Virtual-assisted lung mapping (VAL-MAP) is spreading as a preoperative marking method for small lung cancer. However, it is sometimes difficult to recognize the pigment during the operation. Therefore, VAL-MAP, which uses indocyanine green (ICG) and indigo carmine, is performed, combined with systemic ICG intravenous injection for identification of the intersegmental plane (ICG intravenous method) during thoracoscopic segmentectomy in our hospital. We evaluated 15 cases of thoracoscopic lung segmentectomy for small lung cancer using VAL-MAP with ICG and intravenous ICG at our hospital. Complications associated with VAL-MAP with ICG involved only one case of mild pneumothorax. Seven (18.4%) of the mappings were difficult to recognize under a normal visual field during surgery, whereas all but one mapping was recognizable under infrared light. Fluorescence areas by VAL-MAP with ICG and by intravenous ICG were generally easily identified. Segmentectomies with a sufficient margin, that is, a margin / tumor size ratio (M / T) ≥1, were achieved in all cases. The combination of VAL-MAP with ICG and intravenous ICG was considered safe and useful during thoracoscopic segmentectomy for early-stage lung cancer.

We report the management of 46 patients who required treatment for air leak after surgery for primary lung cancer. Thirty-seven patients had a smoking history and 28 patients had pulmonary emphysema. Bilobectomy was performed in 3 patients, lobectomy in 38 patients, segmentectomy in 4 patients, and partial resection in one (video-assisted thoracic surgery in 31 patients). Five patients required reoperation at 3.2±2.6 days after surgery. Forty-one patients and 2 patients who received reoperation required pleurodesis at 5.3±2.5 days after surgery. Pleurodesis with OK-423 was performed in 25 patients, with minocycline in 17 patients and 50% glucose in one. Pleurodesis was successful in 42 of 43 patients. One died due to acute exacerbation of interstitial pneumonia. The duration of chest tube insertion was 9.7±2.7 days, and the length of hospital stay was 14.5±7.1 days in 45 patients with successful treatment. On the other hand, the duration of chest tube insertion was 3.1±1.8 days, and the length of hospital stay was 7.9±4.4 days in patients who required no treatment. Those with pleurodesis around postoperative day 5 could be discharged about 2 weeks after surgery. Pleurodesis with OK-432 was effective.

Chest trauma is common in cases of multiple traumas and can be fatal. We encountered a case in which persistent bleeding associated with multiple traumas with a coagulation abnormality was successfully controlled with minimum wound formation through video-assisted thoracoscopy (VATS). An 89-year-old man experienced an injury to his chest and abdomen due to a traffic accident. Computed tomography revealed diaphragm rupture, splenic injury, and mesenteric damage. Therefore, emergency laparotomy, transabdominal diaphragm repair, and intrathoracic observation were performed. After closure, we performed VATS because of persistent hemorrhage from the chest tube. Observing the bleeding point and arresting bleeding with marked accuracy made it possible to arrest the bleeding while minimizing the size of the open wound. Although the main choice for chest trauma management is thoracotomy, by reducing the size of the wound in the presence of abnormal coagulation, the risk of sustained bleeding can be reduced and surgical invasion can be suppressed. Thoracoscopic surgery may be useful for patients with chest trauma who exhibit persistent bleeding in cases of abnormal coagulation despite stable circulation.

A 45-year-old man had been followed up for postoperative chemotherapy after preoperative chemotherapy for pancreatic cancer (PC). Six months after the operation, computed tomography revealed an osteosclerotic mass in the right 4th rib, but no other lesions suspected of metastasis were identified. A primary chest wall tumor was also included in the differential diagnosis, but the CA19-9 level was gradually increased, suggesting PC metastasis. We performed chest wall tumor resection for local control. The CA19-9 level rapidly decreased after the operation. Histopathological examination revealed those the tumor cells infiltrated the existing bone tissue and proliferated in the form of glandular tubules, and the histological features resembled those of the previous PC. PC has a poor prognosis, and no case of bone metastasis resection has been reported. However, if the primary lesion of PC can be controlled and the growth of bone metastasis is slow and isolated, resection is considered to be one of the applicable treatments.

Secondary pneumothorax in association with pulmonary metastasis from sarcoma is rarely seen, with osteosarcoma being the most common histology. We report a case of pulmonary metastasis from osteosarcoma presenting with pneumothorax. A 14-year-old boy was diagnosed with osteosarcoma of the tibia and underwent surgical resection of the tumor. Six months after the completion of adjuvant chemotherapy, he presented with a right moderate pneumothorax. Computed tomography revealed a small cystic lesion in the right upper lobe, whereas no other solid nodules were seen, suggesting metastases. During surgery, a cystic lesion was identified as the source of air leakage and was completely resected surgically. Histological findings showed abnormal spindle cells that were compatible with osteosarcoma spreading to the subpleural space. We conclude that clinicians should be aware of the possibility of pulmonary metastasis when pneumothorax is encountered in a patient with osteosarcoma and the surgical approach is beneficial for the treatment of pneumothorax and confirmation of the pathological diagnosis.

A 66-year-old man was admitted to our hospital because of repeated secondary right-side pneumothorax with severe emphysema. Pneumothorax was controlled temporarily by chemical pleurodesis with OK432; however, he developed pneumothorax several times during hospitalization. Considering his severe emphysema, chest tube drainage and chemical or autologous blood pleurodesis was performed repeatedly instead of surgical treatment. Thereby, his chest cavity gradually became sparsely isolated. As pneumothorax relapsed again during hospitalization, a chest drainage tube was inserted; however, insufficient chest drainage was suspected. Although his respiratory condition did not significantly worsen with the chest drainage tube, he later complained of general fatigue and showed a depressed level of consciousness. Biochemical examination of the blood revealed marked hyponatremia, and with further examination, he was diagnosed with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Computed tomography showed an isolated, tensioned air space in the pleural cavity, and another drainage tube was inserted; subsequently, his symptoms and electrolyte abnormality improved. We considered that the cause of SIADH in this case was elevation of the pleural cavity pressure because of insufficient drainage due to sparse isolation of the pleural cavity resulting from repeated pleurodesis.

Vasovagal reflex and cardiac dysfunction due to intrathoracic warm distilled water are rarely but occasionally seen as complications of lung cancer surgery. However, there has been no report on the frequency, mechanism, or patient background of accidental cardiac arrest during surgery. We encountered four cases of sudden cardiac arrest without mechanical compression of the heart or catastrophic bleeding during surgery. One patient underwent mediastinal lymph node dissection, and three suffered cardiac arrest during flushing with warm distilled water in the thoracic cavity. In all four cases, the cardiac arrest time was within two minutes due to manual heart compression and natural resumption of spontaneous heartbeat, and no serious complications or sequelae occurred after the operation. However, one patient suffered cerebral infarction at seven days after surgery, although the infarction improved with heparin administration, and no sequelae were noted. Accidental cardiac arrest during surgery can occur during intrathoracic irrigation, but appropriate treatment with an anesthesiologist on hand can lead to a favorable course without any serious complications or sequelae.

A 78-year-old woman was found to have a 5-mm nodular lung shadow on surveillance CT after gastric resection for gastric cancer. Eighteen months later, the nodule had increased to 8 mm in diameter. Lung carcinoma or pulmonary metastasis was suspected, and she underwent thoracoscopic partial lung resection. A diagnosis of ciliated muconodular papillary tumor was made. The tumor was composed of pilus cells and goblet cells that showed papillary proliferation in a lepidic growth pattern. There has been no recurrence in the 2 years since surgery. It has characteristics of both benign and malignant tumors but remains poorly characterized. This is rare, being the 38^th reported case in Japan.

A 57-year-old woman with an abnormal shadow on a chest radiograph was admitted to our hospital. In the lingular segment of the left lung, a 2.7 cm nodule with calcification was detected on chest CT suspected as a hamartoma or an inflammatory myofibroblastoma. Although the appearance of the tumor was similar to hamartoma, a left inferior lingular segmentectomy was performed because the tumor was near to inferior lingular vessels and showed atypical inflammatory adhesions to neighboring pleura. The pathological diagnosis was benign PEComa. Furthermore, inflammatory cells such as lymphocytes, plasma cells and eosinophils were seen, which has not been reported. It is important to perform careful follow-up observation and accumulate case reports.

Case 1: A 72-year-old male was pointed out as showing bilateral multiple nodules on chest CT. The nodules were positive for FDG-PET but transbronchial lung biopsy showed no evidence of malignancy. After 6-year observation, the nodules grew slowly, and the patient underwent VATS wedge resection of the left lower lobe. Pathologic analysis confirmed the diagnosis of pulmonary amyloidosis. Case 2: A 71-year-old male presented with a lobulated, well-defined nodule in the left upper lobe on chest CT. The nodule was positive for FDG-PET and suspected to be primary lung cancer. VATS left upper lobectomy was performed. We diagnosed this case as nodular pulmonary amyloidosis based on pathological findings.

A 50-year-old female who had undergone a hysterectomy 20 years earlier for a uterine myoma was admitted to a hospital because of dyspnea on exertion. This time, she was referred to our department because of shadows noted on a chest radiograph. Computed tomography revealed two shadows with clear borders, approximately 60 and 20 mm in diameter in the left upper and right lower lobes, respectively. Since malignancy could not be ruled out, we performed thoracoscopic right wedge resection and left pneumonectomy. The histological examination revealed a tissue image similar to that of a uterine myoma. Therefore, we diagnosed the tumor as a pulmonary benign metastasizing leiomyoma. Benign metastasizing leiomyoma is rare. It is important to check whether there is a history of uterine leiomyoma in female patients with multiple lung tumors.

A 19-year-old pregnant woman who had received treatment for juvenile rheumatoid arthritis with oral prednisolone (15 mg per day) since 13 years of age was referred to our hospital at gestational week 13 for prolonged cough that had persisted for one week. A chest radiograph showed right pneumothorax. A chest tube was inserted for drainage, and the air leak stopped within a couple of days. She recovered without additional treatment and was discharged from the hospital. However, the pneumothorax recurred at gestational week 15 and a chest tube was re-inserted for drainage. Chest computed tomography revealed pulmonary bullae in the right upper lobe. Video-assisted thoracoscopic lung resection of bullae was performed on gestational week 16 day 3 for prolonged air leakage. The postoperative course was uneventful and she was discharged on the 5th postoperative day. She experienced no recurrence of pneumothorax and delivered a healthy baby at gestational week 39 day 2. Video-assisted thoracoscopic surgery should be considered for pregnant women with pneumothorax after 16 weeks of gestation.

First and second brachial arch syndrome is a congenital disease characterized by deformities of the face, oral cavity, ears, and spine. Because multiorgan deformity including the upper airway is seen, it is difficult to treat patients with this syndrome who show respiratory complications. A 24-year-old woman who had been followed up for first and second brachial arch syndrome in another hospital complained of a high fever and appetite loss in September 2019. Although antibiotics had been administered for three days, the symptoms showed no improvement. Therefore, she was referred to our hospital. A chest radiograph showed right massive pleural effusion and she was diagnosed with acute empyema by enhanced computed tomography (CT). Video-assisted thoracic surgery (VATS) was performed immediately. Because she had an uncomplicated postoperative course, she was discharged on the 10^th postoperative day. We report treatment for a patient with acute empyema and first and second brachial arch syndrome.

A 67-year-old man was referred to our hospital because of pain in his right shoulder and chest. Radiological findings showed a well-circumscribed tumor located in the right first intercostal space. The tumor was extirpated via video-assisted thoracic surgery. The pathological diagnosis was a desmoid tumor. Although all symptoms disappeared after the surgery, the surgical margin was considered to be positive. To prevent local recurrence of the tumor, adjuvant radiotherapy of 60 Gy was carried out. Although desmoid tumors are histopathologically benign tumors, they can aggressively invade the surrounding tissue, and so they tend to recur. Since desmoid tumors are located in higher intercostal spaces, the treatment strategy should carefully consider the important surrounding organs and postoperative quality of life.

The patient was a 64-year-old woman who had received treatment for tuberculous pleurisy. A tumor was located from the right tenth intercostal space to the subcutaneous area. Incisional drainage was performed. We diagnosed the patient with chest wall tuberculosis by PCR amplification. Since flushing and antibiotics were ineffective and the wound did not close spontaneously, we performed partial resection of the 11^th rib and wide debridement of the abscess. However, the wound was reopened for surgical site infection with MRSA. We started negative pressure wound therapy (NPWT) for drainage and wound healing. The wound margin was shrunk by NPWT, and closed without a muscle flap procedure. No local relapse has been observed for about six years.

A 70-year-old woman was admitted to our hospital with progressive pain and swelling on the left costal arch. Computed tomography (CT) revealed a 12-cm osteolytic mass with calcification arising from the left 6th rib. In addition, computed tomography (CT) suggested that the mass had invaded the liver and stomach. Magnetic resonance imaging (MRI) showed a high-intensity mass in a T2-weighted image, and there was a space between the mass and stomach and liver, suggesting that the invasion of organs in the abdominal cavity was unlikely. Chondrosarcoma of the rib was suspected based on image studies and she underwent surgery. The tumor was resected along with partial resection of the 5th to 8th left ribs, sternum, and diaphragm to achieve a 3-cm margin. Intraoperative diagnosis of chondrosarcoma was made with frozen-sectioning, and cut-ends revealed no malignancy. Microscopic examination showed atypical tumor cells with a proliferating cartilage matrix, and the tumor was diagnosed as a chondrosarcoma of the ribs with surgical ends negative for malignancy. Since chondrosarcoma is less sensitive to chemotherapy and radiotherapy, wide surgical resection is the first-line treatment. We report a case of primary chondrosarcoma that originated in the rib and was treated successfully by surgery.

A 79-year-old man was found to have an abnormal shadow on chest computed tomography (CT) during follow-up of IgG4-related disease (IgG4-RD). A 30-mm ground-glass opacity nodule in segment 2 of the right lung was observed, which showed an increase over time, bronchoscopy was performed, and the nodule was diagnosed as adenocarcinoma by biopsy. The nodule showed positive uptake (SUVmax 2.0) upon FDG-positron-emission-tomography (PET). He underwent a right upper lobectomy and lymph node dissection by video-assisted thoracic surgery. The histopathological diagnosis was pT2aN0M0, stage IB, and in the background lung, marked fibrosis and infiltration of lymphocytes and plasma cells were observed, and IgG4-positive plasma cells were also confirmed. The background lung was diagnosed with IgG4-related respiratory disease (IgG4-RRD). The tumor also showed infiltration of plasma cells and IgG4-positive plasma. Postoperative adjuvant chemotherapy was not performed, but the patient has been alive for a year and a half without recurrence.

A 56-year-old man was admitted with complaints of mild left shoulder pain and dyspnea. He had a medical history of surgery for bilateral metachronous spontaneous pneumothorax. A chest radiograph showed mild left pneumothorax and pneumopericardium. Chest CT showed multiple bulla in the left upper lobe, and free air in the pericardium. The patient was diagnosed with postoperative recurrence of left spontaneous pneumothorax with a congenital pericardial defect. In cases of persistent pulmonary fistula or empyema after lung resection, treatment is difficult. Therefore, we performed surgery for the pneumothorax with closure of the pericardial defect. Intraoperatively, a 3×2 cm pericardial defect was found on the ventral side of the main pulmonary artery. We closed the defect using a pericardial fat pat and resected the bulla by video-assisted thoracic surgery. Asymptomatic congenital pericardial defects do not necessarily require surgical intervention in general. We report surgical cases of spontaneous pneumothorax with congenital pericardial defects in Japan.