We retrospectively investigated 1679 patients who underwent lung resection for lung cancer at our hospital between January 2009 and September 2019. Patients' median age was 66 years; the study included 956 men and 723 women. Fifty-one patients had a history of gastrectomy; postoperative pneumonia occurred in five patients (9.8%) with and in 21 patients (1.3%) without a history of gastrectomy (p = 0.001). Comparison between patients with and without postoperative pneumonia based on multivariate analysis revealed that a history of gastrectomy (p < 0.001) and lobectomy or extended resection (p = 0.040) were risk factors for postoperative pneumonia. A history of gastrectomy may be associated with the risk of postoperative pneumonia in patients who undergo lung resection for lung cancer. Considering the risk of postoperative pneumonia, careful perioperative management is warranted in patients with lung cancer and a history of gastrectomy.

We analyzed 60 patients with chest trauma requiring hospitalization at Yokosuka Kyosai Hospital from April 2013 to December 2018.

They included 20 cases of falling down (33%), 18 of traffic accident (30%), and 15 of falling from a height (25%).

Rib fractures were noted in 53 cases (88%), and the average number of fractured ribs was 3.7±2.2.

In 58 cases accompanied by hemothorax or pneumothorax, 42 required thoracic drainage, and 5 necessitated surgical repair (2 hemostasis, 1 air leak closure, 2 hemostasis and air leak closure).

The average length of hospital stay was 13.7 days. No patients died during hospitalization, and outcomes in our hospital were relatively good.

However, chest trauma is associated with a high mortality risk and some cases require surgical repair.

It is necessary to treat patients with thoracic injury appropriately, not only in the primary care setting but also during hospitalization.

Introduction: In Japan, owing to the medical insurance system, it is usually necessary to diagnose lung malignancy by intraoperative frozen section when performing robot-assisted thoracoscopic surgery (RATS) for patients without a preoperative diagnosis. In this study, we reviewed our RATS lobectomy cases to investigate the effect of the presence or absence of preoperative diagnosis on surgery.

Materials and Methods: This study included 48 patients who underwent RATS lobectomy between December 2018 and October 2021. The patients were divided into two groups: a non-Dx group, which contained 34 patients without preoperative diagnosis of lung malignancy, and a Dx group, which contained 14 patients with a preoperative diagnosis of lung malignancy.

Results: The median time from surgery commencement to the start of console use (pre-console time) was 49.0 (17-156) and 22.5 (13-45) min in non-Dx and Dx groups, respectively, being significantly longer in the non-Dx group (p < 0.05). Conversely, the median console time was 124 (57-318) and 171 (87-234) min in non-Dx and Dx groups, respectively, being significantly longer in Dx group (p < 0.05). Consequently, the median total operative time was 200.0 (126-418) and 221.0 (132-315) min in non-Dx and Dx groups, respectively, showing no difference between the two groups (p = 0.18). Furthermore, the mean number of stapler cartridges used was 6.5 (SD 1.9) and 5.9 (SD 1.3) in non-Dx and Dx groups, respectively, with no significant difference (p = 0.26).

Conclusions: There was little influence on the total operative time or number of stapler cartridges used, irrespective of the presence or absence of a preoperative diagnosis of lung malignancy. Thus, RATS lobectomy was considered possible in cases without a preoperative diagnosis with the same quality as that in cases with a preoperative diagnosis of lung malignancy.

A 53-year-old man was diagnosed with stage IV (cT2aN0pM1a) lung adenocarcinoma of the left lower lobe harboring an EGFR mutation. He was treated with gefitinib. He received molecular targeting drug therapy and chemotherapy, but the tumor increased in size. We performed left lower lobectomy with combined resection of the diaphragm as salvage surgery because he refused chemotherapy, requested salvage surgery, and no other metastasis was observed. The pathological stage was IIB (ypT3N0M0). He was treated with osimertinib after salvage surgery. One year after salvage surgery, liver metastasis was observed, and radiofrequency ablation was performed. Three years after salvage surgery, brain metastasis and mediastinal lymph node recurrence were observed. He underwent craniotomy, and received radiotherapy for mediastinal lymph node recurrence. Our findings suggest that salvage surgery offers long-term survival in some patients.

A 19-year-old man presented with persistent cough and fever, raising the possibility of pneumonia, and the symptoms improved with antibiotics. However, one week later, an abnormal shadow was noted in the right hilum, and he was referred to our department. Chest CT showed no continuity between the right B¹ and central bronchus, and the interrupted B¹ root communicated with a cystic lesion, 4.8 × 3.8 cm in size, with niveau located on the dorsal side of the tracheal bifurcation. In addition, V¹⁺²⁺³ flowed into the superior vena cava. The mass was diagnosed as bronchial atresia in communication with a mediastinal cyst with partial anomalous pulmonary venous return. The upper right lobe of the lung and mediastinal cyst were resected in a single mass because of repeated pneumonia considered to be caused by bronchial atresia. The diagnoses of mediastinal cyst and bronchial communication were confirmed on examination of the excised specimen, and the cyst was histopathologically diagnosed as an esophageal cyst. We report a rare surgical case of congenital bronchial atresia with an esophageal cyst and partial anomalous pulmonary venous return.

Pulmonary nocardiosis, a systemic infection that shows hematogenous dissemination, may occasionally result in a brain abscess. Pulmonary nocardiosis with extrapleural abscesses is rare. We report a case of pulmonary nocardiosis with brain and extrapleural abscesses mimicking malignant disease.

A 49-year-old woman with immunodeficiency secondary to immunosuppressive therapy for myasthenia gravis presented with high fever. She underwent computed tomography (CT), which revealed bilateral multiple pulmonary infiltrative shadows. Repeat CT performed 10 days later revealed multiple pleural nodules, and brain magnetic resonance imaging revealed a nodule (5 mm in diameter) in the left parietal lobe. We performed thoracoscopic thoracotomy for accurate and prompt diagnosis. Intraoperative findings confirmed that the pleural nodules were extrapleural abscesses. Bacterial culture studies of pus yielded a filamentous bacterium suggestive of Actinomycetes. Following genetic analysis, the organism was identified as Nocardia farcinica based on its 16S ribosomal DNA sequence, whose examination was conducted at Medical Mycology Research Center, Chiba University, and the strain was registered and preserved at the research center (#IFM 11783). Finally, the patient was diagnosed with pulmonary nocardiosis. Oral trimethoprim/sulfamethoxazole treatment was administered over 11 months postoperatively. Recurrence of nocardiosis was not observed over 2 years after treatment.

A 49-year-old man was admitted to our hospital with bloody sputum and chest pain. Computed tomography revealed bilateral multiple nodules, including a 54 × 43 mm cavity lesion in the left lung, a 119 × 87 mm mass with calcification in the posterior segment of the liver, and a right adrenal mass. Bronchoscopy was performed, but no diagnosis was made. Thoracoscopic left S5 partial lung resection was conducted for definitive diagnosis. The pathological diagnosis was echinococcosis. The patient was diagnosed with hepatic echinococcosis, bilateral multiple lung metastases, and right adrenal metastases. The liver and right adrenal mass were considered resectable. Lung resection preceded because the patient had respiratory symptoms. Partial resection was performed in two stages for multiple nodules in the right and left lungs. Posterior segmentectomy, partial S2 liver resection, cholecystectomy, and right adrenalectomy were performed later. All pathological findings indicated echinococcosis. Albendazole was administered after the diagnosis was confirmed, and its administration is still ongoing. A total of 12 years and 3 months have passed since the surgery, and no increase in residual lung lesions has been observed.

Thymic lymphoepithelial carcinoma (LEC) has been classified as a subtype of thymic carcinoma, and has pathological features similar to those of lymphoepithelioma, an undifferentiated type of nasopharyngeal carcinoma. It has been reported that thymic LEC is a rare tumor, accounting for 6% of all thymic carcinomas. We herein describe a resected case of thymic LEC.

A 68-year-old man was referred to our hospital with an anterior mediastinal tumor that had been found on computed tomography (CT) during a medical checkup. The tumor size on the initial CT was measured at 10 mm, and follow-up CT after 6 months showed slight enlargement. We diagnosed the tumor as a stage-I thymoma according to the Masaoka classification of thymic epithelial tumors, and performed thoracoscopic partial thymectomy. The final pathological diagnosis was thymic LEC. The patient received adjuvant radiotherapy, and has been observed without any sign of recurrence for 37 months since the surgery.

Pulmonary arteriovenous malformations (PAVM) are often associated with hereditary hemorrhagic telangiectasia (HHT). Embolization using a coil or plug is the first choice of treatment. There are no reports of complications such as penetration of the coil into the thoracic cavity or empyema. A woman in her twenties with a history of HHT underwent coil embolization of the right S10 PAVM at another hospital five years ago. She visited our hospital with right chest pain and was admitted with mild right pneumothorax. After admission, pleural effusion increased, and blood examination showed an increased inflammatory reaction. Thoracoscopy was performed. In addition to empyema, the coil was exposed through the visceral pleura. We diagnosed empyema due to penetration of the coil into the thoracic cavity. After thoracoscopic debridement, we placed sutures in the lungs around the coil and closed the puncture site. After discharge, she continued to have a small amount of bloody sputum. Computed tomography three months after surgery showed a cystic lesion around the coil. As we suspected that the bronchus and coil were connected, we performed right lower lobectomy six months after the first surgery.

A 72-year-old man was referred to our hospital with complaints of cough and left anterior chest pain. Chest CT revealed a huge mass in the left thoracic cavity, and the mass caused mediastinal deviation and left pulmonary atelectasis. An ultrasound-guided needle biopsy was performed and the histological diagnosis suggested dedifferentiated liposarcoma. Surgical resection was started with video-assisted thoracic surgery (VATS), followed by left thoracotomy for the purpose of extirpation from the thoracic cavity. The tumor originated from the anterior mediastinum, and no invasion of the surrounding lung or chest wall was observed, which enabled us to perform en bloc resection of the tumor. The pathological diagnosis was dedifferentiated liposarcoma. Herein, we present a case of excision of dedifferentiated liposarcoma with a huge mass originated from the anterior mediastinum. The patient was alive and well without tumor recurrence 1 year after surgery. VATS was very effective to resect a tumor from the mediastinum in our case because the huge tumor occupied most of the left thoracic cavity.

A peripherally inserted central catheter is easier to insert and associated with a lower risk than a centrally inserted central catheter. Abscess formation and vessel perforation related to the catheter tip have been reported using both catheters. We encountered a case of mediastinitis caused by a peripherally inserted central catheter. Herein, we report this case.

A 60-year-old man complained of fever and difficulty eating during chemotherapy for hypopharyngeal carcinoma. A central catheter was peripherally inserted.

Although an antibacterial agent improved his fever and inflammatory findings temporarily, his condition worsened one week later. The catheter was removed 15 days after insertion because of obstruction. On the same day, computed tomography showed some findings of mediastinitis. We urgently performed thoracoscopic mediastinotomy and he recovered through intensive care.

There are 9 reported cases of mediastinitis caused by a central venous catheter including our case. Three of them were diagnosed as infectious mediastinitis and necessitated surgical treatment. If the mediastinitis is caused chemically by an anticancer agent or hyperalimentation, conservative therapy may be possible. However, if suspecting infectious mediastinitis, surgical treatment should be performed urgently.

Ehlers-Danlos syndrome (EDS) is a group of hereditary diseases causing connective tissue fragility due to genetic abnormalities in collagen and its modifying enzymes. We report two surgical cases of pneumothorax associated with EDS. Case 1 was initial-onset left pneumothorax in a 43-year-old woman with a history of retinal detachment and multiple cavitary lesions of the bilateral lungs on preoperative imaging. Intraoperatively, air leakage was observed from the cavitary lesion of the left lower lobe, and wedge resection of the lung was performed. The lung tissue was extremely fragile, and additional air leakage was observed from both the grasped lung parenchyma and staple line. Additional stitches and biological tissue adhesive were needed to control the air leakage. The patient was diagnosed with classical EDS after the operation. Case 2 involved recurrent right pneumothorax in a 38-year-old woman. She had a history of perforation of the descending colon and was diagnosed with vascular EDS. Air leakage was observed from the cyst in the right upper lobe intraoperatively, and the cyst was sewn. Since the lung tissue was very fragile and another air leakage occurred from the grasped lung parenchyma, it was excised with an automatic suture device and covered with absorbent suture reinforcement. Parietal pleura scraping was added to promote intrathoracic adhesion. Although elastic fibers were pathologically maintained in the resected specimens of both cases, the lung tissues were extremely fragile. For patients with diagnosed or suspected EDS during pneumothorax surgery, it is essential to adopt protective measures that address the tissue fragility.

Fetal adenocarcinoma of the lung is a rare tumor resembling the developing fetal lung. We herein report two cases of high-grade fetal adenocarcinoma. Lobectomy with lymph node dissection was performed for the patients. Fetal adenocarcinoma was combined with acinar adenocarcinoma in the first case. The second case was diagnosed as pure fetal adenocarcinoma of the lung. Both cases showed no lymph node metastasis, and their pathological stage was determined as IB and IA3, respectively. The first case relapsed with brain metastases 18 months after surgery. It has been reported that patients with high-grade fetal adenocarcinoma have a poorer prognosis than those with typical types of adenocarcinoma. However, it is not clear which chemotherapy regimen is efficacious for the treatment of patients with this special type of adenocarcinoma. Further clinicopathological research of high-grade fetal adenocarcinoma is required.

In patients with interstitial lung disease and lung cancer, we should be aware of post-treatment acute exacerbation of interstitial lung disease. Treatment for lung cancer is often challenging in patients with severe interstitial lung disease. We report a surgical case of lung cancer and grade IV interstitial lung disease according to the Japanese Respiratory Society severity classification for interstitial pneumonia. A 73-year-old woman with interstitial pneumonia and suspected clinical stage IA3 lung cancer in the right lower lobe was referred to our hospital. Upon admission, the resting PaO₂ was 68.1 torr and the minimum SpO₂ value on a 6-minute walking test was 83%. The classification of interstitial pneumonia was grade IV and the patient required home oxygen therapy during exertion; thus, wedge resection was performed via video-assisted thoracoscopic surgery. The pathologic diagnosis was squamous cell carcinoma (pathologic T1cN0M0-stage IA3). The patient has experienced no recurrence in the 4 years since surgery.

Ex vacuo pneumothorax is a rare complication following thoracentesis, in which an increased negative intrapleural pressure around the vulnerable pleura results in pneumothorax because of the inability of the lung to completely re-expand after fluid removal. Over the last decade, two cases of ex vacuo pneumothorax were reported at our hospital. These pneumothoraxes occurred because of the inability of the lung to re-expand after drainage of malignant pleural effusions. Although the treatment of ex vacuo pneumothorax is controversial, surgical treatments were required because the air leakage from chest tubes was significantly large in these cases. Thoracoscopy revealed several aerial fistulas but no bullae. Also, the vulnerability of the pleura due to malignant pleurisy was noted; thus, sticking a fibrin sheet or polyglycol sheet with fibrin glue for the vulnerable pleura rather than excising the areas of aerial fistula was appropriate. After the repair of aerial fistulas, air leakage was under control and the postoperative courses were favorable.

The patient was a 66-year-old woman who had been diagnosed with bipolar mood disorder and was receiving outpatient treatment at a local hospital for one month prior to presentation to our department. The patient was found unconscious by emergency medical services after she had stabbed herself in the left side of her neck, both wrists, and left thorax using a 20-cm long knife. She was subsequently transported to our hospital via ambulance. A left hemopneumothorax was diagnosed on chest computed tomography (CT), and free air in the abdomen was visualized on abdominal CT. After thoracic drainage, bleeding persisted and hypotension was observed, so emergency thoracoscopic surgery was performed. Access ports were positioned on the anterior and posterior axillary lines in the seventh intercostal space. The patient bled from the inferior diaphragmatic artery with pulmonary, pericardial, and diaphragmatic injuries. Hemostasis and sutures were applied to the injured diaphragm and lung sites. The interior abdominal cavity was observed from the site of diaphragmatic injury, and it was confirmed that there was no organ damage. The operative time was 2 hours and 35 minutes, and the pre- and intraoperative blood losses were 1800 and 720 mL, respectively, with 8 units of blood transfusion. The thoracic drain was removed on the third postoperative day, and the patient was transferred to a psychiatric hospital on the eighth postoperative day.

Pulmonary actinomycosis is a chronic pyogenic granulomatous disease that requires differentiation from lung cancer and pulmonary tuberculosis. Many cases are difficult to diagnose and lead to surgical resection. Even after the diagnosis is confirmed, surgical resection is sometimes performed due to difficulties caused by antimicrobial therapy. This disease should be treated with antimicrobial therapy after surgery as soon as the diagnosis is confirmed. Here, we present two cases and their outcomes.

Case 1 was an 85-year-old man. He came to our hospital because of a mass found in the left lower lobe on chest CT. The tumor was strongly suspected to be primary lung cancer, and a thoracoscopic left lower lobectomy was performed. A histopathological examination was performed, and the final diagnosis was pulmonary actinomycosis. Postoperatively, there was no recurrence in the absence of antimicrobial therapy.

Case 2 was a 64-year-old woman. She visited her previous doctor because of bloody sputum. Chest CT revealed a right middle lobe infiltration shadow and bronchiectasis. She was then referred to our hospital for treatment. Although the diagnosis was not confirmed, she was treated with antimicrobial agents as non-tuberculous mycobacteriosis was suspected. However, due to repeated symptom flare-ups, thoracoscopic resection of the right middle lobe was performed. Histopathological examination indicated pulmonary actinomycosis. Postoperative antimicrobial therapy was not conducted until the results were available, and recurrence was observed. These findings indicate that antimicrobial therapy should be started as soon as the diagnosis is strongly suspected.

A desmoplastic small round cell tumor (DSRCT) is an extremely rare high-grade tumor that frequently develops in the abdominal cavity of young men. Herein, we report a case of pericardial DSRCT. A woman in her thirties underwent pericardial drainage for congestive heart failure due to cardiac tamponade at a hospital. The pericardial effusion was bloody, and atypical cells were detected on cytology. She was referred to our hospital for a detailed examination. Chest computed tomography revealed a thickened pericardium and large amount of pericardial effusion; however, there was no evidence of the primary lesion. Thoracoscopic pericardial fenestration was performed for tissue collection and drainage of the pericardial effusion. She was histopathologically diagnosed with DSRCT. Although DSRCT has been reported to occur extra-abdominally, this is the first reported case of DSRCT showing pericardial involvement in Japan. There are few atypical cases of DSRCT.

Currently, thoracic surgeons are faced with various challenges that include making important decisions regarding their "career path", "training and education", and "work-style change". Yet, to date, there has been no report on their actual situation. In a special session of the 73rd Annual Scientific Meeting of the Japanese Association of Thoracic Surgery, we conducted a questionnaire survey of all thoracic surgeons and discussed the results in real time based on the compiled data. A total of 2471 members of the Japanese Association of Thoracic Surgery were registered in the field of thoracic surgery and 472 (19.1%) participants provided valid responses. The results of the questionnaire revealed: (1) variation in the current training environment for "young" surgeons, (2) a strong interest of "young" surgeons in their career path, (3) the relatively high level of satisfaction among thoracic surgeons, and (4) a marked generation gap between "young" and "supervising" surgeons. We have prepared this report in the hope that this survey and the discussions held in the session will help by providing knowledge on the current status of thoracic surgeons and lead to the future standardization of training, supporting the career path, and rectifying the generation gap.