We examined 15 cases of spontaneous hemopneumothorax that we encountered at our hospital from April 2006 to December 2018. The average time from diagnosis to surgery was 28.3 hours (2-87 hours). The surgical approaches were thoracoscopically assisted in 13 cases, combined with a small thoracotomy and 3 PORT thoracoscopic procedure in 2 cases. In all cases, the bleeding site was from the cord containing the blood vessels of the pleural wall of top of the chest cavity, and the average total bleeding volume from pre- to intraoperative periods was 1,298 mL (200-2,670 mL). Blood transfusion was required in 4 cases, with 2 involving symptoms of shock before the surgery. The chest drain was removed at an average of 3.1 days (2-7 days) postoperatively, and the average postoperative period was 5.4 days (3-8 days). In 5 cases, multiple bleeding sites were confirmed, and detailed observation inside the chest cavity was important. Spontaneous hemopneumothorax is associated with a high risk of hemorrhagic shock and is considered an indication for emergency surgery, and detailed intrathoracic observation is important.

We report a case of phrenic nerve schwannoma with extensive cystic degeneration. A 27-year-old female was admitted for an abnormal shadow on a chest radiograph. Chest CT showed a 30-mm-diameter, round, heterogeneous mass with thin wall adjacent to the left brachiocephalic artery and aortic arch, and chest MRI showed a cystic mass. We suspected a thymic cyst, but could not rule out a neoplastic lesion. We performed video-assisted thoracoscopic surgery. The tumor adjoined the left phrenic nerve, but it revealed a uniloculated cyst and there was no hypercellular area based on macroscopic findings. We resected the tumor, preserving as many neuron fibers as possible, because the pathological diagnosis during surgery was a cyst. The postoperative pathological diagnosis was schwannoma. Sufficient attention for wall thickening and signs of invasion is necessary when deciding on the surgical indication and excision range.

Traumatic diaphragmatic hernia is caused by major blunt or penetrating trauma with prolapse of abdominal organs into the thoracic cavity. Surgical repair should be performed immediately due to the risk of intestinal necrosis. Postoperative recurrence is a rare clinical condition. We report a case of recurrent traumatic diaphragmatic hernia due to a puncture wound caused by Taeniurops meyeni. A 47-year-old woman was stung on the left side of the chest by Taeniurops meyeni 4 years ago. She was transported to an emergency department in a state of hypovolemic shock. She received thoracic drainage under the diagnosis of traumatic hemopneumothorax. Six months later, she complained of shoulder pain. Radiological finding showed diaphragmatic hernia, and laparoscopic surgery was performed. Two years later, she presented with left chest pain and computed tomography (CT) demonstrated recurrence of the diaphragmatic hernia. The hernia orifice was repaired by suturing and setting a mesh under laparoscopy again. This year, she complained of shoulder pain, and CT revealed re-recurrence of the diaphragmatic hernia. Then, she was referred to our institution. Intraoperative abdominal findings revealed that the omentum had entered the thoracic cavity through a crack in the mesh. We repaired the hole by suturing from the thoracic cavity and reinforcing with fixed-mesh from the abdominal cavity. This report demonstrates that an approach from both the thoracic and abdominal cavities is effective to resolve recurrence of a traumatic diaphragmatic hernia.

A 24-year-old man was referred to our hospital for the treatment of a left spontaneous pneumothorax and hyperthyroidism. Chest computed tomography revealed heart prolapse into the left thoracic cavity, and a congenital defect of the pericardium was suspected. Chest drainage was performed and treatment for the untreated hyperthyroidism was started. Air leakage persisted 1 week after admission. Although minimally invasive therapy was adequate to reduce the risk of a thyroid crisis, pleurodesis was not an option due to the congenital defect of the pericardium. Therefore, a thoracoscopic bullectomy was performed. During surgery, complete defects of the pericardium and left mediastinal pleura were noted. Because of the complete defect of the pericardium and limited pulmonary resection, the risk of incarceration of the heart was considered low. Therefore, no repair was performed. The post-operative course was uneventful.

Esophageal rupture is one of the representative diseases causing chest pain. Its diagnosis is very difficult and misdiagnosis can be fatal. A 50-year-old man, who ate a voluminous bowl of rice with a pork cutlet in the morning, was transported to our hospital because of back pain after vomiting at night. He had been receiving hemodialysis treatment due to focal glomerulosclerosis. Chest CT revealed left pleural effusion with a small air space and stomach dilatation due to its full contents. He was admitted, and in the early morning of the next day, he suddenly developed respiratory acidosis. He entered the ICU, was intubated, and started CHDF immediately. Thoracic drainage was performed, and dark green pleural effusion with a total volume of 1 liter was noted. Retrospective CT revealed an air space next to the esophagous. We made a diagnosis of esophageal rupture. Clipping of the ruptured esophagal part using a gastroscope was performed by a gastroenterologist on the 3rd hospital day. The endobronchial tube was removed on the 4th hospital day. After that, CT-guided percutaneous thoracic drainage failed, and VATS pleural curettage was performed on the 13th hospital day. The onset of postoperative chylothorax was noted, and treatment with a low-fat diet and octreotide was successful. The chest tube was removed on the 13th postoperative day and he was discharged on the 14th postoperative day.

Pulmonary alveolar proteinosis (PAP) is a disease in which surfactant accumulates in the alveoli. On computed tomography (CT), it presents as a crazy-paving pattern of bilateral diffusely thickened interlobular septa and intralobular structures from the hilar to peripheral regions. Here, we report a rare case of localized middle lobe PAP. A 59-year-old man visited our department for the diagnosis and treatment of a middle lobe ground glass nodule (GGN) that had increased in size compared with the CT findings 5 years ago. CT showed a 13-mm part solid GGN in the subpleural area and a 10-mm GGN near the hilum of the middle lobe. The patient underwent thoracoscopic right middle lobectomy because multiple lung cancer was suspected. The histopathologic examination revealed PAP. The present case of localized GGN growing in a subpleural area and in the middle lobe was considered to be a rare type of PAP.

We report two cases of septic arthritis of the sternoclavicular joint with pleural empyema. Case 1. An 78-year-old female with rheumatoid arthritis suffered from SASCJ and secondary empyema. We performed curettage of the clavicle and manubrium of the sternum, decortication of the pleural cavity, and primary wound closure using a pectoralis major flap. The causative organism was Mycobacterium tuberculosis. Case 2. A 70-year-old female with diabetes mellitus suffered from SASCJ after decortication of the pleural cavity due to empyema. We performed curettage of the clavicle and manubrium of the sternum and primary wound closure using a pectoralis major flap. The causative organism was Staphylococcus aureus. SASCJ with pleural empyema is a rare entity, but early diagnosis, systemic examination of the infection area, and making a quick decision regarding the strategy are essential in treatment.

A 71-year-old man complaining of right chest pain was admitted to the Department of Orthopedic Surgery in our hospital. Computed tomography (CT) showed osteolysis of the right 8^th rib. Because a bone tumor was suspected, he was referred to the Department of Thoracic Surgery. Partial resection of the right 8^th rib was performed for the purpose of a definitive diagnosis. Histopathological findings revealed Langerhans cell histiocytosis (LCH). We report a rare case of LCH that originated from a single rib with an adult onset.

We herein report a case of epipericardial fat necrosis (EFN) showing spontaneous regression. A 50-year-old woman was admitted to the emergency department of a nearby hospital due to the sudden onset of pleuritic pain, but the cause could not be identified. Chest CT performed six days after the onset at the second hospital revealed an ovoid lesion with fat attenuation surrounded by a thick rim inside the left epipericardial fat, accompanied by pleural effusion and pericardial thickening. These findings led to examination for inflammatory processes such as pleuritis. On chest CT performed nine days after the onset, the encapsulated fat-density mass remained without any marked changes except for the disappearance of pleural effusion. Follow-up CT performed four weeks after the onset demonstrated resolution of the epipericardial fat lesion. Clinical and serial CT findings, together with the benign and self-limited nature, were consistent with the diagnosis of EFN. EFN is a self-limited disease, and conservative treatment is indicated. However, the lack of information on this clinical entity might contribute to underdiagnosis. Awareness of these clinical features is important to make a correct diagnosis and avoid unnecessary surgical interventions.

Primary pulmonary myxoid sarcoma (PPMS) is an extremely rare low-grade sarcoma characterized by the EWSR1-CREB1 fusion gene newly included in the latest World Health Organization classification. The patient was a 44-year-old male. Computed tomography showed a 2.1-cm-diameter solid nodule in the left superior segment (S6), and left S6 segmentectomy was performed. Histopathological examination revealed a multinodular and lobular tumor. This tumor was composed of polygonal and spindle cells within a prominent myxoid stroma. Fluorescence in situ hybridization revealed clear signal separation within the tumor, demonstrating the presence of EWSR1 gene rearrangement. Although EWSR1-CREB1 gene fusion was not confirmed by reverse transcription-polymerase chain reaction, the tumor was diagnosed as PPMS based on the typical histological findings of PPMS and presence of EWSR1 gene rearrangement.

A limited number of PPMS cases have been reported. Here, we report a case of PPMS along with a literature review.

A 65-year-old woman visited a family doctor for hemoptysis. She was suspected to have bleeding due to an infectious pulmonary cyst and was treated with antibiotic agents. She developed hemoptysis again three months later. Therefore, she was treated with hemostatic and antibiotic agents. However, because the cause of hemoptysis was unknown, she was referred to our department. Video-assisted thoracoscopic S6 segmentectomy of the left lung was performed. Pathologically, was noted a cavity lesion accompanied by pulmonary laceration. Although hemoptysis due to pulmonary cysts can be caused by various factors, the hemoptysis was suspected to occur in a pulmonary cyst, but pathologically it was determined as due to a pulmonary laceration. However, the cause of the pulmonary laceration remains unclear. Pathological diagnosis of this lesion was difficult.

A 61-year-old male underwent a right middle lobectomy for lung cancer. During the operation, two pieces of TachoSil^® sealant sheets were used, one approximately 1 cm² and the other approximately 22 cm² placed one hour later. Approximately 10 minutes after use of the second sheet, the systolic blood pressure dropped sharply to about 40 mmHg, the response to vasopressor administration was poor, and the low blood pressure state continued. No active bleeding was observed in the operative field, while flushing and rash were observed on the face, neck, and upper arm. Thus, it was diagnosed as anaphylactic shock. We considered that TachoSil^® was the causative agent; thus, both sheets were removed and the attachment areas were lavaged with saline. After about 10 minutes, the blood pressure was restored and response to the vasopressor was improved. A drug-induced lymphocyte stimulation test (DLST) was positive. Therefore, we concluded that anaphylactic shock due to TachoSil^® use had occurred in our patient during surgery. TachoSil^®-induced anaphylactic shock is very rare, and we report this case to alert surgeons to its possible occurrence.

The patient was an 88-year-old female, who had been treated with total thyroidectomy and radiotherapy for anaplastic thyroid carcinoma transformed from papillary carcinoma (pT4aN0M0 stageIVA) 5 years previously. She was found to have a suspicious malignant pulmonary nodule in the right middle lobe, primary lung carcinoma, or metastasis of thyroid carcinoma, because of high accumulation of FDG in a FDG-PET study. It was difficult to make a pathological diagnosis by trans-bronchial lung biopsy or CT-guided lung biopsy since the nodule was small and located in the peripheral lung lesion. Thus, we performed video-assisted thoracic surgery (VATS) right middle lobectomy for diagnosis and treatment. Finally, the pathological diagnosis was metastasis of papillary thyroid carcinoma and no anaplastic carcinoma cells were observed. Anaplastic thyroid carcinoma is relatively rare and the prognosis is extremely poor. We present a long-term survival case of anaplastic thyroid carcinoma with an interesting clinical course.

We report two cases of postoperative bronchopleural fistula successfully treated by intrabronchial omentoplasty. Patient 1 was a 70-year-old man with diabetes. He underwent right lower lobectomy for lung cancer (cT1N1M0 cStage IIB). On the 20^th postoperative day, in an outpatient setting, CT revealed bronchopleural fistula. Bronchoscopy showed edematous change of the intermediate bronchus. To avoid additional right middle lobectomy, we performed intrabronchial omentoplasty after debridement. Patient 2 was a 68-year-old woman who was a current smoker. She underwent right lower lobectomy for lung cancer (cT2aN0M0 cStage IB). On the 5^th postoperative day, she received re-operation because of postoperative air leak. On the 14^th postoperative day, she had chest pain and chest CT revealed bronchopleural fistula. Bronchoscopy showed necrotic and ischemic change of the intermediate bronchus close to the bottom edge of the upper lobe bronchus. After debridement with additional right middle lobectomy, we performed intrabronchial omentoplasty to avoid completion pneumonectomy.

Intrabronchial omentoplasty for postoperative bronchopleural fistula is an effective treatment technique to avoid additional lobectomy or completion pneumonectomy in selected patients.

A 26-year-old man with an abnormal lesion on a chest radiograph taken during a medical check-up was admitted to our hospital. Because plain computed tomography (CT) showed an aberrant vessel in the left lower lobe and increased permeability of a part of the left basal segment, he was referred to the Department of Thoracic Surgery. By enhanced CT, he was diagnosed with intralobar sequestration with an aberrant artery arising from the celiac artery. Subsequently, we performed separation of the aberrant artery and resection of the sequestered lung with video-assisted thoracic surgery. He was discharged on the 7^th postoperative day. We report a relatively rare case of intralobar sequestration with an aberrant artery arising from the celiac artery.

We report the case of a 41-year-old female with congenital bronchial atresia (CBA) in whom extensive inflammation led to incomplete lobulation. Her past medical history involved recurrent pneumonia in childhood. Chest MDCT showed B2 occlusion by the mucocele, and inflammatory changes were extensive in the peripheral lung fields of S2 and a part of the middle lobe, leading to incomplete lobulation of the lobes. We diagnosed her with CBA. We performed surgical treatment to prevent recurrent infectious pulmonary complications and long-term lung alteration. It was difficult to approach the interlobular fissure because the right upper lobe and middle lobe were indurated by chronic inflammation. Using a fissureless technique, we performed right upper lobectomy and partial resection of the middle lobe in accordance with preoperative simulation by MDCT. The postoperative course was uneventful. She has remained under follow-up for 2 years with no recurrence. The incomplete lobulation and chronic recurrent inflammation in CBA make surgery approaching an interlobular fissure difficult. Images by MDCT are important to diagnose CBA, evaluate preoperative inflammation, and simulate the operation carefully.

The incidence of primary adenoid cystic carcinoma of the lung is low, reported to be between 0.04 and 0.2% of all primary lung cancers. A good prognosis can be expected with complete resection. However, caution is required as this tumor is associated with a high risk of peribronchial submucosal infiltration and perineural invasion. We pathologically examined proximal peribronchial invasion of primary adenoid cystic carcinoma of the lung in four patients who underwent complete resection at our hospital. The invasion areas predicted by preoperative bronchoscopy and intraoperative macroscopic findings were compared with the pathological findings. Complete pathological resection was achieved in all cases. Three patients underwent left pneumonectomy, and one patient underwent right sleeve bilobectomy. The tumors pathologically invaded the bronchus 10, 14, 15, and 15 mm more proximally than the pre- and intraoperatively expected areas. During the median 10-year observation period, no local recurrences were observed, but there were three distant recurrences. One patient died from the primary disease, while the other three survived. Primary lung adenoid cystic carcinoma tends to invade the bronchus more proximally than the macroscopic predictions. Therefore, it is essential to secure a resection margin of approximately 15 mm from the macroscopic lesion within the range that can be safely reconstructed and evaluate the bronchial stump by intraoperative frozen section analysis.

A 77-year-old man presented to his family doctor with complaints of palpitations and shortness of breath, and was diagnosed with an anterior mediastinal mass and pericardial effusion. Chest computed tomography revealed a 12-cm mass in the anterior mediastinum and suspected involvement from the left and right brachiocephalic veins (LBCV and RBCV, respectively) to the superior vena cava (SVC). Invasive thymoma was suspected, and surgical treatment was performed. Surgery was first conducted through a right posterior lateral incision. The tumor was macroscopically invasive in the pericardium and right upper middle lobe of the lung, so upper middle lobectomy of the right lung was performed. Median sternotomy was then carried out. From the central side of the SVC to LBCV and RBCV, it was difficult to peel away the tumor. Therefore, pericardiotomy was performed, and after bypassing the LBCV to the right atrium, LBCV, RBCV, and SVC underwent complicated resection along with the tumor. Subsequently, revascularization was performed. During revascularization, because of the presence of adhesions in the right ventricle, LBCV, RBCV, and SVC were reconstructed in a T-shape using expanded polytetrafluoroethylene grafts. The patient was discharged from the hospital 20 days after surgery, taking anticoagulant medication. No thrombus formation was observed as a late complication of the patient's revascularization.