112 of the 221 patients with spontaneous pneumothorax treated at this hospital were having their first episode. Sixty one patients (54%) recoverd with conservative therapy (non-VATS). Six (5 %) recovered naturally during observation. Twelve (11%) required needle aspiration, 43 (38%) tube thoracostomy and 51 VATS, 23 of them was the following non-surgical treatment. In 28 patients VATS treatment after informed consent had been obtained. The time required for tube thoracostomy and hospitalization for the VATS group was less than that for either the group given only medical treatment or the group which underwent both VATS and medical treatment (p<0.001). Spontaneous pneumothorax recurred in none of the 21 patients who were followed after VATS. The rate of recurrence for the medical treatment and VATS groups differed significantly. No patient treated with VATS developed complications. With informed consent, VATS is thus considered to be the first choice of treatment for first spontaneous pneumothorax because of it is minimally invasive.

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From 1974 to December 1994, among 445 patients who underwent surgical treatment for spontaneous pneumothorax, 54 cases were bilateral spontaneous pneumothorax. Twelve cases occurred synchronously and 42 cases occurred metachronously. The characteristics of bilateral synchronous spontaneous pneumothorax were as follows : 1) There was no difference of frequency according to age group, 2) Most cases were first attacks, 3) Patients had no severe symptoms. The characteristics of bilateral heterochoronous pneumothorax were as follows 1) Frequent occurrence in teenaged patients, 2) Interval between unilateral operation and contralateral pneumothorax was from 5 days in the shortest case through 8 years in the longest case, and there was no removable relation between interval and age. For treatment, bilateral one-stage operation by thoracoscopy may be recommended for bilateral synchronous pneumothorax and the cases of unilateral pneumothorax who had past history of contralateral pneumothorax. For cases of unilateral pneumothorax with no past history of contralateral pneumothorax, however, only the unilateral pneumothorax should be treated and the other side should be treated when and if pneumothorax occurs.

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Four preservation methods were evaluated with canine lung transplantations : Group I (n= 10), high frequency oscillation (HFO) preservation in a cool box ; Group II (n=4), PGI₂ flushing of pulmonary vasculature before HFO preservation ; Group III (n=5), immersion hypothermia preservation ; Group IV (n=4), PGI₂ flushing prior to immersion hypothermia preservation. The lung was harvested as an en-bloc graft with the heart after cardioplegic arrest. Pulmonary vasculature flushing was then performed with a specific solution composed of the donor's blood, Ringer's solution, albumin, mannitol, and heparin. In groups II and IV, PGI2 was generally given before cardioplegic arrest. All grafts harvested were preserved for 12 hours by HFO (30 Hz with 2-4 cm H₂O of intratracheal pressure) in a cool box or immersion in cold (4°C) saline. Orthotopic transplantation was used for single left lung transplantation. The function of the transplanted lung was tested by measurement of pulmonary artery pressure and evaluation of gas exchange ability during occlusion of the native lung's pulmonary artery on the 3rd postoperative day. Eight of the 10 in Group I survived for 3 days and 6 of them tolerated the test. All animals in Group II survived for 3 days with satisfactory results. In Group III, all 5 animals died within 2 days. In Group IV, 3 of the 4 survived for 3 days but could not tolerate the test.
These results indicated the apparent effectiveness of two procedures : HFO for preservation and the general use of PGI₂ prior to the start of the preservation procedure.

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We studied postoperative complications, changes in performance status and lung function values of 84 elderly patients (over 75 years old) in comparison with 80 of younger resected lung cancer patients (60 to 74 years-old) from 1983 through 1992. The preoperative lung function tests revealed the presence of more severe obstructive lung disease (chronic emphysema) in the elderly group than in the younger group. The lobectomies caused the same degree of restrictive lung impairment in both groups. The common postoperative complications in the elderly group were pneumonia, difficulty in expectoration, atelectasis, arrhythmia nd hypoxemia. Changes in the performance status after lobectomies in the elderly group were significantly worse than in the younger group. These results indicate a high incidence of postoperative complications in the elderly group suggesting latent cardiovascular or pulmonary problems. It is suggested that when lung surgery must be performed for elderly patients, careful management should be necessary during perioperative period.

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An abnormal shadow was pointed out on the chest X-ray of 70 year old man. There were many calcifications and pleural effusion on the right side of the chest. Thoracoscopic biopsy did not yield a definitive diagnosis. But metastatic tumor, chest wall tumor, osteosarcoma and inflammatory disease could be excluded. Diffuse malignant pleural mesothelioma was strongly suspected.
On October 25, 1994, right extended extrapleural pneumonectomy and mediastinal lymphnode dissection was performed. The pericardium and the diaphragm were reconstructed by a dorsal flap. The pathological diagnosis was biphasic type diffuse malignant pleural mesothelioma with remarkable osseous and cartilaginous formation.

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A 60-year-old male visited our department because of dyspnea on exertion. During the previous seven years, he had been undergone operations, for insulinoma of the pancreas, hyperplasia of parathyroid glands and pituitary adenoma. Four years earlier he had also had an anterior mediastinum tumor resected, which was found on histo-pathologic examination to be a thymic carcinoid. Chest X-ray, CT scan and MRI on admission showed a large anterior mediastinum tumor and bulky swelling of the mediastinal lymph nodes. The brachiocephalic vein and SVC were compressed by the tumor. A bypass operation was performed to connect the lt. brachiocephalic vein to the rt. atrium to prevent SVC syndrome. One year later, he died of a pulmonary embolism after surgery for recurrent pituitary adenoma. Although it is well known that thymic carcinoid is frequently associated with endocrine disease, reports of thymic carcinoid with multiple endocrine neoplasm-type I are rare. Our experience suggests that additional mediastinal dissection is necessary for curative surgery for the thymic carcinoid.

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A 33-year-old man was admitted because of an abnormal shadow on chest x-ray. Chest x-ray and CT showed a 4 × 4 cm well-defined hilar tumor in the right upper lobe.
Lobectomy of the right upper lobe was performed. The tumor was a clear-bordered yellowish soft mass and the postoperative pathological diagnosis was inflammatory pseudotumor.
Microscopically, the tumor showed marked infiltration of foamy macrophages in the center of the tumor and infiltration of plasma cells in the periphery of the tumor.
This case was considered as one type of the early stage of inflammatory pseudotumor.

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The authors report a 42-year-old male who had hemoptysis with an abnormal shadow on chest X-ray films in 1992. He was admitted in 1995 because of a recurrent hemoptysis. Chest X-ray films showed an abnormal cystic shadow in the right middle lung field. Chest CT revealed a cystic shadow with some septal formations. He underwent thoracoscopic surgery with an Endo GIA (autosuture equipment) and double clipping techniques to resect the middle lobe with a diagnosis of CCAM type 1 or intrapulmonary bronchial cyst. Macroscopic examination of the surgical specimen revealed a large cystic lesion with thick walls and septal formation. Microscopic examination showed multiple cysts to be lined by ciliated stratified columnar epithelium and the wall to be composed of elastic tissue without cartilage plates. These findings supported the diagnosis of CCAM type 1. He has been well for 9 months after surgery.

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A 65-year-old female was admitted because of an abnormal shadow on a routine chest x-ray. Chest x-rays and chest CT scan revealed a well defined cystic shadow in the left lower lobe and an enhanced funicular shadow of the feeding artery.
Thoracotomy was performed to resect the sequestrated lung. The sequestrated lung was the intralobular type and presented as a simple fluid-filled cyst.

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A 65-year-old male worker was wounded in the neck by crushed stone. Angiography showed a foreign body in the left internal jugular vein and a fistula from the left common carotid artery to the left internal jugular vein. Surgical removal of the foreign body and closure of the fistula were performed. There is a risk of fatal complications from intra-vascular foreign body. If nonsurgical techniques cannot remove such a foreign body, surgery must be performed.

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A 21-year-old female was treated with left oophorectomy and wedge resection of the right ovary in December, 1992. The pathological diagnosis was immature teratoma (Grade 1). In September 1994, she consulted her family doctor with a complaint of dyspnea on effort. Chest X-ray showed a mass-like shadow in the right lower lung field with right pleural effusion. The cytology of pleural effusion was negative for malignant cells but serum AFP level was elevated. The chest X-ray and serum AFP level suggested the possibility of pulmonary metastasis of immature teratoma. She was treated with combined chemotherapy (VAB-6) at the Department of Obstetrics and Gynecology of Kyoto University. After she had received 3 courses of combined chemotherapy, serum AFP level decreased to 18.9 ng/ml, and she was referred to our Hospital, for the purpose of thoracic operation. After curative resection, the pathological diagnosis was pulmonary metastasis of immature teratoma (Grade 1).
The postoperative course was uneventful and serum AFP level decreased to 5.1ng/ml. She was then transferred back to the Department of Obstetrics and Gynecology of Kyoto University to receive postoperative combined chemotherapy.

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Benign mediastinal teratomas sometimes perforate adjacent organs. The frequency of perforation is reported to be 36% of all benign mediastinal teratoma. We report a case of benign mediastinal teratoma perforating the right lung. A 12-year-old female developed pneumonia on May 20, 1993 and was admitted to a local hospital on June 12. She was transferred to our hospital with complaints of sudden chest pain, severe cough and fever for further examination and treatment on June 17. An abnormal shadow was seen on her chest X-ray film and increase in size of this shadow was observed for 5 day before admission. A preoperative diagnosis was mediastinal teratoma and she was performed an operation on June 21. The tumor was observed on the right side of the anterior mediastinum and adhered to the right upper lobe of the lung so firmly that it was necessary to resect the part of the right lung. Histopathological findings showed that the tumor was a mature teratoma perforating the right lung because of the abscess in lung to which it adhered.

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A 60-year-old male with squamous cell lung carcinoma was admitted. The preoperative laboratory findings were high serum calcium (12.8 mg/dl) and PTH-related protein-C (PTH-rP-C) (85.5 pmol/l). After basal segmentectomy both serum calcium and PTH-rP-C became normal. In the analysis of tumor tissue, mRNA of PTH-rP was detected by the reverse transcriptase-polymerase chain reaction (RT-PCR) method. The patient is alive with no recurrence one year after operation.

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An anterior mediastinal tumor (6×5×4 cm) was removed from a 47-year-old female. The biochemical examination of the liquid contents obtained from the cystic part of the tumor demonstrated low protein concentration (0.3g/dl) but a high concentration of amylase (429 IU/l), CEA (62.7ng/ml), and CA 19-9 (greater than 240U/ml). Amylase isozyme analysis by electrophoresis showed that three pancreatic types of amylase comprised at least 65% of the total amylase. The tumor was believed to originate from the left thymus and strong adhesions to the left lung were found. The tumor and the part of the lung were removed en bloc. Pathological examination showed a mature teratoma and pancreatic tissue with Langerhans' islands. Early fibrosis and tissue lysis between the tumor and the lung, and inflammatory cell infiltration, accumulation of histiocytes and formation of lymphoid follicles in the lung were also observed. These findings suggested an early perforation in a mediastinal teratoma into the lung. In this patient the early process of perforation into the lung could be seen because the operation could remove the tumor en bloc with the lung within two months of the onset of left chest pain before the tumor could have perforated into the free thoracic cavity.
The pancreatic tissue and the high value of amylase (429IU/l), including mostly three pancreatic types of amylase, in the tumor suggested the mechanism of perforation by a mediastinal teratoma. The teratoma of this patient would have perforated completely into the lung or the bronchus later. This case illustrates the importance of the early removal of mediastinal teratomas.

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A 34-year-old female was first found to have an abnormal shadow in her lt lower lung field at the age of 29. At the age of 34, diaphragmatic hernia was diagnosed when she was operated on for uterine myoma. CT scans, roentgenography of the small intestine and Ba-enema revealed a Bochdalek hernia. Hernia was repaired through thoracic approach. Parts of the small and large intestines and greater omentum had herniated into the thoracic cavity without a hernia sac and caused atelectasis of the it lower lobe. We replaced the hernial contents into the abdominal cavity. The defect of the diaphragm was 6×6 cm in the posterolateral region. We closed the defect directly. Post operative recovery was good. Now, two years after operation, there has been no recurrence of the hernia.

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A 68-year-old male underwent pulmonary lobectomy and 20 Gy of intraoperative radiation therapy for lung cancer in another hospital. Endoscopy revealed an esophageal radiation ulcer three months later. The patient was transferred to our hospital because of an esophagobronchial fistula accompanied by pneumonia nine months after operation. As the symptoms worsened in spite of conservative therapy, two-staged operative treatment was performed. The intrathoracic esophagus was treated by stripping the mucosal layer. The muscle layer of the lower esophagus was utilized for repair of the fistula as a pedicled muscle flap laid on the fistula. Esophageal reconstruction was performed in the second stage operation. Utilization of the esophageal muscle layer seems to be a useful way for the treatment of an esophagobronchial fistula when the esophagus cannot be preserved. Intraoperative radiation therapy should be carefully planned keeping in mind that the esophagus can be severely injured with a dose of 20 Gy.

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A 43-year-old male presented with bloody sputum. Bronchofiberscopic findings revealed a nodular tumor in the left upper division bronchus, which was diagnosed as squamous cell carcinoma by transbronchial biopsy. The tumor had superficial invasion to the left main bronchus and the basal bronchus. Pneumonectomy by conventional standards had been planned ; but considering his quality of life, preoperative PDT was performed. Four weeks after PDT left upper lobectomy was done. The patient had a good postoperative course and is alive 10 months after surgery without any evidence of recurrence or residual disease.
This suggests that PDT as preoperative adjuvant therapy may contribute to the management of advanced lung cancer by reducing the amount of resection.

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