Air-aspiration therapy for primary spontaneous pneumothorax is recommended in various guidelines, but the results in recent years are not clear. Air-aspiration therapy can manage all or part of the course in an outpatient setting; the significance is marked. In this study, we examined the end point of the wait completion until surgery or 10 days of progression completion in 20 patients who underwent air-aspiration therapy and provided consent in accordance with adaptation criteria as a clinical study. There were no complications, and the completion rate was 75%. The therapy can be an option for initial treatment of patients with primary spontaneous pneumothorax.

Spontaneous hemopneumothorax is a relatively rare condition. When accompanied by bleeding or symptoms of shock, it may require an emergency operation. We examined 8 cases of emergency operation for spontaneous hemopneumothorax from April 2014 to March 2019. The emergency operation was performed a median of 17.0 hours (6-60) after onset. Five patients presented with symptoms of shock. All patients showed bleeding from the apex of the parietal pleura. The median volumes of preoperative blood loss and total blood loss were 1350 mL (200-2000) and 1356.5 mL (400-3035), respectively. The median duration of drainage after surgery and postoperative stay were 2.0 days (1-6) and 4.5 days (3-14), respectively. Three of the eight patients were recurrent cases, and 2 of them had shown a pleural adhesion band at the apex on computed tomography (CT) at the onset of the previous spontaneous pneumothorax. Spontaneous pneumothorax with such a band should be indicated for surgery.

The case was an 81-year-old male. During a visit to a local hospital, a mass lesion was identified in the left middle lung field on a chest radiograph, and so he was referred to our department. Chest abdominal computed tomography showed a 47-mm mass in the left S6, but there was no obvious lymphadenopathy or distant metastasis. The patient was diagnosed with squamous cell carcinoma based on bronchoscopy. Video-assisted thoracoscopic left lower lobectomy was planned.

The patient had previously undergone percutaneous coronary intervention (PCI), but with no significant stenosis based on coronary angiography (CAG) two years prior. We then performed video-assisted thoracoscopic left lower lobectomy without discontinuing antiplatelet drugs, but he developed very late stent thrombosis 2 h postoperatively. Although thrombus suction was successful, the patient died of low cardiac output syndrome.

A major problem with first-generation drug-eluting stents is stent thrombosis. It is important for thoracic surgeons to know in advance the type of coronary stent and when it was placed, and to evaluate the risks and take appropriate measures when performing surgery for patients after previous PCI.

The case involved a 43-year-old woman with severe mental retardation. Massive hemoptysis was repeated, and chest CT revealed bronchodilation of the right middle lobe and multiple inflowing arteries that were markedly dilated, and so we decided to operate. Since the involvement of multiple blood vessels was suspected, it was considered difficult to cure with embolization alone, and the operation was planned. Arteriography was performed before surgery, and severe shunts were observed between the middle lobe pulmonary artery and bronchial artery, between the middle lobe pulmonary artery and inferior phrenic artery, and between the middle lobe pulmonary artery and bronchial artery. Almost all the arteries were embolized to reduce bleeding during the operation. Surgery was performed with a fifth intercostal thoracotomy, the adhesion between the middle lobe, chest wall, and diaphragm was removed, and the inflowing internal thoracic artery and inferior phrenic artery were carefully ligated and separated. The inflow artery could be safely blocked due to decreased blood flow by embolization. Finally, the thick bronchial artery was removed by ligation and the middle lobectomy was completed. A postoperative tracheostomy was performed because of difficulty in exudation due to comorbidities. The operative time was 223 minutes, the amount of bleeding was small, and blood transfusion was not necessary. Especially for bronchiectasis with arterial shunt, preoperative embolization was considered to be useful for reducing blood loss during surgery.

A 50-year-old male, with a medical history of respiratory non-tuberculous mycobacteriosis (NTM) and allergic bronchopulmonary aspergillosis (ABPA) and treated with 17.5 mg of prednisolone per day, presented with symptoms of a prolonged low-grade fever, cough, and bloody sputum. CT showed two independent lesions of complex aspergilloma on the upper lobe and segment 6 of the right lung. As both of the lesions were refractory to anti-fungal medicine, en bloc resection of the upper lobe and segment 6 was performed, while taking care to avoid dissecting the major fissure to reduce the risk of intrapleural dispersion of fungus or bacteria. The post-operative course was uneventful, and the patient was discharged on the 13^th day after surgery.

A 17-year-old man complaining of a high fever and cough was admitted to our hospital. A chest radiograph showed right pneumonia and pleural effusion. Although antibiotics were administered for about one week, there was no improvement of symptoms. At this time, he consulted us and laboratory data showed marked hypoproteinemia and proteinuria. Then, we suspected the complication of nephrosis syndrome. Furthermore, enhanced computed tomography showed massive pleural effusion and the intrathoracic exchange of multi-chambers. Subsequently, he was diagnosed with acute empyema. At the same time, inferior vena cava (IVC) thrombosis was detected. After the immediate insertion of an IVC filter, video-assisted thoracic surgery (VATS) for acute empyema was performed. Concurrently with empyema treatment, further examination for renal disease was performed. According to the laboratory data, urinary protein was 32.5 g per day and anti-Sm antibody was positive. Furthermore, ten days after surgery, butterfly erythema appeared on his face. He was diagnosed with systemic lupus erythematosus (SLE) based on all symptoms and laboratory data. Steroid therapy was started by the Department of Nephrology. After the improvement of all symptoms associated with SLE, he was discharged in the 4th postoperative month. We encountered a case of SLE diagnosed by the onset of acute empyema.

A 55-year-old man had been treated for rheumatoid arthritis with methotrexate. After 3 months, chest CT revealed a mass with multiple nodes in the anterior mediastinum. Based on the results of MRI and FDG-PET, malignant lymphoma, thymic hyperplasia, and cystic thymoma were suspected, so total thymectomy was performed using the VATS technique. Histopathological findings revealed multilocular thymic cyst but no neoplastic lesions. This is a rare case that was difficult to preoperatively diagnose.

A 68-year-old man conducted left upper lobectomy ND2a-2 for lung adenocarcinoma (cT2aN0M0 Stage IB). He postoperatively had fever, and left pneumonia and abscess localized in the left hilum was suspected based on computed tomography. Antibiotic treatment (Ampicillin/Sulbactam) was not effective, and surgical debridement was indicated under the diagnosis of empyema on postoperative day 17, which identified multidrug-resistant Streptococcus mitis in pleural effusion. Although sensitive antibiotic treatment (Levofloxacin+Clindamycin) improved left lung infiltration, the patchy consolidation of the right lung progressed. Because bronchoalveolar lavage from the right lung revealed elevation of the proportion of lymphocytes, we suspected drug-induced pneumonia. Despite the discontinuation of antibiotics, the patient showed respiratory failure with hypoxia without improvement of the consolidation in the right lung. Thus, we differentially diagnosed secondary organizing pneumonia, and steroid pulse therapy was administered. The respiratory status and right lung infiltration rapidly improved. The steroid dose was gradually decreased and discontinued and no recurrence of organizing pneumonia was observed for one year after surgery.

Secondary organizing pneumonia should be considered when encountering intractable postoperative pneumonia after pulmonary resection.

A 75-year-old female with no history of tuberculosis or thoracic surgery presented with anemia after chest contusion secondary to falling on the floor. CT revealed a hemothorax and hematoma on the angle of the right mediastinum and diaphragm, and a mass on the right diaphragm with partial calcification of its margin. Angiography showed extravasation from a right mediastinal branch of the left gastric artery to the traumatic hemothorax; thus, embolization was performed. The size of the traumatic hemothorax had been reduced in the course of 4 months. Contrarily, the mass on the right diaphragm showed a gradual increase in size; therefore, we performed total capsule excision of the mass. Histopathological findings were compatible with chronic expanding hematoma (CEH).

A 64-year-old man was shown to have a nodular shadow, of 2.5 cm in diameter, in his left upper lobe when he was hospitalized for a complete examination. He was then referred to our hospital for further evaluation and treatment. Because lung cancer was suspected, based on a special examination, we performed thoracoscopic left upper lobectomy and lymph node dissection. General anesthesia with a double lumen endobronchial tube (DLT) was used. A stapling device to divide the lung parenchyma was not used because his interlobar fissure was complete. Upon the completion of surgery, no air leak was observed from the thoracic drain, but massive air leaks and bloody drainage were noted immediately after cough during extubation of the DLT. Thus, we performed a re-operation and inspected the thoracic cavity with a thoracoscope. The visceral pleura of the left lower lobe hilum was detached from the lung parenchyma. We considered that coughing during extubation of the DLT had led to the lung injury.

An 82-year-old man was referred to our hospital with dyspnea and diagnosed with right middle lobe adenocarcinoma pT2bN0M0 (stage IIA). He was also diagnosed with a right aortic arch (Stewart classification Type I); however, no other congenital heart anomoly was identified. Three-dimensional computed tomography revealed that the left brachiocephalic trunk was the first branch originating from the right aortic arch, followed by the right common carotid artery and right subclavian artery, and an aortic diverticulum was detected in the descending aorta. We performed right middle lobectomy and lymph node dissection. During dissection of the mediastinal lymph nodes, we observed the right recurrent nerve encircling the right aortic arch. No postoperative complications such as recurrent nerve paralysis were observed. Surgeons performing operations for lung cancer in patients with a right aortic arch should conduct careful exploration of the operative field to trace the course of the recurrent nerve and also carefully decide on the extent of dissection of the mediastinal lymph nodes. We conclude that further research is warranted to establish an optimal range of lymph node dissection in such cases.

Currently, automatic suture devices are generally used during surgery for safe closures and tissue cuts. We report a case of postoperative bleeding from an intercostal artery injured by the bronchial stump following cutting with an automatic suture device. A 73-year-old man with a part-solid ground-glass nodule in the right lower lobe was referred to our division for further evaluation and treatment. He was suspected to have primary lung cancer, cT1miN0M0 stage IA1, and underwent right lower lobectomy and lymph node dissection via thoracoscopic surgery. Five hours after surgery, bloody drainage of 500 mL was observed. We diagnosed it as postoperative bleeding and repeated surgery. Active bleeding was observed from the intercostal artery at the front of the vertebral body. Considering that the stump of the right lower bronchus was located very close to the bleeding point, we suspected that contact and friction of the bronchial stump with the intercostal artery caused vascular injury and postoperative bleeding. The bleeding was stopped by transfixing suture of the artery and covering the bronchial stump with a PGA sheet and fibrin glue.

Herein, we report a rare case of postoperative bleeding from an intercostal artery injured by the bronchial stump. Based on the intraoperative findings, covering the bronchial stump should be considered during thoracoscopic lobectomy.

We herein report a case of resected lung adenocarcinoma that was difficult to distinguish from infectious lung disease by imaging. Chest computed tomography showed a nodular shadow in the right upper lobe of the right lung, and bronchoscopy was performed, but no definitive diagnosis was made, so follow-up observation was conducted. One month later, cough appeared, and the nodular shadow increased rapidly, exacerbating the inflammatory response. Although Tazobactam/Piperacillin Hydrate (TAZ/PIPC) reduced the lesion and improved the inflammatory response, the nodular shadow did not disappear completely, and it was diagnosed as mucinous lung adenocarcinoma by surgery. Even if lesion reduction is achieved by antibiotic administration, when the lesion persists, lung cancer may co-exist. It is necessary to consider such cases carefully and perform follow-up so that the optimal treatment timing is not missed.

Müllerian cysts, which are thought to be caused by insufficient degeneration of the Müllerian ducts, rarely arise in the posterior mediastinum. Müllerian cysts of the posterior mediastinum mostly occur in perimenopausal females and are located predominantly in the paravertebral region (Th3-8); however, the clinical picture or course is still unclear due to the rarity of the pathology. We herein report the case of a growing Müllerian cyst in the posterior mediastinum. A 46-year-old woman was referred to our hospital because of the presence of a mass shadow in a chest radiograph on routine check-up. Chest computed tomography revealed a mediastinal cyst adjacent to the 4th and 5th thoracic vertebrae. It increased in size during a follow-up period of one and a half years, and we performed thoracoscopic resection for diagnosis and treatment of the growing cyst. Immunohistochemistry revealed that the cells lining the inner surface of the cyst wall were positive for estrogen and progesterone receptors; therefore, the lesion was finally diagnosed as a Müllerian cyst. When an unilocular cyst is detected in the thoracic paravertebral region of a perimenopausal woman, it may be a Müllerian cyst. In such cases, it should be borne in mind that the cysts can grow in size if they are not resected.

Disseminated intravascular coagulation syndrome (DIC) is rare as a side effect of UFT therapy provided as postoperative chemotherapy for lung cancer. The present case was a 66-year-old man whose medical history only included a past infection of HBV. We performed right lower lobectomy with lymph node dissection by video-assisted thoracoscopic surgery for adenocarcinoma of right lung S6b and started UFT therapy one month after the surgery. However, the patient visited the hospital complaining of a fever and poor physical condition six weeks after starting UFT therapy, and was urgently hospitalized when liver injury was detected. We stopped UFT therapy and started the treatment for liver injury, but DIC developed on the next day. We therefore started thrombomodulin, after which his condition improved, and he was discharged 23 days after being admitted. In this case, because we did not detect any increase in the amount of HBV-DNA, we diagnosed him not with liver damage due to reactivation of HBV but with drug-induced liver injury due to UFT. While we tend to prescribe UFT for outpatients readily, we should observe patients' progress carefully for at least two months after starting therapy, as this treatment may cause drug-induced liver injury and DIC.

Anhidrotic ectodermal dysplasia is an inherited disorder that is complicated by a NEMO (Nuclear factor-κB essential modulator) gene abnormality and its associated immunodeficiency. Here, we describe a 23-year-old man with medical complications who underwent surgery for an infectious pulmonary cyst. He had repeatedly developed pneumonia and a right lung cyst, and became antibiotic-resistant over time. He was diagnosed with colon-type Crohn's disease at the age of 23 years. Because of his lung cyst infection, he was unable to be treated with steroids and biological agents; therefore, surgery was planned. He underwent a right lower lobectomy for a right lung cyst, which extended from S6 to 10. There has been no report on surgical treatment for anhidrotic ectodermal dysplasia. Close control of body temperature was necessary during surgery to prevent hyperthermia given that the patient was unable to sweat, and no heater was used. We administered 600 mg of clindamycin (CLDM) during surgery. Steroid administration for Crohn's disease was planned to start 1 month after surgery, and the bronchial stump was covered by an intercostal muscle flap. Postoperatively, the patient underwent expectoration with a nebulizer and analgesia with epidural anesthesia. His postoperative course was satisfactory and uneventful. In this case, surgical resection was effective.

An 84-year-old male patient with severe arteriosclerosis obliterans of both lower extremities developed right leg compartment syndrome after surgery in a lateral decubitus position. In a left lateral decubitus position, he underwent right lower lobectomy on thoracotomy for primary lung cancer. Although, during the operation, we returned him to a supine position, hypotension and hypoxia were observed. From the first post-operative day, he suffered spontaneous pain and swelling of the right lower leg. We diagnosed him with compartment syndrome, and performed fasciotomy on the same day.

Even when we perform operations in a lateral decubitus position for a long period, patients should be managed while keeping the risk of compartment syndrome in mind.

A 77-year-old male fell onto a mattress and a needle pierced his chest wall seventy years ago. Although he visited a physician the following day for extraction, it could not be located and so removal was not possible. The patient was followed and remained asymptomatic, although he later requested magnetic resonance imaging examination. Chest computed tomography (CT) was performed, which revealed several high-intensity shadows considered to be associated with the needle along the posterior surface of the right 9th rib. However, it was difficult to distinguish whether the location was intra- or extra-thoracic; thus, video-assisted thoracoscopic surgery was performed, and the needle was safely located and removed. In the present case, use of an intraoperative fluoroscopy device was useful because the needle was fragile, making extraction difficult.

The postoperative course was good.