In the present study, we performed a retrospective analysis of critical situations in thoracic surgery between April 2007 and March 2015 at Hyogo College of Medicine Hospital. Critical situations involved 11 cases (0.42%). The causes of the critical situations were as follows: hypotension led to critical situations in 5 cases, fatal arrhythmia in 4 cases, and hypoxia in 2 cases. Critical situations were caused by surgical techniques in 8 cases and by patients' complications in 3 cases. As a result of analysis of the possibility to avoid the critical situations, they had been potentially avoidable in 8 cases. We consider that precise surgical techniques and sharing surgical strategies among the operating team are effective to avoid critical situations and promote safe operations.

We analyzed the effect of pleurodesis with a 50% glucose solution on patients with pneumothorax, pulmonary air leakage after lung resection, and malignant pleural effusion. Twenty-one male and 8 female patients aged 61.0 on average were injected with 200 mL of a 50% glucose solution into the pleural cavity, and 2 patients were injected with 100 mL of the solution because of their poor performance status. Of the 29 cases receiving 200 mL, 14 involved pneumothorax, 11 involved pulmonary air leakage after lung resection, and 4 involved malignant pleural effusion, including 5 untreated diabetic patients whose HbA1c was 6.7% on average (diabetes mellitus group: DM group). Pleurodesis with a 50% glucose solution was effective for 11 patients with pneumothorax and 9 patients with pulmonary air leakage after lung resection. In most cases, air leakage had disappeared by the first day. Half of the malignant pleural effusion cases were controlled. The 2 cases treated with 100 mL of glucose solution showed a smaller drainage volume, with successful results. A significantly higher temporary rise in the blood sugar level was observed in the DM group, but adverse effects were not seen in either the DM or non-DM group. Chest pain and transient fever were observed in many cases, but these were not serious in any patient. In conclusion, pleurodesis with a 50% glucose solution showed significant effectiveness and safety for patients with air leakage due to pulmonary air leakage after lung resection, and efficiency for malignant pleural effusion was also suggested.

We examined 14 cases of spontaneous hemopneumothorax encountered in our hospital from April 2007 to December 2015. We operated under thoracoscopic guidance in all cases. All cases showed bleeding from a funicular process that included the blood vessel of the apex area parietal pleura, and one case showed bleeding from a funicular process of the mediastinal pleura near the azygos vein. The average blood loss was 1,072 mL (300-2,050 mL); two patients needed transfusion and one patient presented with shock symptoms. In all cases, we removed the thoracic drain by day 3 after surgery and the mean duration of hospitalization after surgery was 3.9 days (2-7 days). Spontaneous hemopneumothorax is an emergency complaint yielding a shock state as a result of massive bleeding. It is not sufficient for thoracic surgeons alone to understand the need for an early operation; it is also necessary to educate physicians and emergency doctors, because when other departments provided the initial response for the 14 cases in our hospital, five patients underwent operations after 24 hours or more. As more than one bleeding site may be present during surgery, detailed intrathoracic observation is important.

We report a rare case of intrapericardial pericardial cyst in a 37-year-old female who was initially referred to a previous hospital with a chief complaint of syncope. Chest CT showed a cystic mass in the pericardial cavity, which compressed the right atrium.

She was diagnosed with an intrapericardial cystic mass with bradycardia and syncope, and referred to our institution for surgery.

Before the operation, we implanted a temporary pacemaker to prevent bradycardia, and thoracoscopic fenestration of the cyst wall was performed.

Intraoperatively, after fenestration, the contents of the cyst were drainaged, and elevation of the heart rate was observed (40→60 bpm). The pathological finding was a pericardial cyst.

While resected cases of pericardial cyst are sometimes reported, those with symptoms are rare, and so we report this case.

Primary pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma is a low-grade B-cell lymphoma, and is reported as a relatively rare disease with a better associated prognosis than lung cancer. It is understood that this disease shows various imaging patterns on chest CT. Here, we report a case of pure ground-glass nodule (GGN) occurrence caused by pulmonary MALT lymphoma. A 61-year-old woman received a PET-CT check-up examination, and a pure GGN of 1.5 cm in diameter in the S4 of the left lung was detected. At the 2-year follow-up, the size of the GGN had slightly increased. We performed left upper lobectomy under video-assisted thoracic surgery because the margin of the tumor was unclear.

Microscopic examination showed small lymphocyte or plasma cell-like tumor cells that were hyperplastic and formed nodules along the alveolus. Immunohistochemically, the tumor cells were positive for both CD20 and CD79a, and immunoglobulin heavy chain gene rearrangement was detected by Southern blotting using frozen tumor sections. Finally, the patient was diagnosed with MALT lymphoma of the lung. The patient remains well with no evidence of recurrence under follow-up.

A 52-year-old man was referred to our hospital with a pulmonary nodular shadow in the right upper lobe (S²), followed by transient coughing. The pulmonary nodular shadow showed a high accumulation on FDG-PET, but trans-bronchoscopic biopsy failed to lead to a diagnosis. A right upper lobectomy was performed because of the possibility of primary lung cancer. Histological findings showed a large number of eggs and the body of an adult parasite in the inflammatory mass. He was diagnosed with Paragonimus westermani infection based on immunological examinations after surgery, and treated with the oral administration of praziquantel.

We evaluated the treatment method for large anomalous arteries and the stumps thereof in cases with intralobar pulmonary sequestration of the left and right lower lung lobes, in which lower lobectomy under thoracoscopy was carried out with favorable outcomes. [Case 1] A 54-year-old male. An anomalous artery was observed diverging from the descending aorta of the chest and flowing into the right lower lung lobe. It was diagnosed as intralobar pulmonary sequestration of the right lower lung lobe, and a VATS lobectomy of the right lower lung lobe was carried out. The anomalous artery, with a diameter of 18 mm, was exfoliated to the lower aorta and ligated from the center using vessel tapes, No. 2 silk thread, and No. 1 silk thread, in that order, after which the peripheral part was separated using an automatic suture device. [Case 2] A 27-year-old male. A VATS lobectomy of the left lower lung lobe was carried out for intralobar pulmonary sequestration of the left lower lung lobe. An anomalous artery, with a diameter of 13 mm, flowing into the left basal segment from the descending aorta of the chest near the diaphragm was treated in the same way as in Case 1. The post-operative dynamic CT indicated no signs of stump swelling of the anomalous artery stumps in either case. The treatment of anomalous arteries at our hospital involves double ligature and the use of an automatic suture device, which we believe guarantees safety and reliability.

Although aberrant fissure of the lung is sometimes noted during pulmonary resection, most cases show a partial or incomplete division. We encountered two cases of pulmonary segmentectomy for lung cancer with a distinct aberrant fissure between the left upper and lingular divisions. In case 1, a 57-year-old man with lung cancer in the left S1+2 underwent thoracoscopic upper segmentectomy. There was a distinct aberrant fissure between the left upper and lingular divisions and the pulmonary artery ran anterior to the anomalous upper bronchus with independent upper segmental branching. In case 2, an 80-year-old woman with lung cancer in the left lingular segment underwent thoracoscopic lingual segmentectomy. There was a distinct aberrant fissure between the left upper and lingular divisions with no aberrant ramifications of the bronchus or vessels except for the common pulmonary vein. Postoperative courses of the two cases were uneventful, and there has been no recurrence of lung cancer to date. Herein, we report these cases with a review of the literature.

We report two cases of sternal fractures successfully treated using bone fixation plates. Case 1: A 52-year-old man was injured in a traffic accident. He suffered from respiratory failure due to a flail chest related to sternal fractures, which necessitated mechanical ventilation. Nevertheless, his respiratory status did not improve, and we performed repair of the sternum with a bone fixation plate. Afterwards, he could be weaned from the ventilator early. Case 2: A 42-year-old man was admitted to our hospital because of a fall-related accident. CT showed a sternal fracture with severe dislocation. There was concern about aftereffects such as a false joint, chronic pain, and limitation of exercise. We performed repair of the sternum as well. The postoperative course was favorable, and he returned to a normal life without any aftereffects. Bone plating for a fractured sternum can show therapeutic efficacy, especially for patients with severe dislocation or respiratory failure related to sternal fracture.

A 79-year-old man was referred to our hospital for the treatment of diabetes mellitus. Chest CT showed lung cancer in the right upper lobe of his lung (c-T2aN0M0, Stage IB) and aortic stenosis with calcification. We performed one-stage surgery for his lung cancer and aortic valve stenosis because the aortic valve stenosis was severe, and progression of the lung cancer following the valvular disease operation was a concern. We performed right upper lobectomy and lymph nodal dissection systemically through a median sternotomy, after the cardiopulmonary bypass standby, and subsequently performed aortic valve replacement under cardiopulmonary bypass. The patient was discharged on postoperative day 17 without any unexpected events. We report the case of one-stage surgery for lung cancer and aortic valve stenosis, which can be performed and facilitate a safe postoperative course. The one-stage surgery for lung cancer and aortic valve stenosis is assumed to be a safe method if preoperative evaluation is precise.

A 67-year-old man underwent wedge resection for early-stage lung cancer of the left lower lobe. The pathological diagnosis was adenocarcinoma in situ (AIS) with a 100% lepidic growth pattern. Three months after the resection, a single pure ground-glass nodule (GGN) of 10 mm in diameter was detected in the left upper lobe on follow-up computed tomography (CT). After another three-month follow-up, the pure GGN lesion was changed to a solid nodule with pleural indentation. Positron emission tomography (PET) showed abnormal uptake to the nodule with a maximal standardized uptake value (SUV-max) of 1.7. Since malignancy could not be excluded, wedge resection was performed. Pathological findings revealed that the lesion was a pulmonary infarction. Pulmonary infarction generally presents as multiple nodal lesions on CT. In this case, a solitary pure GGN was first recognized, which changed to a solid nodule later. These findings are consistent with the time course of pathological findings; therefore, it is considered that we could verify the time course of CT findings. Moreover, since these findings are similar to those of lung cancer, it is suggested that we should be careful on conducting a differential diagnosis.

A 77-year-old man was referred to our hospital because of an abnormal shadow on a chest radiograph during an annual physical examination. Computed tomography of the chest revealed a solid tumor of 30 mm in diameter in the posterior basal segment (S10) of the left lower lobe and a small nodule of 8 mm in diameter in the anterior segment (S3) of the left upper lobe. Transbronchial lung biopsy (TBLB) of the tumor in the left S10 revealed squamous carcinoma of the lung. Intraoperative histopathological examination of the nodule in S3 showed pulmonary adenocarcinoma. We then confirmed that these two lesions were synchronous lung cancers. Wedge resection of the left upper lobe, left lower lobectomy, and left hilar lymphadenectomy were performed. The final pathological diagnosis revealed that the nodule in the left upper lobe consisted of small cell lung carcinoma and well-differentiated pulmonary adenocarcinoma, and the tumor in the left lower lobe consisted of squamous cell carcinoma and large cell neuroendocrine cancer (5%). Here, we report a rare case of synchronous lung cancers with various histopathologic features.

A 79-year-old female with respiratory failure was admitted to our institute. A chest radiograph showed eventration and paradoxical movement of the right diaphragm. Paradoxical respiration due to diaphragmatic eventration was diagnosed as the cause of respiratory failure. We selected a transthoracic radial plication technique to treat the diaphragmatic eventration. The transthoracic radial plication technique is a method of diaphragmatic plication with central tendon preservation. This technique is considered to reduce the risk of recurrence. Two skin incisions were made at the seventh and tenth inter-costal spaces. The bony thorax was exposed through the anterior serratus and latissimus dorsi muscle. The flaccid muscle of the ventral to lateral diaphragm was plicated and sutured to the eighth or ninth rib using an incision at the seventh inter-costal space. The flaccid muscle of the dorsal diaphragm was sutured to the tenth rib using an incision at the tenth inter-costal space. After plication of the diaphragm, the central tendon became taut, and paradoxical movement of the right diaphragm disappeared. The symptom was resolved after surgery. She was discharged to home 54 days after treatment, and is now leading a normal life at 18 months after treatment.

A 77-year-old woman was admitted to our hospital with a chest nodal shadow. Chest CT showed a 9-mm nodule with spiculation in the right middle lobe. We resected the nodule by video-assisted thoracoscopic surgery. There was inflammatory adhesion in the right intrathoracic cavity. It was suggested that the inflammation had been present in the intrathoracic cavity previously. Histopathological findings of the nodule were inflammatory change with hyperplasia of fibrous connective tissue, and phagocytosis of carbon dust. The nodule was an intrapulmonary lymph node. At 9 days after the operation, the patient was discharged from our hospital without any problems.

Fluorine-18-fluorodeoxyglucose accumulation on positron emission tomography is effective to distinguish between malignant tumors and others. However, we report the case of an intrapulmonary lymph node presenting with a lung cancer-like shadow and fluorine-18-fluorodeoxyglucose accumulation on positron emission tomography. Because intrapulmonary lymph nodes influenced by inflammatory disease could accumulate fluorine-18-fluorodeoxyglucose on positron emission tomography, we should take into account intrapulmonary lymph nodes, even if nodules accumulate fluorine-18-fluorodeoxyglucose on positron emission tomography.

The patient was a 68-year-old woman who presented with a typical Cushingoid appearance and elevated serum adrenocorticotropic hormone (ACTH) and cortisol levels, indicating ACTH-related Cushing's syndrome. Although she received Hardy's operation, her symptoms did not improve. Chest computed tomography (CT) showed a 15 mm nodule in the middle lobe of the right lung. However, FDG-PET/CT did not yield useful findings for diagnosis. Then, we performed ⁶⁸Ga-DAOTATOC-PET/CT. The pulmonary nodule showed significant uptake on ⁶⁸Ga-DAOTATOC-PET/CT. We suspected the nodule to be an ectopic ACTH-releasing tumor. Right middle lobe wedge resection was perfomed, and the postoperative histological diagnosis was a typical carcinoid tumor. The serum ACTH level decreased after resection.

A 33-year-old man was referred to our hospital with a 13.9-mm nodule in segment 6 of the right lung. The nodule was followed by computed tomography for one year and then suspected to be lung cancer. Thoracoscopic wedge resection of segment 6 was performed. Histopathologically, the nodule was infiltrated with IgG4-positive plasma cells. The rate of IgG4-positive to IgG-positive cells was about 60%. The serum IgG4 was also elevated, and then the nodule was diagnosed as showing IgG4-related pulmonary disease. Although other lesions of IgG4-related disease were not found, the post-operative serum IgG4 was still elevated.

A female octogenarian was pointed out as showing a nodule in the left upper lung field on a chest roentgenogram two years ago. She was referred to our hospital because of nodule enlargement. Chest CT revealed a nodule measuring 26 mm in diameter and a ground-glass opacity (GGO) measuring 5 mm in the left upper lobe. Left upper lobectomy was performed on the suspicion of left upper lung cancer. Pathological examination of a resected specimen revealed the nodule lesion to be a collision lung cancer with components of papillary adenocarcinoma and clear cell adenocarcinoma, and the GGO lesion was diagnosed as bronchioloalveolar carcinoma, which is a case of synchronous multiple lung cancer in the same lobe. Retrospective reading of the CT scan revealed that two separated nodules grew and collided in the process of enlargement. Detection of the EGFR mutation status for the lesion at 3 locations revealed that all lesions had the same EGFR deletion mutation in Exon 19. Cases of synchronous multiple lung cancer with collision cancer are rare. This is an informative case showing distinct differentiation accompanied with the same EGFR mutation pattern.

A 44-year-old man presented to a local general physician (GP) with gradually deteriorating dyspnea lasting for a few days. The patient was referred to our hospital with the GP's diagnosis of left-sided tension pneumothorax. Computed tomography (CT) revealed that he didn't have tension pneumothorax but a giant tension bulla, which required emergency bullectomy. General anesthesia was started using rapid sequence induction minimizing positive pressure ventilation to avoid cardiopulmonary failure. Because of its rarity in adult cases and its diagnostic similarity, giant tension bulla might be misdiagnosed as tension pneumothorax, although those two diseases should be managed quite differently. CT is useful to distinguish between those two diseases and careful interview focusing on the duration and onset of dyspnea would also be helpful, suggesting giant tension bulla and not tension pneumothorax.

An 18-year-old woman was admitted to our hospital with an abnormal shadow in the superior mediastinum on a chest radiograph. Chest CT and MRI revealed a mass with cyctic and solid components on the right side of the superior mediastinum. Thoracoscopic surgery was performed to remove the mass, diagnosed as a superior mediastinal tumor. The mass existed in the superior mediastinum with a tiny stalk on the cranial side. The resected mass was composed of multiple cysts covered with ciliated columnar epithelium, cartilage, smooth muscle, bronchial glands, and collapsed alveoli. Arteries increased in the specimen, which consisted of thick three-layered walls, but venous drainage was not apparent. The mass was covered with pleura, and pathologically diagnosed as extralobar pulmonary sequestration.

<Background> Empyema with a fistula is a severe disease because chest drainage therapy is insufficient to control the empyema. Therefore, we often perform closure of the fistula and plombage with the great omentum in addition to thoracoplasty. However, empyema patients with a fistula usually have many coexisting illnesses, so the risks of those operations are high.

<Case> A 66-year-old man with left empyema and a fistula underwent continuous chest drainage and washing of the chest cavity with antibiotics. Air leakage from the chest cavity was revealed several days after chest drainage, and so he was transferred to our hospital because his left lung did not expand in spite of continuous chest drainage. Although we considered surgical treatment for him, we chose bronchoscopic intervention due to his coexisting complications, involving diabetes mellitus, anemia, and malnutrition. We placed Endobronchial Watanabe Spigots (EWS) in his leaking bronchus using a bronchoscope three times. After the procedures, the air leakage from the chest cavity disappeared and he was discharged home.

<Conclusion> Treatment of bronchial embolism with EWS by a bronchoscope is useful for empyema with a fistula in order to avoid high-risk surgical treatments due to coexisting illnesses.

A 76-year-old man was referred to us with an abnormal opacity on a plain chest radiograph. Chest computed tomography revealed an irregular nodular shadow measuring 21 mm in the S³ segment of the right upper lobe, which was continuous with an interlobar lymph node (#11s). On the basis of the clinical examination findings, the patient was diagnosed with lung adenocarcinoma of the right upper lobe, clinical T1bN1M0, stage IIA. CT also showed a consolidation with an air bronchogram in the right hilum, and middle lobe hypoplasia was suspected. We confirmed a thumb-head-sized right middle lobe during surgery. Although there was the possibility of the middle lobe serving as a source of repeated infections, we performed right upper lobectomy with wedge bronchoplasty rather than extended sleeve lobectomy, in order to avoid excessive tension on the anastomosis. We report a case of lung hypoplasia with a review of the literature.

A 65-year-old female was admitted to our hospital because of bilateral pleural and pericardial effusion. She underwent pacemaker implantation elsewhere for complete A-V block at age 60, re-implantation at age 61 due to pacemaker pocket infection, and was treated with antibiotics for idiopathic mediastinitis at age 65. She was diagnosed with bilateral chylothoraces and chylopericardium by thoracocentesis and pericardiocentesis. Bilateral pleural drains and a pericardial drain were inserted. Neither lymphangiography nor radioisotope lymphography revealed the site of chyle leakage. Her pleural and pericardial effusion did not decrease in spite of a low-fat diet. So, she underwent thoracoscopic ligation of the thoracic duct and pericardiotomy through the right thorax. After the surgery, pericardial effusion disappeared but pleural effusion persisted. She developed respiratory failure because of pleural effusion, and had to undergo thoracocentesis repeatedly. As her malnutrition progressed gradually due to the loss of chyle, bilateral pleuroperitoneal shunt (using Denver Shunt^®) was performed 84 days after the first surgery. Bilateral pleural effusion was well controled, her nutrition status recovered, and no further therapeutic intervention for chylothorax was required. She underwent removal of the initially inplanted pacemaker lead due to a subsequent septic episode 17 months after the shunt operation, and no further pumping of the shunt tube was needed thereafter. This is a rare case in which the pacemaker lead was a possible cause of chylothorax. We think that pleuroperitoneal shunt can be an effective therapy for persistent chylothorax.

A 79-year-old woman underwent resection of a chest wall tumor and was diagnosed with a solitary fibrous tumor (SFT) in 2009. At the same time, she was diagnosed with diabetes mellitus, and oral therapy was started. The routine follow-up was concluded in 2012, but she was admitted to our department complaining of shortness of breath in August 2015. Chest CT showed a solid tumor and pleural effusion, and she was diagnosed with the recurrence of SFT. Her symptom was improved by chest thoracic drainage and pleurodesis, but she developed disorientation caused by hypoglycemia one month later. She showed no improvements with standard treatment; therefore, we fully examined her. As a result, we diagnosed her with non-islet cell tumor hypoglycemia (NICTH) because we identified big insulin-like growth factor II (big IGF-II) in the serum and IGF-II expression in the primary tumor. The blood sugar was stabilized when she started steroid administration. Therefore, she is receiving outpatient treatment at present. Cases of SFT producing big IGF-II are relatively rare, but attention is necessary for the possibility of causing a hypoglycemic attack.