Chest tubes have been routinely placed in patients undergoing lung resection; however, it may increase pain and cost. Postoperative air leakage is not common in minimally invasive surgery such as video-assisted thoracic wedge resection, leading to the view that it may be possible to omit the chest tubes in some patients. The aim of this study was to evaluate the safety and effectiveness of omitting chest tubes after video-assisted thoracic wedge resection. A retrospective review of medical records was performed involving patients undergoing video-assisted thoracic wedge resection. In the 56 patients showing no air leakage before closing the incision, we omitted chest tubes in 43 patients (drainage-free group) and placed them in 13 patients (drainage group). The patients in the drainage group showed significantly poorer FEV1/FVC. Chest radiograph after surgery showed more subcutaneous emphysemas in the drainage-free group; however, all of them were mild and the patients were cured without any treatment such as aspiration or placement of a chest tube in both groups. The median length of hospital stay was shorter in the drainage-free group, although there were no significant differences. Omitting chest tubes may be feasible in some patients undergoing video-assisted thoracic wedge resection.

Pulmonary benign metastasizing leiomyoma (BML) is a rare disease in which a benign uterine leiomyoma metastasizes to the lung. We herein report a clinicopathological study of 10 cases. The median interval between hysterectomy and lung resection for pulmonary nodules was 114 months (range: 15-240 months). The median tumor size was 11 mm (range: 5-16 mm). While nine patients with multiple nodules underwent wedge resection, one was treated with lobectomy. Hormonal treatment was administered to 3 patients with residual lesions and 1 patient as adjuvant therapy. During the follow-up periods (range: 26-192 months, median: 105 months), seven patients were alive with disease and two without evidence of disease. One patient died of systemic metastases due to atypical leiomyoma diagnosed by reviewing uterine and pulmonary specimens. Diagnostic, surgical, and therapeutic problems associated with this disease were discussed.

A 61-year-old woman presented with a 44-mm well-circumscribed tumor in the anterior mediastinum on chest computed tomography. ¹⁸F-Fluorodeoxyglucose positron emission tomography showed a high-level accumulation of ¹⁸F-Fluorodeoxyglucose (standardized uptake value: 12.07). She underwent thymectomy with combined resection of partial pericardium. Histopathological findings showed that the tumor was a thymic mucinous adenocarcinoma (pT2N0M0 Stage II, and Masaoka stage III). After receiving adjuvant radiotherapy, she was in good health without any tumor recurrence at 6 months after surgery.

The patient was a 33-year-old female. She was pointed out as showing an abnormal shadow in the left upper pulmonary field in a chest roentgenogram on annual screening. Chest CT showed a cystic lesion in the left lung upper lobe suspected to be a bronchogenic cyst. She was followed-up because she presented with no symptoms. She visited a hospital because of fever, back pain, and bloody sputum 5 years before the surgery. She was diagnosed with bronchial cystic infection and pneumonia, and was treated with an antimicrobial agent. However after that, cystic infection and relatively severe pneumonia requiring hospitalization repeated 4 times in 3 years. She was referred to our hospital for further examination and treatment. Chest CT revealed a cystic mass in the left lung upper lobe. Chest CT also suggested adhesion to the left subclavian artery, aortic arch, and main pulmonary artery. Then, we performed left upper division segmentectomy using indocyanine green to determine the intersegmental plane via anterolateral thoracotomy. The postoperative diagnosis was a bronchogenic cyst. Here, we report a patient with a left lung upper lobe bronchogenic cyst treated by left upper division segmentectomy.

Case: An 80-year-old woman with left lung cancer underwent thoracoscopic partial resection after virtual-assisted lung mapping. A left-sided double-lumen tube (DLT; 35 Fr) provided intraoperative ventilation for 110 min. Resistance occured behind the vocal cords during intubation, making it difficult to place the DLT in the left main bronchus. Hoarseness and dyspnea were observed on postoperative day 1. Her symptoms worsened, and she was diagnosed with subglottic stenosis. We administered systemic steroids and inhalation of adrenaline through a tube inserted to the cricothyroid ligament. Subglottic stenosis gradually improved, and the tube was removed on postoperative day 8. Subglottic stenosis after operative DLT insertion is a rare complication; however, it should be clearly understood and appropriately managed.

An inflammatory pseudotumor (IPT) is an uncommon lesion composed of spindle cell (resembling myofibroblastic cells) proliferation and inflammatory cell infiltration with lymphocytes and plasma cells. An inflammatory myofibroblastic tumor (IMT), which had been included in IPT, is predominantly composed of myofibroblastic cells and has a malignant phenotype. Preoperative diagnosis is often difficult due to the lack of specific radiographic findings and an insufficient amount of tissue needed for diagnosis. We report two cases of IMT and one case of IPT. Case 1: A 30-year-old female had right hypochondrial pain. Computed tomography (CT) showed a 7.8 cm mass on the right diaphragm. A solitary fibrous tumor was suspected and resected. The postoperative pathological diagnosis was IMT. Case 2: A 58-year-old female. Post-surgical follow-up CT of breast cancer revealed a 1.4 cm nodule in the right lower lobe of the lung. It was suspected to be primary or metastatic lung cancer, and lower lobectomy was performed. The pathological diagnosis revealed IMT. Case 3: A 60-year-old female had an abnormal shadow pointed out in her health check-up. CT showed a 3.5 cm irregular mass in the right lower lobe of the lung. The preoperative diagnosis was IMT by CT-guided lung biopsy and lower lobectomy was performed. The pathological diagnosis of resected specimens was IPT. In all 3 cases, we could diagnose patients after resection.

The approach for surgical resection of a tumor developing in the thoracic apex may affect surgical invasiveness and possible occurrence of postoperative neurological dysfunction. A 44-year-old female was referred to our hospital due to a tumor shadow in the right apical region found on a chest radiograph. Magnetic resonance imaging findings suggested that it was a benign tumor including a schwannoma. Because of enlargement over time, surgery was performed. Narrow band imaging was useful to identify nerves and the capsule of the tumor. Therefore, subcapsular resection by a thoracoscopic approach with narrow band imaging could help avoid postoperative neurological dysfunction.

A 70-year-old man was being followed up after surgery for cancer of the ascending colon. Computed tomography revealed a nodule in the lower lobe of the right lung, enlarged hilar and mediastinal lymph nodes, and a nodule in the right hepatic lobe. Biopsy of the pulmonary nodule revealed primary lung cancer. Curative lung resection and hepatectomy were scheduled. In the lung, right lower lobectomy along with hilar and mediastinal lymph node dissection was performed. Histopathological findings showed that 90% of the tumor comprised primary lung adenocarcinoma cells, while 10% of the tumor comprised high columnar adenocarcinoma cells within the main tumor. Immunohistochemical staining of the primary lung adenocarcinoma was positive for TTF-1 and CK7 but negative for CK20 and CDX2. On the other hand, immunohistochemical staining of the high columnar cells was positive for CK20 and CDX2 but negative for TTF-1 and CK7. The main tumor was diagnosed as primary lung cancer pT2aN2M0, stage IIIA, and the part comprising high columnar cells was diagnosed as metastatic colorectal cancer within the primary lung cancer. The resected liver tumor was diagnosed as colorectal liver metastasis. The patient received adjuvant chemotherapy for lung cancer but died of lung cancer within 22 months.

We report a case of simultaneous lung metastatic resection and diaphragmatic plication for dyspnea after combined resection of the phrenic nerve for a thymoma and metastatic resection.

A 69-year-old woman had undergone combined resection of the right phrenic nerve for an invasive thymoma 3 years ago. Two years after the operation, left lung metastasis and bilateral pleural dissemination were observed, so left lower lobe partial resection and bilateral pleural dissemination resection were performed. The patient suffered from dyspnea in a supine position after the operation, so she required the use of non-invasive positive pressure ventilation. A year later, a new right lung metastasis was observed. Right lower lobe partial resection was performed with right diaphragmatic plication simultaneously to prevent exacerbation of respiratory distress. Postoperatively, dyspnea in a supine position markedly improved, and it became possible to sleep in a supine position without using non-invasive positive pressure ventilation. For the 8 years since the operation, no recurrent lesions or exacerbations of respiratory symptoms have been observed.

In the presence of phrenic nerve palsy, chest surgery should be considered for possible postoperative dyspnea. A surgical approach should be designed to minimize damage to the respiratory muscles, and if postoperative dyspnea is a concern, consideration should be given to performing diaphragmatic plication simultaneously.

An asymptomatic 70-year-old woman had undergone an extended thymectomy 13 years previously, and video-assisted left pleurectomy was performed for the disseminations of thymoma. Four months after discharge, she presented with persistent diarrhea. Colonoscopy revealed geographic ulcerative lesions from the cecum to ascending colon. A biopsy specimen showed inclusion bodies in the cell nuclei. Laboratory studies showed hypogammaglobulinemia. A diagnosis of Good's syndrome was established after the onset of cytomegalovirus enteritis. Preoperative evaluation of the immune status for recurrent thymoma should be conducted because the patients may have subclinical immunodeficiency.

We report a case of late recurrence of breast cancer with metachronous oligometastases to the bilateral lungs. A 66-year-old woman was referred to our department due to a slow-growing tumor in the left lung. She underwent breast-conserving surgery and axillary dissection for left breast cancer at the age of 45 and upper lobectomy of the right lung for breast cancer metastasis at the age of 55. Subsequently, the patient developed local recurrence in the left breast at the age of 63. Preoperative chest CT examination for the second breast surgery revealed a small solitary nodule in the upper lobe of the left lung that had grown gradually for three years. With a suspicion of primary lung cancer or pulmonary metastasis, wedge resection under video-assisted thoracoscopic surgery was performed to make a definite diagnosis. The histopathological findings of the resected specimen were consistent with adenocarcinoma that was immunohistochemically positive for ER and negative for TTF-1 and Napsin A. Based on the study, we diagnosed the lung tumor as pulmonary metastasis from breast cancer. Even for metachronous oligometastatic breast cancer with a long disease-free interval, surgery would be feasible if complete resection could be achieved in each stage.

Postoperative air leakage is one of the most common complications after lung resection. Intractable cases due to micro bronchopleural fistula occasionally require reoperation or bronchial embolization. We report a case of intractable air leak after segmentectomy in a patient with rheumatoid disease. A 62-year-old man had been treated for rheumatoid disease by tofacitinib. He developed acute empyema with a fistula after undergoing examination for an abnormal shadow. Computed tomography demonstrated a mass shadow with bronchodilation in the right upper lobe of 49 mm in diameter. Although the causative bacteria were not identified, his disease was diagnosed as a lung abscess. We performed segmentectomy for the lesion. Postoperative air leakage had been prolonged, but we could not identify a micro bronchopleural fistula on reoperation. Air leakage continued after the reoperation. We added omental implantation and performed bronchial embolization using an Endobronchial Watanabe Spigot and cyanoacrylate multiple times. This paper reports a difficult case of controlling postoperative air leakage. Wound healing was poorer than usual, and this case showed a rare clinical course. Tofacitinib may affect wound healing beyond the recommended washout period.

Cholesterol granuloma is a benign lesion that develops in response to reactions of foreign-body giant cells to cholesterol crystals. This is a well-recognized condition affecting the middle ear and paranasal sinuses.

We report a rare case of an incidental cholesterol granuloma in the thymus of a 52-year-old man. Computed tomography showed a 23-mm nodule with calcification in the anterior mediastinum. Based on imaging findings, thymoma was suspected, and thoracoscopic thymectomy was performed for diagnosis and treatment. Histological findings indicated cholesterol granuloma in the thymus.

Cholesterol granuloma occurring in the thymus is often difficult to differentiate from thymoma or malignant tumor. This case is accompanied by findings suggestive of hemorrhage in the histopathology, suggesting the possibility of cholesterol granuloma formation as a result of hemorrhage. By comparing the present case with previous reports regarding the cause of cholesterol granuloma and imaging findings, we discussed findings that may help to differentiate cholesterol granuloma in the anterior mediastinum.

We report a patient who developed severe Clostridioides (formerly Clostridium) difficile infection (CDI) after lung cancer surgery. A 71-year-old female patient with lung cancer underwent a thoracoscopic left S¹⁺² segmentectomy. Antibiotics were administered until the 7th postoperative day (POD) due to placement of a chest drain for persistent air leakage. She was discharged on the 8th POD, but her left lung collapsed slightly and pleurisy was suspected. Antibiotic therapy was restarted on the 13th POD. On the 19th POD, she had watery stools and vomiting, and was diagnosed with CDI based on CD toxin positivity. Despite severe CDI, the patient was successfully cured by intensive care management with vancomycin and metronidazole. The risk of CDI is high for immunocompromised individuals such as the elderly and cancer-bearing patients. Although reports of CDI after thoracic surgery are rare compared with those after digestive and orthopedic surgeries, given the increase in lung cancer surgery for the elderly with underlying illnesses and the commonization of segmentectomy, closer attention to the appropriate use of antibiotics and perioperative management is necessary.

A 69-year-old man presented to the clinic with an abnormal shadow in the chest that was revealed by a roentgenogram. Computed tomography (CT) revealed a 40-mm tumor located in the left upper mediastinum, displacing the trachea to the right side. There was no tumor invasion of the tracheal mucosa based on bronchoscopy. He was diagnosed with schwannoma, and surgical resection was planned. We decided to perform median sternotomy for tumor resection. The tumor was located between the brachiocephalic trunk and left common arteries, and there was tracheal displacement toward the right side. It originated from and encased the recurrent laryngeal nerve. The neural epithelium was dissected under continuous neuromonitoring, and the tumor between the capsules was resected. He did not experience hoarseness and was discharged from the hospital on the eighth postoperative day. The patient was well without tumor relapse at twelve months postoperatively. Intraoperative neurostimulation and neuromonitoring approaches for the intracapsular resection of a schwannoma originating from the recurrent laryngeal nerve are recommended because these may reduce the risk of neural injury.

This case involved a 74-year-old female. A year ago, an anterior mediastinal tumor, suspected of being a thymoma, had been noted on computed tomography (CT). Eight months ago, the patient developed hepatitis B. While under hepatitis B treatment, anemia was also diagnosed. After further examination, the patient was diagnosed with pure red cell aplasia (PRCA). Four months ago, the anemia progressed to the point that the patient needed a weekly 2-unit red blood cell transfusion. Although the anterior mediastinal tumor had not grown on CT re-examination, the patient was admitted for surgical resection of the tumor in order to improve the anemia. The patient underwent extended thymothymectomy via a median sternotomy. Upon histological examination, the resected tumor was diagnosed as type AB thymoma (WHO classification) and Masaoka stage II. The postoperative course was uneventful. Two months after surgery, the anemia went into remission, negating the need for blood transfusion and immunosuppressive therapy. No recurrence of symptoms has been noted in the 18 months since surgery. The optimal management of thymoma-associated PRCA remains unclear. We report a patient with pure red cell aplasia with thymoma who was successfully treated by extended thymothymectomy alone.

A 36-year-old woman was referred to our hospital with a diagnosis of right pneumothorax during menstruation. Although pneumothorax was mild and it was the first episode, surgical treatment was selected in consideration of future fertility treatment hopes. Thoracoscopy during the next menstrual cycle revealed the presence of diffuse, disseminated blueberry lesions on the parietal pleura, visceral pleura, and diaphragm. The middle lobe containing the visible lesion was partially excised for diagnosis.

The cut end and diaphragm surface were covered with a polyglycolic acid sheet. Pathologically, the diagnosis was associated with catamenial pneumothorax including findings of immunostaining. On the 2nd postoperative day, adhesion therapy was performed to prevent recurrence, which has not been observed for the past two and a half years. Pathologically diagnosed catamenial pneumothorax is rare, and this time we confirmed disseminated endometrial tissue under thoracoscopic surgery in a woman desiring future fertility treatment, and pathologically proved and treated it.

Resection of apical chest tumors is difficult because they are usually adjacent to major vessels and the brachial plexus. The transmanubrial approach can provide good exposure of the thoracic outlet and preserve shoulder movement. However, visualization of the dorsal and caudal sides of the tumor is poor, especially in cases of large tumors. Herein, we present the case of a large apical schwannoma resected using the transmanubrial approach combined with video-assisted thoracoscopic surgery. A 48-year-old man with an apical chest tumor measuring 8 cm on his right superior mediastinum was referred to our hospital. The tumor was compressing the subclavian vessels and was suspected to be a schwannoma arising from the brachial plexus. The transmanubrial approach was adopted, and the tumor was dissected from the vessels and nerves. We inserted a thoracoscope through the third intercostal space, which provided good visualization of the dorsal and caudal sides of the tumor and facilitated its successful resection. The transmanubrial approach combined with video-assisted thoracoscopic surgery is a safe and less invasive procedure for large apical chest tumors.