Local therapies for stage I non-small cell lung cancer (NSCLC) are divided into surgical and radiation therapies among patients with limited physical preservation for lobectomy. A prospective Phase II study of stereotactic body radio therapy (SBRT) (JCOG0403) revealed that the overall 3-year survival rate (3-YSR) was 76.0%, the 3-year progression-free survival rate (3-YPFR) was 69.0%, and the rate of morbidity ≥ grade 3 was 9%. However, there have been few reports of prospective multicenter studies regarding surgery for stage I NSCLC among high-risk patients. Thus, we investigated this in the setting of a prospective multicenter observational study. Thirty-two high-risk NSCLC patients were accrued, with 30 males, and a median age of 74 years (61-85 years). There were 2 cases of morbidity ≥ grade 3 (6.3%) but no postoperative deaths. The margin local control rate was 96.9% (1 surgical margin recurrence), local recurrence control rate was 75.0% (8 recurrences in the ipsilateral thorax), 3-YSR was 79.0%, and 3-YRFR was 75.9%. Sublobar pulmonary resection among patients with limited physical preservation for lobectomy with stage I non-small cell lung cancer (NSCLC) provides safe and feasible results comparable with those of SBRT.

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Thopaz™ is a new digitalized suction system which can quantitatively evaluate the amount of air leakage after lung resection. The aim of our study was to investigate the management criterion by comparing Thopaz™ and a conventional suction system. The study population was 25 patients who underwent pulmonary resection. In the evaluation of the amount of air leakage using a conventional suction system, the degree was classified into four categories (-, ±, +, and++). The volume of air leakage was measured simultaneously twice a day by a conventional suction system and Thopaz™. The mean amounts of air leakage assessed by Thopaz™ were 4, 20, 63, and 662 mL/min, respectively, within the four categories for a conventional suction system. We demonstrated a correlation between the quantitative evaluation using Thopaz™ and conventional qualitative evaluation. In a clinical setting, this study may contribute to the introduction of Thopaz™.

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The resection of certain recurrent malignancies can prolong survival, but the resection of recurrent pancreatic cancer is typically contraindicated because of poor outcomes. We retrospectively analyzed patients who received pulmonary metastasectomy from pancreatic cancer. Nine patients operated on from Jan. 2004 to Dec. 2014 were included in this analysis. During the study, 3 patients developed recurrence after metastasectomies. The other 6 patients are alive without recurrence. There were trends toward a good prognosis after relapse in the prolonged disease-free interval group. Patients with resectable pulmonary recurrence of pancreatic cancer after a prolonged disease-free interval should be considered for pulmonary resection.

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A 65-year-old woman was referred to our hospital after a chest radiograph revealed an abnormal shadow during a routine physical examination, which was identified as an anterior mediastinal tumor of 4 cm in diameter on chest computed tomography (CT). Based on integrated 18-fluoro-2-deoxyglucose positron emission tomography, and computed tomography findings of low-level accumulation, we suspected that the tumor was a thymoma. Complete resection of the thymus via a median sternotomy was undertaken, and the histopathological diagnosis was WHO type B1 thymoma. On postoperative day 4, swelling with redness and pain was observed at the superior perimeter of the incision site. Based on deep sternal wound drainage culture yielding gram-positive cocci, laboratory data showing an inflammatory response, and chest CT findings, we diagnosed her with mediastinitis. Vacuum-assisted closure (VAC) of the wound resulted in an improvement of the inflammatory response and a negative blood culture, and she was discharged from the hospital on postoperative day 26. In this case, VAC therapy was an effective therapy for mediastinitis after thymoma resection.

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A 69-year old woman received the diagnosis of an anterior mediastinal tumor of 15 mm in diameter and was followed up 5 years ago. She suddenly developed a chest pain and cough, and chest CT showed that the tumor diameter had increased to 31 mm and showed inflammatory findings. However, the tumor had reduced to 19 mm on chest CT after 2 weeks. Because the cause of the inflammatory change was unknown and was relapse a possibility, we decided on an operative strategy. We performed partial thymectomy by median sternotomy. The pathological diagnosis was thymic cancer but mostly necrotic tissue, and the surgical margin was negative. She was followed up closely without treatment.

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Recently, the surgical treatment of pleurectomy/decortication (P/D) has been attracting attention as a part of radical treatment for malignant pleural mesothelioma. We encountered a case involving a female in her 20s with no obvious macroscopic lesions in the visceral pleura who underwent extended P/D for malignant pleural mesothelioma. The patient was a 25-year-old female with no history of exposure to asbestos. She became aware of pain in her left chest from 1 year prior to presentation, for which pleural inflammation was suspected, antibiotics were prescribed, and the symptoms resolved. The symptoms recurred 2 months ago and left pleural effusion was observed. It was diagnosed as epithelial malignant pleural mesothelioma upon conducting a pleural biopsy. A left extended P/D was carried out. Although hardly any macroscopic lesions were observed in the visceral pleura, it was possible to carry out complete resection macroscopically (total visceral resection). Intraoperative bleeding and pulmonary fistulas were within the acceptable range, there were no postoperative complications, and the patient was discharged from hospital on Day 7 after surgery. There were no differences between the immediate post- and preoperative PS, and anticancer treatment was initiated on Day 32 after surgery.

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Resection and reconstruction of the superior vena cava and brachiocephalic vein are rarely required; as such, guidelines for their peri- and postoperative management do not currently exist. Rather, each is managed with an empirical anticoagulation regimen. A 60-year-old woman developed a pulmonary embolism on the 11^th day after prosthetic graft reconstruction for a mediastinal tumor because of graft thrombosis. Lacking the symptoms of upper body swelling and facial edema, her major complaint was respiratory discomfort, and contrast computed tomography revealed a defect. The postoperative pathological diagnosis was follicular lymphoma. There have been some reports on graft occlusion and stenosis, but reports on pulmonary embolism are rare. In this case, inadequate anticoagulant therapy was one cause of the pulmonary embolism. Pulmonary embolism after prosthetic graft reconstruction is rare; however, once it occurs, the clinical course is fatal. Adequate anticoagulant therapy in the early postoperative period is required in order to prevent the early-stage graft thrombosis, and we recommend graft patency evaluation before rising.

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A 75-year-old woman was referred to our hospital because of an abnormal shadow on a chest roentgenogram, and was diagnosed with lung cancer. Right upper lobectomy was performed, and the histopathological analysis showed that the cancer was papillary adenocarcinoma. Three years and 7 months after the first lung surgery, she underwent partial resection of two tumors in the left lung. The two tumors were pathologically diagnosed as small cell carcinoma with intrapulmonary metastasis and squamous cell carcinoma. Four years and 4 months after the first surgery, she again underwent partial resection of a tumor in the right lung. The tumor was pathologically diagnosed as squamous cell carcinoma. All three surgical treatments were successful, and the patient has been free from relapse and surviving for over 2 years since the last surgery.

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Reports of treatment methods during surgery for the lungs with radiation pneumonitis have been rare. The case was a 65-year-old male patient who was diagnosed with stage IV thymic cancer based on the Masaoka classification. He underwent 4 courses of CDDP+ETP and gamma knife treatment for cerebral metastasis. After a decrease in the size of the primary lesion and disappearance of the cerebral metastasis were confirmed, surgery was performed to remove the remaining tumor together with the thymus gland and to partially excise the parietal pleura together with the left upper lobe. During the surgery, an aerial fistula was confirmed in the region of radiation pneumonitis and was closed with stitches. On postoperative day 90, when a left thoracostomy tube was inserted to examine the decrease in left pleural fluid, an aerial fistula was confirmed. During surgery on postoperative day 120, a fistula was observed in the region of radiation pneumonitis, and was covered with intercostal muscle. Although the patient survived for 3 years after the surgery, 2 episodes involving a decrease in left pleural fluid, fever, and a sensation of dyspnea were confirmed during the follow-up observation, suggesting that the fistula had not closed. In the region of radiation pneumonitis, wound healing and immunity are markedly reduced due to a decrease in blood flow. Therefore, a pulmonary fistula in the region of radiation pneumonitis requires careful repair, and it is recommended that such a fistula be covered with either a muscle flap or pericardial adipose tissue.

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A man in his 50s was admitted to our hospital with a diagnosis of pulmonary adenocarcinoma of the left upper lobe. Chest computed tomography (CT) showed a mass of 39 mm in diameter in the left upper lobe. He underwent a thoracoscopic left upper lobectomy with systematic lymph node dissection. Cerebral infarction developed 8 days after surgery. Magnetic resonance imaging revealed an infarction of the right middle cerebral artery area. Contrast-enhanced CT (CECT) showed a thrombus in the stump of the left upper pulmonary vein. Anticoagulant therapy using intravenous heparin followed by oral warfarin sodium was started immediately. The patient has been undergoing rehabilitation for left hemiplegia. Pulmonary vein thrombosis after a pulmonary lobectomy is rarely reported, but it has the potential to cause a lethal complication. Therefore, we recommend CECT for patients in the early postoperative period after a left upper lobectomy to detect any pulmonary vein stump thrombus as early as possible.

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We report a 57-year-old man with secondary lung cancer developing after chemoradiotherapy for small cell lung cancer. The patient developed radiation pneumonitis after having achieved the complete remission of small cell lung cancer. The radiation pneumonitis diagnosed on computed tomography appeared to progress into a nodular lesion which resembled focal fibrosis. Because of a successive increase in size, the nodule was eventually diagnosed as lung adenocarcinoma by percutaneous needle biopsy. The patient underwent complete resection without any significant perioperative complications. We describe this instructive case in order to stress the importance of not delaying the timing of diagnosis and treatment of such an eccentric nodule arising within radiation pneumonitis.

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A 76-year-old man with lung adenocarcinoma consulted our department. Preoperative computed tomography revealed division of the right upper lobe by an intralobar fissure, and the presence of an azygos lobe was diagnosed. The 29-mm irregular nodule in S1b was in contact with the azygos fissure. We scheduled right upper lobectomy and mediastinal lymph node dissection. On intraoperative thoracoscopy, the azygos lobe could be identified through the meso-azygos and azygos vein. The azygos lobe could be smoothly slipped out of the pleural cavity. Mediastinal lymph node dissection was safely performed by dissection of the meso-azygos and superior mediastinal pleura. We report a rare case of primary lung cancer associated with the azygos lobe and a review of the literature.

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Background. Spinal cord infarction is rare. There are some reports of spinal cord infarction occurring after an operation under general-epidural anesthesia. Case. A septuagenarian man underwent right S2 segmentectomy under general-epidural anesthesia. He suffered from right leg muscle weakness and imperception from the right nipple to lower limb since the 1st postoperative day. These symptoms continued after the discontinuation of epidural anesthesia. He was diagnosed with incomplete Brown-Sequard syndrome at Th6-8 and his spinal cord infarction was proven by MRI. The epidural catheter was removed and he underwent anticoagulant therapy, antihydropic therapy, and rehabilitation treatment. Vesicorectal disorder was relieved and he became ambulatory due to improvement of the leg muscle strength. Conclusions. Spinal cord infarction can be caused by anesthesia or surgery, and it is necessary to pay attention to patients with risk factors: advanced age, arteriosclerosis, diabetes, dyslipidemia, smoking, cerebral infarction, coronary heart disease, and cancer. Because of a potential for spinal cord infarction, the indication of epidural anesthesia should be decided carefully.

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Postoperative pneumonia is sometimes a life-threatening complication of lung resection. We report a case of severe aspiration pneumonia after surgery in relation to GERD following distal gastrectomy. A 76-year-old man with lung cancer, which was diagnosed as clinical Stage 1A, underwent right lower lobectomy. Although he had no particular sign of aspiration, pneumonia occurred on postoperative day 6, and he was pointed out as showing dysphagia by an otolaryngologist. Furthermore, GERD showed worsening after surgery, leading to the aspiration of gastric juices, which induced chemical lung injury. The pneumonia was so severe that tracheostomy was performed to protect the respiratory tract. However, pneumonia could not be uncontrolled, and so laryngectomy had to be conducted. We regard GERD following distal gastrectomy as a risk factor of postoperative intractable pneumonia.

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Most cases of foramen of Bochdalek hernia become severely symptomatic in the neonatal period when intraperitoneal organs prolapse into the chest cavity. However, in rare cases, patients remain asymptomatic for years and the condition is diagnosed after they reach adulthood. We treated an adult case of foramen of Bochdalek hernia and achieved total repair with thoracoscopic surgery alone. The patient was a 38-year-old woman who had delivered twins at the age of 27. She complained of discomfort and pain in the left chest of a few day's duration and was examined at our hospital in September 2012. Based on plain chest radiographs and computed tomography of the chest, a diagnosis of left diaphragmatic hernia was made. In November, the patient underwent totally thoracoscopic surgery with differential lung ventilation in the right half-lateral decubitus position. At this time, thoracoscopy revealed adult Bochdalek hernia. The hernia orifice was closed with 2-0 absorbable interrupted sutures and reinforced with Gore-Tex Dual Mesh^®. The patient was discharged on the 8^th hospital day, and has remained well with no recurrence for 2.5 years since surgery.

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An 80-year-old woman with clinical stage IA lung adenocarcinoma underwent a right upper lobectomy with complete lymph node dissection. On the 4th postoperative day (POD), wheeze and dyspnea on effort developed, considered to be the result of an edematous right middle bronchus, pointed out by chest CT. Despite treatment with corticosteroid and antimicrobial agents, her symptoms worsened due to the progression of bronchial edema to the right main bronchus, which led to a massive atelectasis of the right lung. She received endotracheal intubation and mechanical ventilation for two days from the 6th POD. The bronchial edema gradually resolved by treatment with corticosteroid and diuretic agents. No recurrence of the bronchial edema has occurred to date. Bronchial asthma, interstitial pneumonitis, and heart failure were excluded by examinations; therefore, this postoperative lymphedema was considered to have been caused by lymph node dissection. Postoperative lymphedema is a rare complication which can be resolved by appropriate treatments.

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A 66-year-old man was referred to our department for detailed examination of a tumor found at the apical site of the heart during investigation for chest pain. Computed tomography (CT) demonstrated a 38×32 mm, low-density tumor adjacent to the left ventricle. Magnetic resonance imaging (MRI) revealed the tumor with a low signal intensity in T1-weighted images and a high signal intensity in T2-weighted images without the enhancement of contrast medium. The tumor was initially diagnosed as a pericardial cyst based on the findings described above. Although it remained asymptomatic, the size of the tumor had gradually increased nine months after the first diagnosis. Video-assisted thoracic surgery (VATS) was planned to resect the tumor. Since no lesion was found on the pericardium via a thoracoscopic survey, intraoperative ultrasonography prior to incision of the pericardial sac was adopted to ensure that the mass actually was an intrapericardial cyst. In the pericardial cavity, we found a cyst firmly attached to the apical epicardium. Subtotal resection was selected to avoid damage to the ventricular muscles. The cyst wall had a lining of ciliated epithelium without smooth muscles or bronchial glands and was pathologically diagnosed as a bronchogenic cyst.

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Thrombosis in the pulmonary vein stump after lobectomy has recently been receiving attention, especially in association with left upper lobectomy. We report two cases of organ infarction caused by a thrombus in the pulmonary vein stump after left lung lobectomy. One case involved renal infarction after left upper lobectomy. The other case involved cerebral infarction after left lower lobectomy. Thrombosis in the left inferior pulmonary vein stump is very rare. We confirmed the thrombus in the PV stump by contrast-enhanced CT in both cases. A thrombus in the PV stump may cause serious whole body organ infarction in the same way as a left atrial thrombus. The thrombus in the pulmonary vein stump disappeared with anti-coagulation therapy.

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Background: Thoracotomy and limited resection such as wedge resection are often chosen for patients who undergo esophagectomy because intraoperative bleeding and damage to the feeding artery caused by the gastric tube should be avoided as a result of adhesion in the thoracic cavity. Case: A 56-year-old male presented with an abnormal shadow in his right upper lobe on chest CT during a preoperative check-up for esophageal cancer. The shadow became more prominent after esophagectomy, and the accumulation based on SUV max was 10.25 on PET. The shadow was thought to be primary lung cancer, but metastatic lung cancer from esophageal cancer could not be ruled out. Video-assisted thoracic surgery (VATS) was performed for diagnosis and treatment. The gastric tube strongly adhered to the right lung but the tumor was apart from the adhesion. The adhesion was separated, but some pulmonary pleural tissue was left on the gastric tube to avoid injuring the feeding artery. After adhesiotomy, wedge resection was performed and the tumor was diagnosed as adenocarcinoma by frozen section diagnosis, after which a right upper lobectomy was performed. Conclusion: Complete video-assisted thoracic right upper lobectomy could be performed for the patient after esophagectomy. The lung adhered to the gastric tube, and some pulmonary pleural tissue was left on the gastric tube to preserve the feeding artery.

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Sarcoid reaction of a lymph node may mimic metastasis or recurrence of malignant cancer. Here, we present three cases of sarcoid reaction with lung cancer. Case 1 was a 65-year-old man with segment 9 (S9) ground-glass opacity (GGO) and lymphadenopathy, who underwent a right lower lobectomy. Case 2 was a 61-year-old woman with S3 GGO and lymphadenopathy, who underwent a right upper lobectomy. Histopathologically, the tumors of both cases were well-differentiated adenocarcinoma of the lung (T1bN0M0) with epithelioid granuloma formation in the lymph nodes. Case 3 was a 51-year-old man, who underwent a right upper lobectomy and dissection of the regional lymph nodes to treat squamous cell carcinoma of the lung (T3N0M0), and post-operative chemotherapy was administered. After a 10-month follow-up, cervical and mediastinal lymphadenopathy was detected. Biopsy of a lymph node revealed epithelioid granuloma formation due to sarcoid reaction. Hence, histological investigation of lymphadenopathy is required even in cases of pre- and post-operative states of malignant cancer.

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A 68-year-old male had undergone bronchoscopy repeatedly for a pulmonary tumor in the upper segment of the right lower lobe (S⁶) since 2009, and had been followed up without a definite diagnosis. In 2014, he was referred to our hospital complaining of hemoptysis and a high fever. Chest CT revealed a right-sided cavity-forming destroyed lung with pleural effusion. Mycobacterium avium was detected in 6-week cultured sputum. He underwent bronchial arterial embolization and was administered antibiotics, and his condition improved. He underwent right middle and lower lobectomy for the destroyed lung. The histopathological diagnosis was pulmonary actinomycosis, and he was treated with amoxicillin for 6 months. He has been well without any recurrent lesions for 9 months since the surgery. Pulmonary actinomycosis is often too difficult to diagnose. We encountered a surgical case of pulmonary actinomycosis that transformed to a destroyed lung over a long-term course.

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A 17-year-old girl with chest pain visited our hospital and was diagnosed with left pneumothorax. Chest CT revealed a localized emphysematous area and a small nodule in the left S6 segment with absence of the B6 bronchus. Bronchofiberscopy and MRI confirmed a diagnosis of congenital bronchial atresia accompanied by mucoid impaction. We performed thoracoscopic left S6 segmentectomy because of prolonged air leakage derived from the emphysematous region in the S6 segment that was clearly distinguished from other segments. Pneumothorax due to congenital bronchial atresia is a rare disease. Segmentectomy including the affected region is recommended for similar cases.

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Techniques to repair visceral pleural injuries during thoracoscopic surgery are used selectively to achieve hemostasis and pneumostasis. The approximation of adjacent visceral pleura using continuous suturing is often deployed to repair a larger defect of the pleura. Thoracoscopic continuous suturing is one of the most difficult procedures to perform correctly among the thoracoscopic suturing techniques. To overcome the cumbersomeness of thoracoscopic continuous suturing, we developed a looped suture closure technique for repair of the visceral pleural injury, and employed extracorporeal knotting, extracorporeal needle adjustment and extracorporeal traction of the thread by an assistant. This technique can be easily performed with only a minor intraoperative complication and a few postoperative air leaks, being acceptable for use in thoracoscopic surgery.

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