Descending necrotizing mediastinitis (DNM) is an illness typically caused by pharyngeal and odontogenic infections spreading to the mediastinum, which can follow a severe and sometimes fatal course. Here, we examined the clinical course of 13 patients who underwent mediastinal drainage in our hospital. Out of the 13 patients, 12 underwent thoracoscopic mediastinal drainage with an approach from the right thoracic cavity. Two cases had undergone cervical drainage in an otolaryngology department before extension into the mediastinum was observed, and thus mediastinal drainage was performed as a secondary surgery. The mean length of the post-operative hospital stay was long, at 46 days. There was a single case of postoperative mortality, involving a patient who had to wait approximately 2 weeks before receiving a diagnosis. A definitive consensus on drainage methods and approaches for treating DNM has not yet been reached.

Nevertheless, early diagnosis and less invasive surgical mediastinal drainage using a thoracoscopic approach are considered beneficial for improving the survival rate in patients with DNM. Further, identifying the route of extension by CT can help predict subsequent disease progression to some degree, which can be useful for selecting the optimal surgical modality.

We retrospectively analyzed 90 patients admitted with rib fractures between 2015 and 2019 to Japanese Red Cross Fukui Hospital, which is a secondary emergency hospital. The median age was 72.5 (16-96) years, the median number of rib fractures was four (1-10), median length of hospital stay was nine (2-60) days, and discharge states of patients were 68 (75.6%) returning to their home or nursing home, and 22 (24.4%) transferring to a rehabilitation hospital. Seventy-five (83.3%) patients had combined injury, of whom 68 (75.6%) and 18 (20%) patients including duplications suffered from chest and non-chest injuries, respectively. We performed tube thoracostomy in 35 (38.9%) for hemopneumothorax; the median length of drainage was three (1-13) days, and the median time from injury to drainage was two (0-17) days. We performed two emergency operations for massive hemothorax, and five operations: two for flail chest, and three for rib displacement with sharp fragments entering the thoracic cavity. Pneumonia occurred in four patients (4.4%), of whom two needed mechanical ventilation. Rib fracture is a common trauma in daily practice. The management of rib fractures is comprehensive. Although conservative treatment is the main treatment for rib fractures, surgical stabilization may be optimal. It is important to evaluate combined injury, pay careful attention to the probability of late-onset-hemopneumothorax or pneumonia, and cooperate with health care workers involved in respiratory care and discharge support from the beginning of hospitalization.

The endobronchial extension of thymoma is extremely rare. Herein, we report a recurrent thymoma patient with endobronchial polypoid growth. A 59-year-old man, with a past history of extended thymectomy for a type B3 thymoma with partial resection of the left upper lobe and combined resection of the left phrenic nerve, presented to a hospital with a chief complaint of cough. Chest computed tomography revealed an ill-defined mass in the left upper lobe of the lung. An endobronchial polypoid tumor occupying the bronchus of the left upper lobe was detected by bronchoscopy. Although biopsies were performed, definite evidence of malignant tumor cells could not be confirmed. He was referred to our hospital for surgery with a suspicion of primary lung cancer. During the surgery, a large tumor was located in the left upper lobe. Evaluation of intraoperative frozen sections of the tumor was suggestive of thymoma, and the left upper bronchial stump was positive for tumor cells. We performed left upper lobe sleeve lobectomy along with pulmonary artery reconstruction to correct a kink in the left main pulmonary artery. He was discharged from the hospital on post-operative day (POD) 22 after surgery with instructions for continued rehabilitation.

The development of thoracic empyema following lung abscess induced by transbronchial biopsy is a serious complication. Here, we report two cases of thoracic empyema induced by transbronchial biopsy. Case 1 was a 68-year-old man who developed thoracic empyema after transbronchial biopsy for squamous cell carcinoma of 47×34 mm in the left upper lobe with mediastinal lymph node metastases. His lung cancer was diagnosed as cT2aN2M0, Stage IIIA. After curettage under VATS (Video-assisted Thoracic Surgery) was unsuccessful, open window thoracostomy was performed for infection control. The post-operative course was satisfactory, and he began chemotherapy two months after open window thoracostomy. Case 2 was a 69-year-old man who had primary lung cancer of 58×48 mm in the lingular segment with no lymph node metastasis. Transbronchial biopsy revealed adenosquamous carcinoma. Then, he developed a high fever and dyspnea. Computed tomography of the chest 7 days after transbronchial biopsy showed a consolidation with an air- fluid level and pleural effusion in the left chest cavity. He underwent left upper lobectomy and curettage under VATS. The post-operative course was uneventful. In conclusion, surgical treatment is necessary for most patients with thoracic empyema following lung abscess induced by transbronchial lung biopsy, and so it is important to consider surgery.

A 71-year-old-man, who had undergone left pneumonectomy for pulmonary tuberculosis forty-seven years ago and chest drainage for empyema twelve years ago, was admitted to our hospital with a diagnosis of chronic empyema after complaining of gradually worsening dyspnea. Chest CT showed a huge mass shadow in the left chest cavity and mediastinal shift to the right side. The symptoms did not improve despite chest drainage. We performed open-window thoracostomy for empyema with methicillin-resistant coagulase-negative staphylococci (MRCNS) infection. A large amount of hemorrhagic granulation tissue and fibrous fibrin clot, covered by a dense capsule, were removed as much as possible, but some capsule remained, associated with the risk of massive bleeding. On the basis of pathological findings, we diagnosed the mass as a chronic expanding hematoma (CEH) with bacterial infection. The postoperative course was favorable with daily wound treatments. In conclusion, considering the risk of bleeding during surgery, an adequate surgical strategy should be formulated.

This paper reports a case of peribronchial Rosai-Dorfman disease (RDD). A 61-year-old woman presented with wheezing and was diagnosed with bronchial asthma. The patient received drug therapy to treat the bronchial asthma, but her condition did not improve. Computed tomography revealed thickening of the bronchial wall around the bronchus intermedius and the bronchi of the lower and middle lobes of the right lung. The bronchial lumen was stenotic. Bronchoscopy was used to confirm mucosal uplift in the bronchus intermedius. The peripheral bronchi were obstructed. A definitive diagnosis could not be made by bronchoscopic biopsy. FDG-PET showed accumulation with a maximum standard uptake value of 15.3 in the thickened area. Malignant lesions could not be ruled out, and surgery (middle and lower lobectomy of the right lung+ND2a-2) was performed. Pathological findings from the resected specimen revealed fibrosis around the bronchial vessels due to infiltration of histiocytes and phagocytosis of lymphocytes and erythrocytes by histiocytes (emperipolesis). On immunostaining, histiocytes were stained positive for CD68 and S100, and negative for CD1a. By pathological examination, a definitive diagnosis of RDD was made. The postoperative course was good, and signs of recurrence were not observed in the follow-up period of 5 years and 4 months.

A 71-year-old woman consulted our hospital for examination of abnormal chest shadows. She underwent a thoracoscopic right lung partial resection, was diagnosed with primary pulmonary cryptococcosis, and started treatment. A large tumor in the anterior mediastinal that progressed rapidly, appeared 1 month after surgery. The tumor in the anterior mediastinal progressed to infiltrate the lungs, hilum, and abdominal lymph nodes, and increased pleural effusion.

The diagnosis of the tumor by percutaneous needle biopsy was T-cell lymphoma, and the patient started chemotherapy. The final diagnosis was adult T-cell lymphoma due to being positive for HTLV-1 antibody, HTLV-1 provirus, and CCR4. She was treated for adult T-cell leukemia, but the chemotherapy was not effective. The patient died within 4 months of starting chemotherapy.

Case. Postoperative systemic embolic morbidities including cerebral infarctions are relatively rare but lethal complications after anatomical lung cancer resection. Herein, we report a case of simultaneous multiple thromboembolism soon after left upper lobectomy. A 76-year-old man underwent left upper lobectomy with mediastinal nodal dissection for left lung cancer. The patient was discharged on postoperative day (POD) 7. On POD15, he experienced lower abdominal pain. Contrast-enhanced computed tomography (CT) demonstrated embolic occlusions in both the upper mesenteric artery and left kidney, diagnosed as superior mesenteric artery thrombosis and left renal infarction. Anticoagulant therapy was administered, and his condition was successfully recovered until discharge. Recently, left upper pulmonary vein stump thrombus has been considered as a possible cause of postoperative systemic embolic morbidities. We should pay special attention to postoperative management after left upper lobectomy.

Surgical treatment of pleuroperitoneal communication requires reliable identification of the fistula. In this report, we present a case of successful identification of the fistula using indocyanine green (ICG) dye with infrared thoracoscopy. The patient was a 53-year-old male suffering from massive ascites, diagnosed with renal sclerosis on hemodialysis and liver cirrhosis due to non-alcoholic steatohepatitis. Examination revealed a massive right pleural effusion, when the patient complained of cough and shortness of breath. He was diagnosed with pleuroperitoneal communication, and thoracoscopic surgery was performed. ICG solution was injected through a peritoneal catheter inserted on the day before surgery. Although only a subtle change was detected under natural light, leakage of the dye from a fistula was clearly confirmed using infrared thoracoscopy. The fistula was excised using an endostapler, and the staple line was covered with a polyglycolic acid sheet and fibrin glue. This method was useful for detection of the fistula during surgical repair of pleuroperitoneal communication.

Herein, we report a case of pulmonary infarction and abscess after bronchial artery embolization for hemoptysis caused by a racemose hemangioma. A 39-year-old man with hemoptysis was admitted to our hospital. Computed tomography findings were indicative of left pulmonary artery pseudoaneurysm. Angiography was subsequently performed but no hemorrhagic site was identified. Embolization of the left pulmonary artery was performed. Seven days after embolization, hemoptysis recurred. Angiography revealed a racemose hemangioma along the left B¹⁰, and embolization was performed to treat it. High fever developed the day after embolization. Blood tests revealed high levels of leukocytes and C-reactive protein. An emergency thoracoscopic left lower lobectomy was performed to treat pulmonary infarction and abscess. The postoperative course during hospitalization was uneventful. The patient was followed up in the outpatient department postoperatively, but no further recurrence of hemoptysis occurred after discharge. If the source of bleeding is not clear and both pulmonary arteries and bronchial arteries are embolized, pulmonary infarction and pulmonary suppuration may rapidly worsen a patient's general condition, so it is necessary to prepare for immediate surgical intervention.

A 67-year-old man who underwent cholecystectomy developed portal vein thrombosis due to postoperative cholangitis. One year after surgery, he noticed weight gain and ascites, and treatment with diuretics was started. Despite the treatment, pleural effusion appeared, and he was admitted to our hospital for dyspnea due to increased pleural effusion.

As a chest radiograph revealed marked pleural effusion on the right side, chest drainage was performed.

He was diagnosed with pleuroperitoneal communication and underwent video-assisted thoracoscopic surgery (VATS). A small hole in the diaphragm was confirmed by thoracoscope, and the diaphragm including the hole was resected using a stapler with polyglycolic acid (PGA) sheet. There was no recurrence of the pleural effusion. In the treatment of pleuroperitoneal communication, VATS using a stapler with PGA sheet is a feasible method for closure of a diaphragmatic hole.

We report a surgical case of an ectopic mediastinal parathyroid adenoma involving a 37-year-old female who presented with hypercalcemia and an increased level of intact parathyroid hormone. Computed tomography showed a 2.5-cm anterior mediastinal tumor and Technetium-99m-Methoxy Isobutyl Isonitrile (^99mTc-MIBI) parathyroid scintigraphy revealed increased uptake of MIBI in this tumor. We performed thoracoscopic surgery using carbon dioxide insufflation in her right thoracic cavity and resected the anterior mediastinal tumor. She developed hypocalcemia and numbness of her limbs on postoperative day 1. We administered an intravenous injection of calcium gluconate, and her serum calcium levels returned to normal. However, the numbness of her limbs persisted until postoperative day 9. We continued to administer calcium aspartate by mouth from postoperative days 2-17. The standard treatment for primary hyperparathyroidism is surgical resection of the parathyroid tumor. Serum calcium levels typically decrease during the early postoperative period, with the lowest serum calcium levels observed from postoperative days 2-4 in the majority of cases. However, in 4-24% of patients, hypocalcemia persists beyond this period. Although thoracoscopic surgeries have resulted in shorter hospital stays, patients with primary hyperparathyroidism require careful follow-up of physical findings and serum calcium levels after resection of the ectopic mediastinal parathyroid adenoma.

The patient was a woman in her 50s. On physical examination, a chest radiograph showed a well-defined tumor shadow overlapping the cardiac shadow in the lower left lung field. Chest-enhanced CT and three-dimensional CT showed an abnormal artery with a maximum diameter of 8.5 mm that diverged from the descending thoracic aorta and directly flowed into the left lung segment. The lower left lobe was normal, and no apparent pulmonary sequestration was observed. The patient was diagnosed with anomalous systemic arterial supply to a normal basal segment (Pryce type I). Since the distribution area of the abnormal arteries was mostly confined, only abnormal artery resection was performed using an autosuture device under thoracoscopy. Chest-enhanced CT showed a decrease in pulmonary vein flow in the area of distribution of abnormal arteries, six months after surgery. For relatively rare cases of anomalous systemic arterial supply to a normal basal segment (Pryce type I), surgery involving resection of the aberrant artery may be successful and lead to a favorable outcome.

We report a case of thymolipoma with thymic hyperplasia involving a female teenager aged 16 years old. She was pointed out as showing cardiomegaly on a chest radiograph in a medical checkup conducted as part of high school entrance, and referred to our department. She had no symptom and no physical findings of note. Chest CT and MRI indicated a huge anterior mediastinal mass, with a maximum size of 17 cm. We conducted anterior mediastinal tumor resection and total thymectomy with VATS and a median sternotomy approach. Based on pathological findings, the tumor comprised a mix of thymic hyperplasia and adult fat tissue. This was not a typical thymolipoma; there are some rare reports of thymolipoma with thymic hyperplasiay. We made a diagnosis of thymolipoma with thymic hyperplasia. Thymolipoma is a rare tumor, and diagnosis sometimes may be difficult when there is a rare combination of pathological tissue. This represents an unusual case of thymolipoma with thymic hyperplasia.

Introduction: Interstitial pneumonia with pneumothorax caused by a giant bulla is difficult to treat. We report a patient who had been treated for recurrent left pneumothorax with an emphysematous giant bulla and intestinal pneumonia. Case: A 75-year-old man who had been diagnosed with interstitial pneumonia was treated with a corticosteroid, an immunosuppressant, and home oxygen therapy. He presented with the sudden onset of dyspnea. Left tension pneumothorax was diagnosed and treated with thoracic drainage. We performed an operation under general anesthesia because of conservative therapy failure. After separating dense adhesions from the visceral pleura, the giant bulla was identified and partially opened, implanted with oxidized regenerated cellulose (ORC) followed by a pericardial fat pad, and closed with a mechanical stapler. No bulla regeneration was observed around the fat tissue, and no further episodes of pneumothorax were observed for twenty months after surgery. Conclusion: Although it is difficult to determine appropriate treatment for patients with intractable pneumothorax, we treated one patient whose disease was caused by a giant bulla with a reinforcing pericardial fat pad.

Somatostatin receptor scintigraphy (SRS, Octreoscan^®) using somatostatin analogues such as ¹¹¹In-pentetreotide was introduced in Japan in 2015 and is available for the diagnosis and staging of carcinoid tumors that express somatostatin receptors.

Case 1: A 77-year-old man developed subcarinal lymphadenopathy 6 years and 8 months after undergoing right middle lobectomy for a typical pulmonary carcinoid tumor (stage IA). Although ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) revealed only slight accumulation of FDG in the subcarinal lymph nodes, significant accumulation of the tracer was observed with SRS. The patient was diagnosed with lymphatic recurrence of the carcinoid tumor and underwent mediastinal lymph node dissection.

Case 2: A 76-year-old man presented with a right upper lobe lung mass that extended to the orifice of the upper bronchus. Based on video bronchoscopy, he was diagnosed with an atypical pulmonary carcinoid tumor. SRS revealed a right iliac bone lesion that was not identified by FDG-PET/CT. Based on magnetic resonance imaging, the lesion was diagnosed as bone metastasis from a pulmonary carcinoid tumor. SRS could be useful for preoperative staging and postoperative surveillance of recurrence in patients with pulmonary carcinoid tumors.

A 63-year-old man underwent pancreatoduodenectomy for pancreatic head cancer. Twelve years after the surgery, CT revealed a solid nodule with pleural indentation, accompanied by a smaller nodule in the right upper lobe. A high level of ¹⁸FDG accumulation was observed in the nodular shadows and the left inguinal lymph node on PET/CT. Pathological examination of a transbronchial lung biopsy sample revealed adenocarcinoma, which was suspected to be a pulmonary metastasis of the previous pancreatic cancer. However, owing to the clinical course and CT findings, primary lung cancer was also suspected. Therefore, a complete video-assisted thoracoscopic right upper lobectomy and left inguinal lymph node resection were performed to simultaneously accomplish both diagnosis and treatment of the condition. Histopathological evaluations of resected specimens revealed the metastasis of the pancreatic cancer. He received adjuvant chemotherapy after lung resection. Twelve months after the treatment, no recurrence was observed. Generally, pancreatic cancers proliferate rapidly; thus, surgical resection is ineffective, and chemotherapy is the first choice of treatment in the presence of distant metastasis. In contrast, another type of this cancer, also known as oligo-metastatic pancreatic cancer, exhibits slow growth and is suitable for surgical resection. While cases of resectable pulmonary metastasis of pancreatic cancer are rare, surgery can be considered as an effective therapeutic option in such patients.

Case. A 76-year-old man with a right lung tumor was referred to our hospital. The clinical diagnosis was lung cancer cT3N0M0 stage IIB. Right upper lobectomy combined with resection of the chest wall was performed. Bronchoscopy was conducted to check the bronchial stump six days after surgery because the volume of air leakage had increased. During this study, the patient aspirated vomit.

Artificial respiration therapy with steroid was started for acute respiratory distress. Acute treatment was effective; however, the patient died of sudden cardiac arrest 66 days after the operation.

In the management of aspiration pneumonia from vomit after surgery, various disadvantages and adverse effects of treatment should be considered.