The Journal of the Japanese Association for Chest Surgery
Online ISSN : 1881-4158
Print ISSN : 0919-0945
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Showing 1-21 articles out of 21 articles from the selected issue
  • Tsunayuki Otsuka, Yoshihiro Nakamura, Aya Takeda, Tadashi Umehara, Soi ...
    2018 Volume 32 Issue 6 Pages 668-673
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    Open window thoracotomy (OWT) is often performed for patients with bronchopleural fistula (BPF) and for poor-infection-control patients with thoracic empyema. OWT requires an early closing operation in order to avoid mental and cosmetic problems. Two kinds of therapeutic procedures have been reported to be useful for the treatment of thoracic empyema. One is Endobronchial Watanabe Spigot (EWS) for patients with BPF, and the other is negative pressure wound therapy (NPWT) for patients without BPF. We retrospectively evaluated not only these therapies but also combination methods, reviewing 26 patients undergoing OWT between January 2009 and December 2015 in Kagoshima University Hospital. There were 18 patients with BPF and 8 without BPF. Six of the 8 patients without a fistula achieved primary closure of the open window. In six of the 18 patients with fistulas, these closed spontaneously after OWT. Five of the remaining 12 patients with BPF underwent EWS placement, leading to subsequent closure of the fistula or decreased air leakage. Then, they underwent NPWT. One of the 5 patients was contraindicated for the closing operation because of uncontrolled infection. The remaining four who underwent both procedures, EWS and NPWT, achieved open window closure.

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  • Ryo Nonomura, Masao Inoue, Takatomo Yamayoshi, Shigehiko Ito
    2018 Volume 32 Issue 6 Pages 674-679
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    In the present study, we examined 189 patients with chest injury who had been admitted and treated at our hospital over the past 13 years to identify risk factors associated with traumatic hemopneumothorax. The primary endpoint was the presence of thoracic drainage, and the secondary endpoint was the development of traumatic hemopneumothorax. Logistic regression analysis was performed by determining explanatory variables of multivariate analysis by univariate analysis using Pearson's X2 test. Predictive risk factors for thoracic drainage only showed a significant difference in fracture dislocation. Predictive risk factors for the onset of traumatic pneumothorax were two or more rib fractures and fracture dislocations. Even chest trauma with a low AIS score is more likely to lead to complications requiring surgical intervention, and caution is needed in hospital care for thoracic trauma.

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  • Mizuki Morota, Tadasu Kohno, Sakashi Fujimori, Naoko Kimura, Souichiro ...
    2018 Volume 32 Issue 6 Pages 680-685
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    Preoperative evaluation of deep vein thrombosis (DVT), which is a known risk factor for the development of pulmonary embolism (PE), is important prior to performing thoracic surgery. With regard to thoracic surgery, few reports are available on evaluating preoperative DVT using D-dimer levels; thus, we examined the efficacy of D-dimer levels as a test for preoperative screening of DVT and for the perioperative management of patients diagnosed with DVT. Between May 2013 and December 2015, 1,178 patients underwent thoracic operations (video-assisted thoracoscopic surgery [VATS]: 1,153, and open surgery: 25). Ultrasonographic examination was performed in patients whose D-dimer levels were > the cut-off limit of 1.1 μg/mL. We observed that the D-dimer levels were elevated in 260 patients (22%) and DVT was detected in 51 patients using preoperative ultrasonographic examination.

    D-dimer levels were significantly higher in patients presenting with DVT-the DVT (+) group showed a D-dimer level of 3.93 μg/mL (95% confidence interval [CI] 2.65-5.19) vs. the DVT (-) group with a D-dimer level of 2.79 μg/mL (95% CI 2.39-3.19). Nineteen patients from the DVT (+) group needed to be heparinized perioperatively. No patient presented with PE postoperatively. Estimation of D-dimer levels is a valid preoperative screening strategy to evaluate the risk of DVT, which, in turn, is a risk factor for the development of PE.

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  • Yutaka Hirano, Kazuhiro Washio
    2018 Volume 32 Issue 6 Pages 686-690
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    The patient was a 67-year-old female. Chest CT showed a 13-mm nodule in the right middle lobe and a 10-mm ground glass nodule in the left lower lobe. Lung cancer was highly suspected for both nodules. We first performed right middle lobectomy for the right lesion, and it was revealed that V1+2+3 returned to the superior vena cava. Postoperative complications such as heart failure were not observed. Contrast-enhanced chest CT detected no abnormality other than V1+2+3, and the pulmonary blood flow/systemic blood flow ratio (Qp/Qs) was 0.7. Eight months after the initial surgery, left S8 segmentectomy was performed. There were no circulatory or respiratory complications during the operation, and the postoperative course was favorable. The pathological diagnosis for both lung tumors was adenocarcinoma. In most cases, patients with a partial anomalous pulmonary venous connection (PAPVC) have no symptoms, and it is often found incidentally intraoperatively. In cases of lung cancer with PAPVC, severe right heart failure may occur postoperatively, so it is important to keep in mind the possibility of PAPVC preoperatively and carefully evaluate clinical images of pulmonary veins.

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  • Yohei Honda, Norihito Okumura, Tomoaki Matsuoka, Keiji Yamanashi, Ayuk ...
    2018 Volume 32 Issue 6 Pages 691-696
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    Chemotherapy for lung cancer can become difficult or fatal because of infectious diseases. We report a patient with a lung abscess that developed during chemotherapy who underwent surgery after failure of antibiotic treatment, which enabled the patient to undergo treatment.

    A 64-year-old man undergoing chemotherapy for stage IV lung cancer of the right upper lobe suffered from obstructive pneumonia. Despite receiving antibiotic therapy, a lung abscess developed. We operated to remove the abscess because of the risk of lung perforation or empyema. During thoracotomy, we observed that the right upper lobe occupied half of the thoracic cavity. We had to perform right pneumonectomy because of tumor invasion of the right lower lobe and metastatic lymph nodes around the right main bronchus. After the operation, the infection resolved. He was discharged on postoperative day 12, and chemoradiation was introduced on postoperative day 46. Now, at 15 months after surgery, he is undergoing outpatient follow-up. We considered this case to be salvage surgery in a broad sense as well as palliative therapy because the operation not only facilitated control of the lung infection, but also radical chemoradiotherapy.

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  • Hiroaki Murakami, Takahiko Oyama, Ryoichi Kato
    2018 Volume 32 Issue 6 Pages 697-702
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    A 48-year-old man was referred to our hospital because of an abnormal shadow on a chest radiograph. Carcinoembryonic antigen was slightly high. Chest computed tomography revealed a 50-mm tumor in the right upper lobe, and an accumulation of fluorodeoxyglucose was observed in the mass by positron emission tomography. A definitive diagnosis could not be obtained by CT-guided percutaneous needle biopsy, and the possibility of lung cancer could not be ruled out. So, we performed lobectomy for diagnosis and treatment. Mycobacterial staining and culture of the sample obtained from the right upper lobe was positive. The infectious agent was identified as Mycobacterium xenopi by the DNA-DNA hybridization method. He administered chemotherapy after the operation, and no recurrence has been observed to date.

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  • Shinichi Sakamoto, Hiromasa Matsumoto, Hiroyuki Hino, Shoji Sakiyama
    2018 Volume 32 Issue 6 Pages 703-708
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    Refeeding syndrome (RFS) can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding. These shifts cause serious clinical complications. We report a case of an elderly patient with secondary pneumothorax complicated by RFS.

    A 75-year-old man visited a local hospital with fever and dyspnea. A chest radiograph revealed pneumothorax in the right lung, and drainage was initiated. As pneumothorax did not improve and pneumonia occurred in the right lung, he was admitted to our hospital and VATS was performed.

    On the second day after surgery, he developed ventricular tachycardia, and blood chemistry examination showed hypophosphatemia. We diagnosed him with RFS and started nutrition at 200 kcal/day. With a slow increase in energy intake, his clinical condition improved.

    Although RFS is not a rare complication, we cannot always treat it appropriately because the recognition of this disease is insufficient. Elderly patients have a risk of RFS; therefore, it is necessary to be aware of the possibility of RFS after surgery with the aging of society.

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  • Hidehiro Shimizu, Nobutake Tanaka, Tomoya Kono, Ryo Miyahara
    2018 Volume 32 Issue 6 Pages 709-712
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    Lung torsion is a fatal but rare event following lobectomy or chest trauma. We report a case of peripheral lung torsion, the cause of which could not be identified. A 22-year-old man presented with sudden- onset chest pain.

    Computed tomography demonstrated that a peripheral part of the left lower lobe showed counterclockwise torsion toward the hilum, and bronchoscopy showed obstruction of the left B8. We suspected left lower-lobe torsion and performed emergent thoracotomy.

    The peripheral part of the left lower-lobe was hard with a dark red appearance and twisted about 360 degrees around its pedicle at the central portion. The torsion was carefully relieved, but the lung parenchyma of the part of the left lower lobe was not considered to be viable. Therefore, we performed resection of the non-viable part.

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  • Masahiro Adachi, Isao Sano, Shintaro Hashimoto, Ryoichiro Doi, Hideki ...
    2018 Volume 32 Issue 6 Pages 713-718
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    The patient was a 53-year-old female who had undergone hysterectomy because of a uterine fibroid. Several years later, she was asymptomatic, but chest radiograph showed an abnormal lesion and CT revealed a posterior mediastinal tumor. The tumor had enlarged compared with the previous CT, when she underwent gynecological surgery. We suspected a bronchogenic or neurogenic tumor. She underwent posterior mediastinal tumor resection thoracoscopically. Immunohistochemical staining revealed a positive reaction of the lining cells to estrogen and progesterone receptors. Thus, the final diagnosis of the tumor was a Mullerian cyst. She followed an uneventful postoperative course for 6 months.

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  • Yukihiro Terada, Mitsuhiro Isaka, Yoshiyuki Yasuura, Hideaki Kojima, S ...
    2018 Volume 32 Issue 6 Pages 719-724
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    Background. Schwannomas are benign tumors that arise from the peripheral nerve sheath. However, intrapulmonary schwannoma is rare.

    Case. An asymptomatic 36-year-old woman was referred to our hospital for the further examination of an abnormal shadow on chest radiograph. Chest CT showed a well- defined nodule in the right laterobasalis/dorsobasalis segments. The maximum standardized uptake value of the nodule on positron emission tomography was 1.83. Bronchoscopic biopsy could not yield a histological diagnosis, so right basilar segmentectomy was performed. The final diagnosis was intrapulmonary schwannoma.

    Conclusion. We encountered a case of intrapulmonary schwannoma that arose between the segmental bronchi. It is difficult to diagnose intrapulmonary schwannoma preoperatively using radiological images, and we report this case with a review of the literature, mainly focused on PET-CT findings.

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  • Yuichiro Onuki, Yoshihiro Miyauchi, Hidenori Hara, Tamo Kunimitsu, Hir ...
    2018 Volume 32 Issue 6 Pages 725-730
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    The development of a lung abscess induced by transbronchial biopsy (TBB) is a rare but serious complication. Here, we report three patients with malignant lung tumors who developed abscesses after TBB. The patients were two males and one female, and the mean age was 70.7 years. Two patients had primary lung cancer and one patient had metastatic lung cancer. Adenocarcinoma was the histological type in all three cases. Tumors were located in the left upper lobe in two patients and the right upper lobe in one patient. The largest diameter of the tumors based on computed tomography images before TBB was more than 30 mm in all cases. The mean number of days until symptoms developed was 5. In addition, the mean number of days until surgical treatment was performed after diagnosis of lung abscess was 12. Lobectomy was performed for two patients and pneumonectomy was performed for one patient. Lung abscesses associated with malignant lung tumors are often resistant to conservative treatment and consequently necessitate surgical treatment. Inflammation associated with abscesses can spread; therefore, surgery focuses on infection control rather than only curing the malignant tumor. In conclusion, it is important that surgical treatment is not delayed.

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  • Takeaki Miyata, Hanae Higa, Yosuke Motoharu, Takashi Yoshimatsu, Naoki ...
    2018 Volume 32 Issue 6 Pages 731-735
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    For successful lung resection in the presence of anatomical anomalies of the pulmonary artery, preoperative computed-tomography is useful. We report a rare case of right lower lobectomy with mediastinal A7+8+9 branching. A 64-year-old man with a history of surgery for gastric cancer was noted to have an expanding pulmonary nodule in S6 of the right lung. Preoperative three-dimensional computed tomography (3D-CT) revealed mediastinal A7+8+9 branching from the right main pulmonary artery, passing between the superior and inferior vein and along the mediastinal side of the intermediate bronchus. The main lesion was a solid nodule with a pleural indentation measuring 10 mm. Suspecting metastatic lung cancer or lung cancer (cT1aN0M0), right lower lobectomy (ND1b) was conducted along with partial lung resection of S6 because the histological diagnosis of the tumor was adenocarcinoma based on intraoperative pathological examination. A right mediastinal basal pulmonary artery is a rare anatomical variant, and this is the 6th case reported in Japan. To prevent intraoperative injury, it is important to accumulate information from accurately interpreted preoperative 3D-CT and plan the surgical procedure while considering anatomical anomalies.

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  • Masataka Hirabaru, Shotaro Ide, Keiji Inoue
    2018 Volume 32 Issue 6 Pages 736-741
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    A 75-year-old male with an abnormal shadow on a chest radiograph was referred to the hospital. Chest CT and MRI showed a large foliaceous and heterogeneous mass in the left thoracic cavity. The tumor had a smooth surface and clear border and was mixed with a fat component, suggesting a liposarcoma. The tumor was rapidly increased and pleural effusion appeared in 2 weeks, and an operation was performed. A femoral artery and vein were secured prior to the operation, and a thoracotomy was performed at the anterior lateral incision. The tumor was 19 cm in maximum diameter and 1,780 g in weight, and the pathological diagnosis was well-differentiated-type liposarcoma. He followed a favorable course without adjuvant therapy after surgery. Liposarcoma often increases slowly, and we report one case of a rapidly increasing mediastinal primary differentiation-type liposarcoma.

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  • Yoshiro Oshika, Takehumi Nakayama, Kouji Kameda, Kiyohaya Obara, Hiroa ...
    2018 Volume 32 Issue 6 Pages 742-747
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    A 52-year-old male was admitted to our hospital for evaluation of an enlarging mediastinal shadow on a chest radiograph compared with that 2 years prior. Computed tomography revealed an anterior mediastinal tumor. The patient underwent thymectomy with partial resection of the right lung and pericardium. Histopathologically, the tumor was diagnosed as combined thymic carcinoma (squamous cell carcinoma+basaloid carcinoma+mucoepidermoid carcinoma+adenocarcinoma+neuroendocrine differentiation), and tumor cells invaded the pericardium (pT3, Masaoka stage III). Postoperative radiotherapy (50 Gy/25 Fr) was performed. At 18 months after surgery, two tiny nodules appeared in the left lung, and were considered to be lung metastases from the thymic carcinoma. Stereotactic radiotherapy (50 Gy/4 Fr) was performed and the patient was alive at 30 months after surgery without recurrence. The various histopathological features of this case suggested the pluripotent differentiation of the thymic tumor cells.

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  • Yasuaki Kubouchi, Hiroyuki Metsugi, Kunio Araki
    2018 Volume 32 Issue 6 Pages 748-752
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    We encountered a case of right lower lung cancer discovered due to pulmonary dirofilariasis. An annual check-up revealed an abnormal shadow in the right lower lung field of a 70-year-old man. Chest CT showed a pulmonary lesion with clear boundary and calcification in the right S8, coinciding with the abnormal shadow on the chest radiograph. Further, CT showed an irregular nodule with spicula in the right S6. Preoperative diagnoses of the right S6 and right S8 tumors were primary lung cancer and a benign tumor, respectively. An intraoperative needle biopsy was performed of the S6 tumor, leading to a diagnosis of adenocarcinoma, so the patient underwent a right lower lobectomy and mediastinal lymph dissection under video-assisted thoracic surgery. The pathological findings revealed that the irregular mass in the right S6 and well-defined node in the right S8 were adenocarcinoma pT1bN0M0 p-Stage IA2 and pulmonary dirofilariasis, respectively. Up to the present, there have been only 2 case reports of lung cancer coexisting with pulmonary dirofilariasis. Furthermore, this case is the first report of lung cancer discovered due to pulmonary dirofilariasis.

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  • Tomoyuki Kawamura, Naohiro Kobayashi, Kazuto Sugai, Shinji Kikuchi, Yu ...
    2018 Volume 32 Issue 6 Pages 753-757
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    The patient was a 43-year-old woman who had undergone unilateral ovariectomy for a right ovarian granulosa cell tumor two years previously. Follow-up CT revealed a well-circumscribed and homogenous mediastinal tumor, of 21×14×26 mm. The tumor was located anteriorly to the left side of the fourth thoracic vertebra and had been enlarging. Chest MRI revealed a low intensity in the T1-weighted image and high intensity in the T2-weighted image, which indicated that the tumor was a cystic lesion. For diagnosis and treatment, thoracoscopic posterior mediastinal tumor resection was performed. The tumor had a thin capsule within the fluid component and had no adhesion or continuity with the surrounding tissue, including nerves. Pathologically, the inner cells of the tumor capsule formed a mixed monolayer and multilayered ciliated columnar epithelium that partially protruded into the lumen, with a papillary appearance. Immunohistologically, the epithelia were positive for estrogen and progesterone receptors. From these results, the tumor was diagnosed as a Müllerian cyst. In the literature, Müllerian cysts have been associated with menopause, obesity, and surgery for gynecological diseases. In the present case, the tumor grew after surgery for an ovarian tumor.

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  • Hironori Kigoshi, Takamitsu Maehara, Taketsugu Yamamoto, Toshihiro Mit ...
    2018 Volume 32 Issue 6 Pages 758-763
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    A 23-year-old woman with a medical history of hyperimmunoglobulin E syndrome (HIES) presented to our hospital because of acute chest pain. She had already been diagnosed with and prescribed antibiotics for mediastinal abscess at another hospital, but she had stopped going to the hospital. On admission, contrast-enhanced chest computed tomography revealed a mediastinal abscess and pericardial effusion. The pericardium was drained, and methicillin-sensitive Staphylococcus aureus (MSSA) was detected in the pericardial effusion. Although the patient's symptoms were improved by immediate pericardial drainage and antibiotic use, the mediastinal abscess was unaffected. Video-assisted thoracoscopic debridement and drainage of the mediastinal abscess were then performed, and MSSA was discovered in the abscess. Remission of the abscess was finally achieved with the further use of antibiotics, and the patient was discharged on postoperative day 9.

    For HIES patients with mediastinal abscess, surgical drainage should be considered to control infection.

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  • Nobutaka Kawamoto, Takashi Anayama, Ryouhei Miyazaki, Kentaro Hirohash ...
    2018 Volume 32 Issue 6 Pages 764-770
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    For patients with a history of right upper lobectomy who have a second primary pulmonary disease, which is an indication for right lower lobectomy, whether to preserve the middle lobe or to perform completion right pneumonectomy is controversial. We encountered a patient who had a history of right upper lobectomy and a lung tumorous lesion in the right lower lobe, for whom we decided to perform right lower lobectomy with preservation of the right middle lobe. The patient was a 74-year-old man who underwent right upper lobectomy and had pulmonary tuberculosis 56 years previously. At the age of 62 years, the patient underwent right lower lobectomy as surgical treatment for a chronic expanding hematoma in the right lower lobe. The early postoperative course was good, but the patient started to develop pneumonia of the right middle lobe repeatedly after the 10th postoperative year. Finally, the patient had empyema with pulmonary fistula in the right thorax. Fenestration of the right thorax was performed to control the infection. The patient's activities of daily living improved, but he still had recurring pneumonia of the right middle lobe. Most previous reports described a better postoperative course in cases where the right middle lobe was preserved than in cases where completion right pneumonectomy was performed. However, as in the present case, the pulmonary infection in the right middle lobe occurred not only in the early postoperative period but also in the remote period. Long-term observation is desirable for cases with preservation of the right middle lobe, considering that complications may occur in the remote period as well.

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  • Hitoshi Ueda, Hirokazu Kitahara
    2018 Volume 32 Issue 6 Pages 771-776
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    It is difficult to decide on the indication of pulmonary resection for patients with a low pulmonary function. We report a case of pulmonary resection with low pulmonary function for massive hemoptysis. A 62-year-old male who had been diagnosed with pulmonary tuberculosis at the age of 31 developed bronchial asthma and started home oxygen therapy at age 51. When he developed pneumonia at age 60, he was pointed out to have a pulmonary nodule in the right lower lobe. The nodule was diagnosed as squamous cell carcinoma. It was treated with stereotactic radiation because of his low pulmonary function. However, the tumor re-grew at age 61, and he received chemotherapy. During the 4th course of chemotherapy, massive hemoptysis occurred from the tumor. An Univent endotracheal tube was inserted into the trachea and hemoptysis was blocked with a balloon at the right intermediate bronchus. He then started ventilator management and tracheostomy. The source of bleeding was considered to be a branch of the pulmonary artery invaded by the tumor. Thereafter, massive hemoptysis occurred twice. So, we decided on right lower lobectomy for life-saving. After the operation, he gradually recovered, was withdrawn from the ventilator, and his tracheostomy hole was closed 8 weeks after the operation. He was discharged with home oxygen therapy at 11 weeks after the operation. He currently visits the outpatient clinic 9 years after the operation. Even with a low lung function, it is worth considering surgical therapy for massive hemoptysis.

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  • Yoshihito Arimoto, Keigo Sekihara, Fumi Yokote, Satoshi Nagasaka, Sats ...
    2018 Volume 32 Issue 6 Pages 777-780
    Published: September 15, 2018
    Released: September 15, 2018
    JOURNALS FREE ACCESS

    Iatrogenic pneumothorax is a complication of various treatments, and some cases require thoracotomy. A 71-year-old man with a heavy smoking history of 80 pack-years had been treated for pneumothorax. Once the chest tube was removed, pneumoderma appeared. A chest radiograph showed recurrent pneumothorax. When thoracic drainage was performed again, pneumoderma markedly worsened. Also, he complained of progressive dyspnea. Chest CT revealed that the chest tube had migrated to the right lung. At the time of arrival at our hospital, he had developed tension pneumothorax. We performed an emergency operation. We noted severe emphysematous and adhesion between the right lung and parietal pleura. The chest tube had penetrated the right upper lobe over 10 cm toward the hilum. We could not preserve the lung parenchyma and performed right upper lobectomy. The majority of complications involving chest tubes are slight injuries; deep lung injury is a rare and severe situation. We encountered a case of emergency lobectomy for iatrogenic lung injury.

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