumor-like lesion which was covered with mediastinal pleura. We thought that it was abnormal because the mass was clearly swelling from part of the left lobe. We resected part of the left lobe for diagnosis. The mass and left lobe were connected with no clear boundaries. The pathological diagnosis after the operation was thymic hyperplasia as it showed a homogeneous thymic structure with no neoplasm and a tumor-like appearance. Thymic hyperplasia with a localized tumor-like appearance is relatively rare, and so we present it including a literature review.

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A 55-year-old woman was referred to our department because of shadows noted on a radiograph. Computed tomography revealed shadows of circular, uniform nodules of 100-, 5-, and 8-mm diameters and clear borders in the left apical, left posterior basal, and right posterior basal segments of the inferior pulmonary lobe, respectively. All tumors had regressed slightly at the 3-month follow-up, but the tumor in the apical segment of the inferior lobe had enlarged 2 years later, and positron emission tomography showed faint accumulation. Since malignancy could not be ruled out, the tumor underwent thoracoscopic wedge resection. The histological features of the tumor resembled those of a uterine myoma that had been resected 17 years earlier. Therefore, we diagnosed the tumor as a pulmonary benign metastasizing leiomyoma. As this was a rare tumor that had initially regressed, possibly a characteristic of this type of leiomyoma, we report this case and review the available literature.

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We report a resected case of advanced right lung cancer invading the entrance of the right upper bronchus, with inflammatory stenosis of the middle bronchus in a 74-year-old man. We performed right upper and middle sleeve lobectomy. Computed tomography revealed a mass of 52×37 mm invading the ascending pulmonary artery. Transbronchial lung biopsy was performed, but a preoperative diagnosis was not obtained. A bronchofiber could not be passed through the middle bronchus because of the severe inflammatory stenosis. The preoperative diagnosis was lung cancer, and the clinical stage was T2bN0M0, IIA. We performed right upper and middle sleeve lobectomy and combined resection of the azygos arch. We anastomosed the right main bronchus and peripheral part of the intermedius, and then covered it with a pedicled pericardial fat pad. We resected the pulmonary ligament to reduce the tension of anastomosis. The pathological diagnosis was small cell lung cancer, and the final stage was T3N1M0, IIIA. Four courses of adjuvant chemotherapy (CDDP/CPT-11) were administered. No recurrence has occurred to date.

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Background: Critical illness polyneuropathy (CIP) is caused by the axonal degeneration of motor and sensory fibers in patients with systemic inflammatory response syndrome. Case presentation: A 70-year-old man with interstitial pneumonia, rheumatoid arthritis, diabetes, and hypertension underwent lobectomy and lymphadenectomy for a 7-cm squamous cell carcinoma located at the 6^th segment of the right lung. After surgery, respiratory management was required twice because of the exacerbation of interstitial pneumonia and MRSA pneumonia. Muscle weakness prolonged even after the removal of the respirator. In an electrophysiological study, the amplitude of motor nerve conduction, sensory nerve action potential, and nerve conduction velocity were reduced. These findings suggested CIP. Conclusion: The mortality rate associated with cases of exacerbated interstitial pneumonia after lobectomy for lung cancer is high. It is important to keep in mind that CIP may arise during intensive care, which affects activities of daily living.

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A 76-year-old man had an abnormal shadow on chest radiograph. Chest CT and MRI showed a mass of 6 cm in diameter, with calcifications and areas of fat attenuation within it. An axial view showed a well-defined mass between the mediastinum and right lung with an extrapleural sign. A mediastinal teratoma was suspected. Thoracotomy revealed a protruded mass lesion from the right lower lobe. Right lower lobectomy was performed. On histological analysis, a pulmonary hamartoma was diagnosed.

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A 28-year-old woman was transferred to our hospital in her 24th week of pregnancy with dyspnea and back pain. On arrival at the emergency department, she presented with shock vital signs and anemia. Contrast-enhanced chest computed tomography revealed tension hemothorax, passive atelectasis, and 2 enhancing nodules with afferent and efferent vessels on the right side. Telangiectases were evident on her cheeks and fingers, and she had a history of recurrent epistaxis. Based on these clinical findings, we made a diagnosis of tension hemothorax due to rupture of an arteriovenous fistula (AVF), which was associated with hereditary hemorrhagic telangiectasia and grew during pregnancy. In an emergent operation, pulsatile bleeding from the pulmonary nodule located at the surface of the visceral pleura of the right S10 segment was recognized after the removal of a massive pleural hematoma. Wedge resection of this bleeding nodule was performed. Additionally, we resected 2 other pulmonary nodules, resulting in 3 wedge resections of AVFs in total. The postoperative course was uneventful, and she delivered a healthy infant by cesarean section in her 37th week of pregnancy. Surgical resection seems to be a safe and definitive treatment for ruptured pulmonary AVF which caused tension hemothorax during pregnancy. In this report, we also describe our treatment strategy for pregnant patients with pulmonary AVF.

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A 59-year-old male, with a history of bronchial artery embolization (BAE) for the treatment of hemoptysis, underwent pulmonary resection and lymph node dissection for primary lung cancer. Twenty days later, he developed a bronchopleural fistula (BPF) resulting from bronchial ischemia. Covering the BPF using a pedicled omental flap was unsuccessful, and the patient subsequently died due to acute exacerbation of interstitial pneumonia. Pulmonary resection and lymph node dissection carry a high risk of bronchial ischemia in patients with a history of BAE.

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We report a case of localized malignant pleural mesothelioma. A 70-year-old male was admitted to our hospital with acute abdominal pain due to choledocholithiasis. Incidentally, a chest radiograph showed a large tumor in the left lung. Malignant cells of the lung were found on a percutaneous aspiration cytology test. Left upper lobectomy of the lung with partial chest wall resection was successfully performed. The tumor was pathologically diagnosed as localized biphasic malignant mesothelioma. No relapse had been observed as of about three years after the surgery.

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An asymptomatic 69-year-old man with a history of asbestosis was found to have an abnormal shadow in his left lung field on a chest radiograph. Chest CT revealed an 80×65-mm calcified mass in the dorsal portion of the left thorax. CT-guided needle biopsy revealed osteosarcoma. The tumor showed expansive and non-invasive growth and the adjacent ribs were intact, based on which the tumor was clinically diagnosed as an extra-skeletal osteosarcoma derived from the chest wall, pleura, or lung. FDG-PET and a bone scintigram revealed abnormal accumulation in the tumor but not at distant sites. The patient underwent thoracotomy. The tumor was resected with resection of part of the lung and the 3^rd to 6^th ribs together due to firm adhesion to the tumor. The tumor showed a solid and well-bordered appearance. Histological examination revealed the proliferation of spindle cells and chondro- and osteo-tissue formation, and the absence of rib and lung involvement was confirmed. Methothelioma-specific markers were negative based on immunohistochemistry. The final pathological diagnosis was extraskeletal osteosarcoma derived from soft tissue of the chest wall. The patient was followed-up without adjuvant therapy. One year after the surgery, tumor recurrence of pleural dissemination was suspected by CT, and so the patient underwent tomotherapy, but no tumor re-growth had been noted as of 1 year after treatment.

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We report ischemic colitis induced by pleurodesis with 50% glucose solution for spontaneous pneumothorax. A 97-year-old man visited to our hospital due to dyspnea. A chest radiograph showed right pneumothorax, and the insertion of a chest tube was performed. We instilled 50% glucose solution into the thoracic cavity because of prolonged air leakage for 5 days. After the instillation, a large drainage volume of 1,960 mL/4 hours was observed, and the patient developed prerenal acute renal failure followed by ischemic colitis. Remission of the ischemic colitis was achieved by fasting, and air leakage stopped 6 days after the instillation of 50% glucose solution. Marked pleural effusion may be induced osmotically or by pleuritis caused by hypertonic glucose solution. Ischemic colitis as a complication of pleurodesis with 50% glucose solution has not previously been reported, and it should be considered as a possible complication when we perform this method.

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Bronchogenic cysts are commonly located in the middle mediastinum. We report the rare case of a bronchogenic cyst in the thymus. A 65-year-old woman was admitted to our hospital for the diagnosis and treatment of a mass in the anterior mediastinum detected by thoracic CT. Enhanced CT and MRI showed a 2-cm-diameter cystic mass with viscous fluid in the thymus. We preoperatively diagnosed the mass as a bronchogenic cyst rather than a thymic cyst. We performed video-assisted thymectomy. Histologically, there was a layer of ciliated epithelium on the inner side of the cyst, and we diagnosed the tumor as a bronchogenic cyst in the thymus. Bronchogenic cysts should be included in the differential diagnosis of any cystic mass in the anterior mediastinum.

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A male in his 70's presented with a right lung tumor after undergoing resection of rectal carcinoma and a metastatic lung tumor. Partial resection of the right lower lobe was performed for the lung tumor. Air leakage developed after the procedure, and the leak was covered with a TachoSil^® tissue-sealing sheet. The patient exhibited a sudden reduction in blood pressure after 20 minutes, which we considered to be due to anaphylactic shock caused by TachoSil^®, as he also exhibited flushing of the facial surface and all four limbs, with little or no effect of treatment with ephedrine and phenylephrine. Notably, his blood pressure recovered five minutes after removing TachoSil^® and providing saline lavage. Physicians should consider the possibility of anaphylactic shock induced by the use of TachoSil^® during surgery if a patient shows a significant reduction in blood pressure.

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A 67-year-old male with a left lung tumor presented at our hospital. He was diagnosed with squamous cell carcinoma (cT2aN0M0 cStage IB). Left upper lobectomy with mediastinal lymph node dissection was performed, and the pathological findings showed poorly differentiated squamous cell carcinoma (pT2aN0M0 pStage IB). Seventy-six days after the operation, fever and left pleural effusion were recognized on outpatient follow-up. Surgery was indicated because of suspected empyema. However, pleural dissemination was found, and no pathogenic bacteria were detected within the specimen. His serum G-CSF level was elevated before the second operation, but had not been elevated before the first operation. Immunohistochemical staining with an anti-G-CSF monoclonal antibody showed positive results in the tumor from the second, but not the first, operation. Based on these findings, we diagnosed the patient with a G-CSF-producing lung cancer showing recurrence after complete resection.

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