Recently, the efficacy of early surgical stabilization of traumatic rib fractures (SSRF) was reported, and a rib-specific plate was made available in Japan. Between January 2017 and January 2022, we performed SSRF in 13 patients and SSRF combined with video-assisted thoracic surgery (VATS) in 7 patients. In cases of SSRF alone, we observed a postoperative pneumothorax and suspected intraoperative lung injury. Additionally, in a case of SSRF using a mandible plate, the plate was found to be broken during postoperative follow-up. Therefore, we currently use a rib-specific plate for the procedure. We believe that VATS is efficacious in SSFR for preventing perioperative complications. Additionally, we recognize the usefulness of rib-specific plates designed according to the anatomy of the thorax.

To evaluate the efficacy and safety of CT-guided marking at our institution, we retrospectively analyzed backgrounds and complications of 244 patients with 267 lesions who underwent preoperative marking for tumor localization. Hookwires with nylon thread (VATS marker) were placed in 223 lesions (83.5%), and 44 lesions (16.5%) were marked with a dye method (indigocarmine).

The marking completion rate was 98.5% and success rate was 99.3%. Complications were pneumothorax in 110 cases (41.2%), intrapulmonary hemorrhage in 76 lesions (28.5%), marker dropout in 14 lesions (6.3% of VATS marker placements), and air embolization in one case (0.37%).

In a study of two groups divided by the marking method, pneumothorax was significantly more common in the group with VATS marker placement.

Three predictors of pneumothorax and intrapulmonary hemorrhage were: 1) age, 2) distance from the visceral pleura to tumor along the puncture route, and 3) marking technique.

CT-guided marking with puncture of the lung parenchyma requires careful attention to complications, as well as appropriate case and marking method selection.

An 87-year-old woman was referred to our hospital for further examination after a slow-growing shadow was found on her chest radiograph during a medical checkup. A chest computed tomography exam revealed a 40-mm tumor in the medial-basal segment (S7) of her right lung. Her preoperative blood test showed markedly elevated levels of progastrin-releasing peptide (ProGRP) of 3650 pg/mL. A pathological exam of the transbronchial biopsy specimen revealed characteristic carcinoid features. Thoracoscopic right S7 segmentectomy was performed as a limited operation. The final histopathological diagnosis was atypical carcinoid. Following surgery, the ProGRP levels normalized and the patient is currently disease-free at 18 postoperative months. Although cases with increased ProGRP levels in pulmonary carcinoid patients have been reported, our case demonstrated the highest ProGRP levels reported so far. ProGRP can be considered a useful tumor marker in patients with carcinoid tumors.

A female in her 70s underwent total hysterectomy and bilateral adnexal resection for clear-cell ovarian cancer, and right anterior chest pain developed one year after the operation. Computed tomography (CT) showed a 10-mm nodular shadow on the first to third intercostals adjacent to the right sternum and a nodular shadow on the upper lobe of the right lung. Accumulation of 18-fluorodeoxyglucose (FDG) was observed on positron emission tomography (PET)-CT, and ovarian cancer metastasis to the chest wall and lung was suspected. The thoracic wall lesions had a relatively clear margin, and no FDG-accumulation in the ribs nor sternum was observed. Wedge lung resection and excision of the parasternal lesions were performed under 3-port video-assisted thoracoscopic surgery. The resected lesion was diagnosed as ovarian cancer metastasis by pathological examination. There have been few reports on patients with parasternal metastases from ovarian cancer. Under such conditions, cancer cells that disseminate in the peritoneum metastasize to the lymph nodes through the diaphragm, possibly via the lymphatic system and subsequently to the parathoracic lymph nodes.

Descending necrotizing mediastinitis (DNM) is a disease caused by oropharyngeal infection and is associated with a high mortality rate. We report a case of DNM with bilateral empyema, acute pericarditis, esophageal stenosis, and laryngeal dysfunction. A 41-year-old man was transported to our hospital complaining of chest pain after a sore throat persisting for a week. Computed tomography showed abscesses with air from the left tonsil to periesophageal area and bilateral pleural effusions. We diagnosed the patient with DNM with bilateral empyema. Consequently, two operations were required during the course of treatment. Acute pericarditis was confirmed on admission, and pericardial drainage was required on day 11 owing to obstructive shock with increased pericardial effusion. Because scarring around the larynx and esophagus was caused by the spreading inflammation in the subacute stage, dysphagia with poor opening of the esophageal orifice and poor laryngeal elevation were recognized. Rehabilitation with esophageal ballooning was effective. In cases of DNM, various complications could appear according to spreading inflammation; therefore, timely and appropriate treatment is important.

A 28-year-old woman presented with fever and was found to have infiltrative shadows in the left lower lung field based on a chest radiograph. Later, chest computed tomography (CT) showed discrete areas of increased rarefaction in the basal segment of the left lung. She was referred to our hospital for further examination and treatment.

Chest contrast-enhanced CT revealed three aberrant arteries arising from the descending aorta and an anomalous vein draining into the hemiazygos vein. She was diagnosed with intralobar pulmonary sequestration (Pryce type III), and surgery was planned. During the surgery, it was observed that the pleura of the left lower lobe was white and exhibited a growth of capillaries. After ligating the aberrant arteries and anomalous vein, indocyanine green (ICG) was injected intravenously and unstained areas were identified in the anterior (S8), lateral (S9), and posterior basal segments (S10) of the lower lobe of the left lung. The superior segment (S6) of the left lung did exhibit any unstained area. Due to the presence of unstained areas, we conducted video-assisted left basal segmentectomy. After ligating the left basal artery, vein, and bronchus, we re-administered ICG intravenously and confirmed that there were no unstained areas. We present a case of intralobar pulmonary sequestration in which intravenous ICG was administered after ligation of abnormal blood vessels and the pulmonary artery, vein, and bronchus of the left basal segment, and then left basal segmentectomy was performed.

A 50-year-old woman was incidentally found to have a left lung mass 11 years ago. She was diagnosed with pleural effusion, because the mass shadow was between the lobes and localization of the mass had changed. An abnormal shadow was discovered on a plain chest radiograph during a health checkup. Chest computed tomography (CT) revealed a mass shadow with calcification in the left pulmonary lingual segment. As a solitary fibrous tumor was suspected because of changes in localization of the mass, surgery was performed. The mass was a pedunculated lesion rooted at the pulmonary hilum and it showed no continuity with the normal lung. We found two blood vessels, each communicating with the superior pulmonary vein and pulmonary artery. These abnormal vessels were dissected collectively, and the mass was removed. The resected specimen showed some lung parenchyma. Based on the pathological and intraoperative findings, we diagnosed the patient with extralobar pulmonary sequestration (EPS). EPS with the pulmonary artery serving as the inflow artery and pulmonary vein serving as the return vein is extremely rare, and so we report it.

Estimation of resting energy expenditure using indirect calorimetry is the most recommended method for determining energy dosage in nutritional management. In addition, the stress factor estimated by comparison with the basal metabolic rate derived from the Harris-Benedict equation can be used to understand the pathophysiology of disease. We performed indirect calorimetry in three patients with bronchopleural fistula after lung cancer surgery (two patients underwent open-window thoracotomy followed by two-stage radical surgery, and one patient underwent one-stage radical surgery), and were able to objectively establish the amount of energy required for treatment. The estimated stress factor was 1.5 (corresponding to moderate infection or higher) in the acute phase, and 1.2-1.6 in the chronic phase when the inflammation had subsided after open window thoracotomy. There have been no reports on the stress factor for severe complications such as bronchopleural fistula or the status after open window thoracotomy: therefore, the estimated stress factors in our case series could be useful for nutritional therapy in cases where indirect calorimetry is not available.

The patient was a 60-year-old man who was found to have a nodular opacity in the left lower lung field on chest radiograph during a health checkup. An irregularly shaped nodular opacity, 2.1 cm in size, was seen in the left lower lobe (S¹⁰) on computed tomography for closer examination. A definitive diagnosis based on bronchoscopy was considered difficult, and a policy of definitive diagnosis by surgery was adopted. Partial lung resection that included the lesion was performed, and a diagnosis of pulmonary epithelioid hemangioendothelioma was made with immunohistochemical staining. Although this was a single mass, multiple lung and bone metastases developed in the early postoperative period. However, control of the disease was achieved with multimodal therapy. Cases of this disease successfully treated with radiotherapy, chemotherapy, steroid therapy, and other modalities have also been noted involving patients with multiple or recurrent lesions, but there is no established therapy. When rapid exacerbation is seen, treatment is often difficult, and the course needs to be carefully observed.

The patient was a 59-year-old male. After a traffic accident, intra-abdominal hemorrhage was noted by his previous physician, and he was sent to our hospital. Damage control surgery and splenic artery embolization were performed. He required intensive care with a ventilator. Diaphragmatic eventration was identified as the cause of respiratory failure, and the patient was referred for surgery. The patient's flaccid diaphragm was pulled and sutured with 4 stitches of polyethylene thread from the mediastinal side to thoracic wall. The patient's respiratory status was stable postoperatively. The patient was weaned from the ventilator the next day, the drain was removed on the second day, and the patient was transferred to a hospital for rehabilitation on the eighth day. We report a valuable case in which a patient with traumatic respiratory failure with diaphragmatic eventration underwent plication of the diaphragm, and his respiratory condition improved markedly.

Complete resection of cysts arising in the middle mediastinum is difficult due to strong adhesion to surrounding tissues, and recurrence may be a concern. We herein report three cases of incomplete resection in seven cases of cysts expressing middle mediastinal tumors, for which surgical treatment was performed at our hospital from September 2008 to October 2020.

The pathological diagnoses were two cases of bronchogenic cysts and one case of a cyst of unknown origin. In all three cases, thoracoscopic middle mediastinal cyst resection was carried out, and ablation using an energy device was performed of residual lesions. In three cases, no recurrence was observed within the observation period despite incomplete resection of middle mediastinal cysts. Although the follow-up period in our cases was relatively short, ablation using an energy device of the cyst wall to treat residual lesions of mediastinal cysts is considered potentially capable of preventing recurrence.

Complete situs inversus is a rare abnormality of autosomal recessive inheritance. The surgical management of this entity is complex because the viscus anatomy mirrors the normal anatomy. Here, we report a patient with complete situs inversus, who underwent lobectomy using video-assisted thoracic surgery for lung cancer of the left upper lobe. The procedure was successfully performed despite the patient's atypical anatomy, which mirrored the normal anatomy. Before the surgical intervention, we created a virtual image of left upper lobectomy in a patient with complete situs inversus by horizontally reversing a typical video of right upper lobectomy.

A 77-year-old woman was referred to our hospital due to abnormal findings on a chest radiograph. Contrast-enhanced computed tomography (CT) showed a 25-mm nodule in the posterior mediastinum that was identical to the azygous vein in its shape and contrast effect. We diagnosed this as azygos vein aneurysm. Video-assisted thoracic surgery was performed to resect the aneurysm. The proximal end of the azygos vein aneurysm was initially dissected to reduce the risk of pulmonary embolism. Histological examination of the resected tissue revealed a saccular dilation of the vein with mixed thick and thin walls containing both fresh and organized thrombi in the lumen. In this case, preoperative enhanced CT showed no apparent thrombosis in the azygos vein aneurysm. Removing the azygos vein aneurysm at an early stage is desirable because thrombosis in an azygos vein aneurysm may not be detected by imaging. This finding also suggested that the proximal end of an azygos vein aneurysm should be resected first to reduce the risk of thromboemboli.