This study retrospectively examined post-operative ipsilateral shoulder pain in patients after thoracic surgery. The study included 205 patients who underwent thoracic surgery in a lateral position from January 1, 2017 to November 30, 2017. Minors and re-operation cases were excluded. Complete video-assisted thoracic surgery (VATS) was performed for 60 patients and mini-thoracotomy for 145 patients. Among the 136 male and 69 female patients, the median age was 71 years. Under complete VATS, the upper extremity on the operative side was fixed in an adducted and medially rotated position parallel to the opposite upper extremity. In mini-thoracotomy cases, the upper extremity on the operative side was fixed in an abducted and medially rotated position. In univariate analysis, there was no significant difference in age, sex, operative time, or bleeding between the groups with and without shoulder pain. Post-operative shoulder pain was significantly weaker in patients who underwent complete VATS and higher in those who underwent lobectomy or more extensive resection. In multivariate analysis, only complete VATS was an independent predictive factor. Only one of the 60 patients who underwent complete VATS complained of mild shoulder pain. Adduction and medial rotation of the upper extremity on the operative side during surgery is thought to be useful in preventing postoperative shoulder pain.

Some reports have demonstrated that fibrinolytic therapy with urokinase is effective for acute empyema and parapneumonic pleural effusion. We aggressively conduct fibrinolytic therapy with urokinase if antibiotic therapy and thoracic drainage are ineffective for acute empyema and parapneumonic pleural effusion. We retrospectively reviewed 70 cases of acute empyema or parapneumonic pleural effusion treated by fibrinolytic therapy in our hospital from January 2012 to February 2017. After 60,000-120,000 IU of urokinase diluted in 100 ml normal saline was injected into the intrapleural cavity via a thoracic tube, the tube was clamped for 3-6 hours, and reopened to maintain it under continuous suction. If the use of fibrinolytics increased the volume of drained pleural fluid, we conducted it on consecutive days. The termination of drainage was based on improvement of the lung expansion by radiological examination and improvement of inflammation by blood examination. Among 70 cases, 65 cases (92.9%) were cured by fibrinolytic therapy. Five cases failed to respond to fibrinolytic therapy and were cured by surgical treatment. There were no side effects of fibrinolytic therapy during the perioperative period. Fibrinolytic therapy is effective and convenient. This procedure might be one of the useful treatment options for acute empyema and parapneumonic pleural effusion.

Objectives: This study aimed to report some problems of robotic surgery and differences between robotic surgery and conventional video-assisted thoracoscopic surgery.

Methods: From January to September 2018, intraoperative problems with robotic surgery were collected and analyzed retrospectively, and divided into known and unexpected problems.

Results: Of the 6 patients who underwent robotic surgery, the procedures were 3 lobectomies and 3 mediastinal tumor resections. The median age was 63 years old, the median intraoperative blood loss was 27.5 mL, the median operative time was 239 minutes, and the median console time was 112.5 minutes. Six intraoperative problems occurred using da Vinci. Of the 6 problems, there were 5 known problems and one unexpected problem. Of the 5 known problems, 4 were unavoidable or due to unclear solutions, but these could be overcome with experience in robotic surgery.

Conclusions: Robotic surgery has some differences and pitfalls compared with conventional video-assisted thoracoscopic surgery. To introduce safe robotic surgery, we should know da Vinci's features, disadvantages, and appropriate indications for robotic surgery, repeatedly conduct surgical simulations as part of a multidisciplinary robotic team, and share informative ways to solve problems among institutions.

Patients undergoing thoracic surgery have various comorbidities. The treatment risk often increases, especially in patients with mental disorder. From January 2012 to December 2017, 16 patients with mental disorder (nine males, seven females; mean age: 68 years old) who had been requiring continuous medication underwent surgery at our institution. We retrospectively reviewed the patients' postoperative clinical outcomes. Respiratory disorders were as follows: eleven patients with malignant pulmonary tumors, three with mediastinal tumors, and two with benign pulmonary tumors. Nine patients with lung cancer received lobectomy as curative surgery. There was no hospital death or serious complications. (Eight patients showed an aggravated mental disorder after surgery, with all receiving surgery for malignant tumors.) Malignant diagnosis by surgery was a significant factor contributing to exacerbation of psychiatric disorder. In patients with schizophrenia, it worsened in an early period, while in patients with mood disorder, it worsened in a later period (mean postoperative days: 16 vs. 39, respectively). It is necessary to pay attention to the characteristics of patients with mental disorders and perform perioperative management according to each case.

We report the case of a 61-year-old man with adenoid cystic carcinoma of the trachea, which was resected with latissimus dorsi flap reconstruction.

The tumor originated in the membranous portion of the intrathoracic trachea covering 10 tracheal rings in length. Transesophageal biopsy was performed and histology confirmed an adenoid cystic carcinoma. A sleeve resection followed by direct end-to-end anastomosis of the trachea was deemed to involve a high risk of dehiscence, and so we decided to perform resection with adequate margins followed by reconstruction of the trachea to avoid undue anastomotic tension. An elliptical excision was made to remove the tumor and the involved membranous tracheal wall. This defect was then reconstructed with a pediculated latissimus dorsi muscle flap. The postoperative course was favorable without severe complications. Histology of the margins showed microscopic tumors, and postoperative radiation therapy with a total dose of 60 Gy was given. The patient is well with no recurrence 42 months after surgery.

This surgical technique was successful in preventing postoperative complications in a case of advanced tracheal adenoid cystic carcinoma.

Solitary fibrous tumor (SFT) is an uncommon tumor of mesenchymal origin. We report a rare case of SFT with a massive left hemothorax. A 35-year-old man visited our hospital with a complaint of sudden chest pain. Chest computed tomography showed moderately sized ipsilateral pleural effusion and a heterogeneously enhanced mass in the thoracic cavity. The thoracentesis fluid was bloody. His condition did not improve with conservative treatment because of progressive anemia; therefore, we performed thoracotomy. Intra-operatively, the tumor was found to have infiltrated the chest wall and left diaphragm. An excision of the tumor and associated resection of the 11 and 12th ribs and intercostal muscle, diaphragm, and external oblique muscles of the abdomen were performed. We considered that rupture of the growing tumor had led to the hemothorax. The pathological diagnosis was solitary fibrous tumor.

The use of nasogastric tubes is common during general anesthesia. We report a case of nasogastric tube migration during bronchial stump closure with an electric stapler.

A 67-year-old man underwent a right lower lobe lobectomy with lymph node dissection. The right lower bronchus was closed with an electric stapler (Powered ECHELON FLEX^®). The cut end of the tube was found in the bronchial stump during formalin injection for resected lung fixation. Subsequent review of surgical video images confirmed that this was the cut end of the nasogastric tube. The proximal part of the nasogastric tube had been intraoperatively removed by the anesthesiologist. This had led to bronchial stump injury, causing a bronchopleural fistula. After reobtaining informed consent, a subsequent operation was carried out during which the bronchial stump was sutured by adding two interrupted sutures with absorbable felt. The stump was covered with the fifth intercostal muscle. There was no air leakage post-operatively. During bronchial stump closure and cutting procedures, no abnormal findings were noted.

In the past decade, the bronchial stump has been closed using manual sutures or manually forced stapling. Therefore, it was considered that migrated nasogastric tubes could be easily recognized. However, current electric staplers can close and easily cut even thickened tissues such as bronchial cartilage and nasogastric tubes without causing any abnormal sensation perceivable by the surgeon. Therefore, the use of electric staplers may lead to unsuspected pitfalls whereby migrated foreign bodies are not perceived during stapling. Careful attention should be paid when using electric devices.

A 67-year-old man underwent left hemicolectomy and colostomy in another hospital because of necrosis from the left side of the transverse colon to the sigmoid colon after open repair of a thoracoabdominal aortic aneurysm, which led to retroperitoneal abscess. Although the abscess had been successfully treated with tube drainage, it exacerbated again. He presented with empyema due to abscess rupture into the left thoracic cavity. We performed open-window thoracostomy to achieve a sterile pleural space, and then applied negative pressure wound therapy. The empyema cavity was filled with granulation tissue, and finally we covered the wound with a skin graft. He died of another disease 34 months after complete epithelialization, showing no relapse of infection.

A 69-year-old woman underwent thoracoscopic left upper lobectomy with nodal dissection for lung adenocarcinoma. When we were dissecting the left main pulmonary artery at the hilum, severe bradycardia suddenly developed, leading asystole. We immediately tapped the heart with a small gauze ball and an index finger through the ports. A spontaneous heart beat resumed one minute after the onset of asystole. We considered the cause of this cardiac event as a vagal reflex and resumed the operation after administering intravenous atropine. A second severe bradycardia emerged on subaortic nodal dissection. The heart rate recovered soon after suspending the nodal dissection. Subsequently, we completed the planned procedure while being cautious about bradycardia. Intraoperative cardiac arrest induced by a vagal reflex during lung surgery has been rarely reported, and all reported cases including the present case were limited to left-side operations. The cardiac plexus is more developed in the left pulmonary hilum, and manipulation around this area involves the potential risk of a serious vagal reflex, which can result in cardiac arrest. Therefore, we should consider intraoperative bradycardia as an adverse sign, and prompt response to bradycardia is required to prevent the occurrence of cardiac arrest.

Among anterior mediastinal tumors, reports of multiloculated tumors are relatively limited, and a multilocular thymic cyst is one of the rare diseases.

In this report, a multilocular thymic cyst is presented, which required differentiation from malignant lymphoma.

The patient was a 40-year-old man, with a BMI of 44.1%. Multiple anterior mediastinal tumors were confirmed by chest CT during follow-up for a left adrenal tumor, sleep apnea syndrome, and bronchial asthma. All of the tumor markers and autoantibodies were negative, FDG-PET/CT showed low accumulation (3 to 4) of SUVmax in the tumor, and T2-weighted chest MRI revealed a multilocular tumor with fluid inside. The tumor was huge, and malignant lymphoma was also suspected. Owing to marked obesity, the patient could not undergo resection of the tumor under single-lung ventilation. So, a surgical biopsy was performed with a 5-cm skin incision in a supine position under two-lung ventilation. The tumor was diagnosed as thymic cysts by rapid pathologic examination. In the resected materials, the cyst walls were thymic tissue, and hyperplasia of lymph follicles was also diagnosed. The surface layer was covered with squamous epithelium. Pathologically, there were cholesteric crystals, atypical giant cells, granulation tissue, hyalinization of the cystic walls, and infiltration of lymphocytes and plasma cells. Currently, the patient shows neither malignancy nor autoimmune diseases. The postoperative course has been uneventful.

A 45-year-old woman was diagnosed with uterine fibroids 8 years ago. However, she refused medical treatment at that time. Recently, she developed blood in her sputum and visited a nearby hospital. Computed tomography (CT) showed a 60-mm-sized mass in the right upper lung field. The tumor was suspected of being primary lung cancer (cT3N0M0 Stage IIB), and thus, surgery was performed. A sarcoma component was detected on postoperative pathological examination of the lung. Because uterine fibroids were large and were highly suspicious of being lung metastatic tumors, they were resected. The pathological diagnosis was uterine fibroids without malignancy. The lung tumor was further investigated because there was no association between uterine tumors and the lung tumor. Additional immunostaining was performed, and the tumor was diagnosed as a pulmonary blastoma (pT3N0M0 Stage IIB) because it stained positive for β-catenin in both the nucleus and cytoplasm. This report describes a case of pulmonary blastoma, which was difficult to differentiate from metastatic pulmonary tumors, including a large uterine tumor.

Pneumonectomy for pulmonary aspergillosis is associated with a high frequency of empyema and bronchopleural fistula. A 46-year-old woman who had contracted pulmonary tuberculosis was referred to our hospital for evaluation of hemoptysis with pulmonary aspergillosis. She had decreased activity when she consulted us, therefore we planned her surgery after rehabilitation training for 2 months as an outpatient. We performed transcatheter arterial embolization of intercostal arteries the day before surgery, and performed a right pneumonectomy in conjuction with covering the bronchial stump with a latissimus muscle flap. She was discharged from our hospital on the 15^th post-operative day with no complications. She has remained well for 3 years and 10 months post-operatively. We obtained favorable results by performing a right pneumonectomy for pulmonary aspergillosis with reinforcement of the bronchial stump and careful peri-operative management. We suggest that bronchial stump reinforcement with a latissimus dorsi flap is an effective method to prevent bronchial stump failure.

We report a case of Müllerian duct cyst in the posterior mediastinum successfully resected by thoracoscopic surgery. A female in her forties was found to have a tumor in the left paravertebral area on Th3. The patient underwent thoracoscopic resection of the tumor. Pathological examination showed a benign cyst that was positive for both estrogen and progesterone receptors on immunohistochemical examination. We review the embryogenesis and pathologic characteristics of Müllerian cysts.

The patient was a 35-year-old male, who was admitted to the hospital complaining of sudden onset right anterior chest pain. Radiological examinations revealed signs of small amount of hemorrhage in the thymic cyst. He was observed without undergoing an urgent operation due to the rapid disappearance of the chest pain. However, the cyst had been enlarged thus total thymus resection was carried out after 6 months from the onset because malignancy could not be denied. A combined resection of the right pleura at the mediastinum was needed owing to the severe adhesion around the lesion. The pathological examination revealed that the lesion was benign thymic cyst with hemorrhage. The thymic cyst in adult is generally asymptomatic and is detected as anterior mediastinal mass on chest radiographs incidentally. Symptomatic thymic cyst with hemorrhage may cause respiratory distress or hemothorax, and may combine thymoma or thymic carcinoma, and therefore surgery is indicated in such a case.

A 55-year-old man underwent thoracoscopic right upper lobectomy with mediastinal lymph node dissection (ND2a-1) for primary lung cancer. He was subsequently discharged from our hospital, but on postoperative day 10 he was taken to a local hospital by ambulance because of epigastric pain and dyspnea. He was diagnosed with cardiac tamponade and emergent pericardial drainage was performed. The amount of the drainage fluid did not decrease, so he was transferred to our hospital for further examination and treatment. As a result, he was diagnosed with pericardial effusion due to lymphatic leakage. Since conservative treatments were not successful, thoracoscopic pericardial fenestration was performed. After the operation, the pericardial effusion was absent on echocardiography. Cardiac tamponade after lung cancer surgery is extremely rare as one of the life-threatening complications; therefore, we have to keep this complication in mind after lung cancer operations.

A 48-year-old man complained of cough, dysphagia, and chest pain. He was diagnosed with advanced inoperable squamous cell carcinoma located in the right S² with mediastinal lymph-node metastases invading the esophagus (c-T4N2M0 stage IIIB). Concurrent definitive chemoradiotherapy (66 Gy) was planned, but he developed a tracheoesophageal fistula in the course of chemoradiotherapy (26 Gy). To resolve the severely complicated status after chemoradiotherapy, right sleeve pneumonectomy with esophagectomy and cervical esophagostomy were performed. Although bilateral recurrent nerve palsy was recognized, he recovered and was discharged 27 days after the salvage surgery following enhanced rehabilitation. Three months after the initial surgery, staged reconstruction surgery was performed using the stomach via the retro-sternal route. Due to intensive care, he is now able to take nutrition orally. We report our successful experience of staged salvage surgical repair for a tracheoesophageal fistula during concurrent definitive chemoradiotherapy for advanced lung cancer.

Case. A 68-year-old woman with a history of an operation for gastric ulcer and radiotherapy for laryngeal and pharyngeal cancers was referred to our department with a solid nodular lesion of 20 mm and a pure ground glass type nodule (GGN) in the left lung demonstrated on chest computed tomography (CT) taken during a routine follow-up. Systemic check-up including FDG-PET showed accumulation in the solid nodule of the left lower lobe. The nodular lesion was diagnosed as adenocarcinoma during surgical excisional biopsy; thus, lower lobectomy and wedge resection of pure GGN with mediastinal dissection were added. Postoperative pathological diagnoses were TTF-1-positive papillary adenocarcinoma only in the solid pulmonary lesion, and TTF-1-negative enteric adenocarcinoma with signet ring cell features in the GGN lesion involving mediastinal nodes. CBDCA+TS-1 was introduced as adjuvant chemotherapy; however, the treatment was disconrinued by the second course due to severe nausea. Conclusion. Even if CT shows pure GGN alone, advanced disease with mediastinal involvement cannot be ruled out.

A 45-year-old man was admitted to our hospital due to sudden left back pain. He had neurofibromatosis type 1 (NF1). Chest computed tomography (CT) showed left pleural effusion. A chest drainage tube was inserted, and bloody effusion was obtained. Because the bleeding source could not be identified by contrast-enhanced CT, we performed thoracoscopic surgery to identify the source, which was near the 11^th costotransverse joint. Bleeding was stopped by direct pressure with a tissue-sealing sheet and fibrin glue.

Subsequent arteriography revealed aneurysms in the 11^th intercostal artery, and transcatheter arterial embolization (TAE) was performed. His postoperative course was uneventful.

It is important to keep in mind that rupture of an intercostal arterial aneurysm might cause hemothorax in patients with NF1. Surgical interventions such as ligation, cauterization, and coagulation might be high-risk procedures because vascular walls in NF1 patients are fragile. Thoracoscopic surgery of temporal hemostasis and subsequent TAE could be a treatment of choice for such cases.