Surgical therapy for patients with severe bullous emphysema still remains controversial. As surgical bullectomy is generally limited to patients with single or a few giant bullae, patients with multiple bullae and bullous emphysema are not considered to be candidates for conventional surgical bullectomy. We performed thoracoscopic carbon dioxide laser ablation in four male patients aged 52 to 71 years with multiple bullae and bullous emphysema. All patients had their chest tubes removed 2 days postoperatively and went home within 40 days. There was no morbidity and no mortality. Postoperative chest computed tomography showed remarkable shrinkage of bullous areas in one patient. Postoperative pulmonary function tests showed slightly increased one second forced expiratory volume (0.35 ± 0.1 liters preoperatively to 0. 42 ± 0.2 liters postoperatively) and slightly decreased vital capacity (1.72 ± 0.4 to 1.52 ± 0.4 liters). Two patients showed improvement in exercise tests and subjective improvement of dyspnea on exertion. We conclude that thoracoscopic carbon dioxide laser ablation is a safe and beneficial treatment for certain patients with severe bullous emphysema.

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Proliferating cell nuclear antigen (PCNA) expression was studied in relation to the frequency of lymphnode metastasis in 65 resected non-small cell lung cancers. PCNA labeling index (LI) % was assayed objectively with flow cytometry. Lymphnode metastasis was found in 13 of 36 adenocarcinomas and in 5 of 29 squamous cell carcinomas. The frequency of lymphnode metastasis correlated positively with tumor size but not with PCNA LI%. In adenocarcinomas, there was no currelation between tumor size and PCNA LI%, but there was no lymphnode metastasis when the tumor was less than 30 mm in diameter and the PCNA LI % was high. It was concluded that PCNA LI% did not correlate with other prognostic factors but showed proliferating potential.

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Among the 385 patients who had pulmonary resection with mediastinal dissection for lung cancer during the past 10 years (1982, 41992, 3) at Toneyama National Hospital, there have been 8 cases of post operative chylothorax. Four patients recovered with conservative therapy, but the other 4 patients required surgery. The sites of chyle leakage were easily identified by the feeding of milk before re-operation.
We used our procedure to prevent post operative chylothorax in all patients undergoing pulmonary resections for lung cancer during the past year. After the induction of anesthesia a nasogastric tube is inserted, and 200 ml of milk is administered through the tube. Since fat has been absorbed and is travelling upward in the thoracic duct by the time of mediastinal dissection, the thoracic duct and chyle leakage can be easily identified and treated. Leakage can be checked again when the operative field is washed. No chylothorax occurred in the 55 patients undergoing this procedure, and there were no complications of milk administration. This method is recommended for the prevention of chylothorax following resection for lung cancer.

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Fifty-seven patient with pT1N0M0 non-small cell lung cancer underwent pulmonary resection at Ishikawa Prefectural Central Hospital between 1982 and 1993. The results of treatment were assessed retrospectively. The overall 5-year survival rate was 91%. In 39 patients with adenocarcinoma it was 84%, and in 15 patients with squamous cell carcinoma it was 100%. Cancer recurred in 18% of adenocarcinoma patients after absolute curative resection. There were significant differences in survival rates between patients with well differentiated and moderately differentiated adenocarcinoma, and between those with moderately differentiated and poorly differentiated adenocarcinoma. The diameter of the adenocarcinoma was also related significantly to lenght of survival (less than 20 mm versus 21-30 mm). We conclude that postoperative chemotherapy is important for 21-30 mm or poorly differentiated adenocarcinoma.

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The 29 patients with neurogenic mediastinal tumors treated from 1972 to 1992 represet 17.6 % of the 165 patients with primary mediastinal tumors. There were 14 schwannomas (48.3%), 1 neurofibroma (3.5%), 3 malignant schwannomas (10.3%), 7 ganglioneuromas (24.1%), 3 ganglioneuroblastomas (10.3%) and 1 neuroblastoma (3.5%). The incidence of malignant tumors was higher in children (4/7, 57.1%) than in adults (3/22, 13.6%). Symptoms related to the disease were noted in 4 patients with benign tumors (18.2%) and in 5 patients with malignant tumors (71.4%). Complete surgical resection was performed successfully in 27 of the 29 patients (93.1%).

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To prevent bronchial fistulas after operations for primary lung cancer since 1992, we have wrapped bronchial stumps protectively with intercostal muscle pedicles in operations on poor risk patients : 1. right pneumonectomy, 2. right middle & lower lobectomy and lower lobectomy, 3. right sleeve lobectomy and pneumonectomy, 4. presence of DM, TIP, renal failure, etc. 5. post systemic chemotherapy. Of the 116 operations for primary lung cancer, 18 bronchial stumps (15.5%) were wrapped with intercostal muscle pedicles. The average age of the 18 patients was 62.2 years. The operations were three right pneumonectomies, three right middle & lower lobectomies, seven right lower lobectomies, two right sleeve upper & middle lobectomies, two right sleeve upper lobectomies, and one left lower lobectomy. The methods of closure of the bronchial stumps were automatic stapling in 13 patients and manual suturing in five. There have been no fistulas in those bronchial stumps wrapped with intercostal muscle pedicles during the past one year and eight months.
Wrapping bronchial stumps with intercostal musle pedicles is inferior to omentopexy in the prevention of inflammation, but it is a useful, easy and quick method which can be applied at the time of pulmonary resection.

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A 63-year-old male who had undergone left pneumonectomy for bronchogenic squamous cell carcinoma (p-T2N2M0. stage IIIA) was found to have a metastatic tumor in the right upper lobe three years after the initial operation. We performed partial lung excision, including the tumor, using video-assisted thoracoscopy. Although air leakage continued for seven days, he was eventually discharged on the 19th post operative day. Pulmonary function tests performed three months after the second operation revealed no further deterioration of function in the residual lung. Further metastasis or recurrence of the tumor have not occurred during a 17-month follow-up period. We suggest that a video-assisted thoracoscopic surgical procedure can be used to resect a pulmonary tumor in the contralateral lung after pneumonectomy.

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A 62-year old male visited our hospital for diagnosis and treatment of recurrent hemoptysis. Bronchoscopy revealed a white polypoid lesion at the orifice of the left bronchial branch B⁶. Biopsy of the polypoid lesion showed an inflammatory polyp. Two months later, bronchoscopy demonstrated edematous and granulated mucosa of the left gronchial branch B⁶. Biopsy of the mucosa showed granular cell tumor which contained S-100 protein. CT scan of the chest and bronchography demonstrated dilated bronchi in the left S⁶. Left lower lobectomy was performed. At present, one year later, there is no evidence of recurrence.

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An abnormal right hilar and mediastinal shadow was detected in the Chest X-ray of a 53 year-old male with cough and low grade fever. Chest CT and MRI demonstrated enlarged right hilar and mediastinal lymph nodes. Thoracoscopic biopsy of the mediastinal lymphnode showed undifferentiated carcinoma. A thorough systemic examination revealed no primary focus. At surgery the right highest, paratracheal, tracheobronchial and hilar lymphnodes were found to be enlarged. The total mass was 10 by 5 cm in size. We performed right upper lobectomy and mediastinal lymphnode dissection because of possibility of a lung origin. The pathological and electron microscopical diagnosis was poorly differentiated adenocarcinoma. Since surgery we have followed this patient for about 13 months, and have not seen any new lesions or recurrence. It may be a very rare case of T0N2M0 lung cancer or a cancer originating from ectopic epithelial cells in the lymphnodes.

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A 73-year-old female who had been treated for Sjögren syndrome and Hashimoto's disease presented with the chief complaint of muscle weakness. The diagnosis was dermatomyositis, and she was examined further for the possible coexistence of a malignant tumor, since that both Sjogren syndrome and dermatomyositis have often been reported to be complicated with a malignant tumor. CT disclosed an anterior mediastinal tumor, which was diagnosed a thymoma. The mass was resected, and thymectomy was also performed. Postoperative pathological examination showed squamous cell carcinoma of the thymus. Intraoperative lymph node dissection was not performed, so postoperative radiation therapy was given, up to a total of 50 Gy. The signs and symptoms of dermatomyositis improved postoperatively, but those of Sjdgren syndrome and Hashimoto's disease did not. The patient is well one year and ten months after operation without any evidence of recurring thymic carcinoma. Detailed examination for possible malignant tumor complicated with an autoimmune disease resulted in successful early resection of thymic cancer. Concomitant extended thymectomy did not, however, remove all the signs and symptons of the autoimmune diseases.

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A 68-year-old male visited a hospital because of an abnormal shadow on his routine chest roentgenogram. He had had exertional dyspnea and coughs during the past year. Diagnostic imaging demonstrated a tumor, 20 × 28mm in size, in the right lower lobe. Transbronchial lung biopsy was performed, and a diagnosis of adenocacinoma of the lung was made. He was admitted to our hospital for an operation. Transesophageal echocardiogram performed because of symptoms of cardiac failure revealed a large mass in the right atrium, suggestive of a cardiac myxoma. First, resection of the right atrial myxoma was performed on cardiopulmonary bypass. Six weeks later he underwant a posterolateral thoracotomy for resection of a lung cancer. A partial resection of the lung was performed without lymphnode dissection, because pleural dissemination was noted. Hemodynamics were stable perioperatively. He was discharged from the hospital 5 weeks after the second surgery, and he is now well, being followed as an outpatient for 6 months at our hospital.

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A 28-year-old woman with atelectasis of the right lung due to tuberculous right bronchial stenosis was successfully treated with a balloon catheter. To prevent re-stenosis, balloon catheter dilation was repeated every 3 months. Her respiratory function improved gradually, and she could teach high school again one year after the first procedure. Helical CT scan was useful in the evaluation of the airway of the bronchus.

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Teratoma in the posterior mediastinum is rare. A 46-year-old male was referred to our hospital because of an abnormal shadow in his left lower lung field on chest x-ray. Computed tomography and magnetic resonance imaging revealed a large heterogeneous mass with calcification in the posterior mediastinum. An aortogram demonstrated that the tumor was fed by intercostal arteries 8, 9, 10, 11 and 12. Some hairs were obtained from the tumor by percutaneous needle biopsy. The tumor was therefore diagnosed a teratoma. It was extirpated through the 7th and 10th intercostal spaces. It rested on the diaphragm and was strongly adhered to the posterior chest wall where the feeding arteries entered the tumor which measured 16 × 10 × 9cm. It contained bone, a bronchus-like structure, fat and multiple cysts which contained sebaceous material and a large tuft of hair. Microscopic examination revealed ciliated epithelium, cartilage, bronchial glands, fat tissue, hair, and stratified squamous epith-elium with keratinization. There were no malignant findings. The pathological diagnosis was mature teratoma.

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A 59-year-old female was admitted to our hospital becuase of an abnormal routine chest X-ray showing a homogeneous mass in the left S¹⁰ Chest CT scan and MRI results suggested an aberrant artery above the left diaphragm. The level of the descending aorta was scanned by herical CT, and three-dimensional images were generated preoperatively. An aberrant artery arising from the descending aorta and a vein draining into the inferior pulmonary vein were visualized clearly by this three-dimensional CT angiography was useful in the preoperative diagnosis of intralobar pulmonary sequestration.

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A case of thoracic trauma in a 48-year-old man is reported. His thorax was struck by iron chips while manufacturing automobile parts. On admission continuous bleeding and air leaking from the chest drain were noted and a diagnosis of pneumohemothorax was made. Emergercy thoracoscopy revealed the pneumohemothorax to be caused by pulmonary parenchymal injury. Under thoracoscopy we extracted the iron chips and sutured the injury site by auto-suture.
Emergency thoracoscopic examination is useful for : 1) direct confirmation as to the site as well as extent of injuries of both the circulatory system (aorta, vena cava, and pulmonary artery/vein) and the respiratory system (lung, trachea, bronchi and diaphragm) : and 2) determination of procedures of either thoracoscopic surgery or thoracotomy.
Thoracoscopic surgery limits the incision size and extent of invasion. Thus patients undergoing such surgery can ambulate and be discharged earlier than those treated by other procedures.

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The cure of chondrosarcomas can be expected only through surgery. Wide resection is the rule to prevent local recurrence. For chondronarcoma of a costal head, and especially of a vertebral body, it is not easy to perform a wide resection.
We tried to remove part of the vertebral body and half of the lamina along with wide chest wall resection in two of our patients, but both died of local recurrence.
Wider resection, including even total replacement of the involved vertebral bodies, may have to be considered at the time of the initial surgery.

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A 28 year-old-female was admitted because of severe dyspnea. A tracheal tumor was seen on her chest lateral X-ray film and thoracic CT scan. Bronchoscopy revealed that the tumor almost occluded the tracheal lumen. Because of occuring respiratory distress during bronchoscopy, emergent bronchoscopic polypectomy was performed with an electrosurgical snare.Histological examination revealed a pleomorphic adenoma. Since the tumor stalk remained in the trachea, tracheal resection was performed two months later. Six years after the operation bronchoscopy showed complete cure of the tumor.

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