The safety and efficacy of fibrinolytic therapy were investigated in patients who underwent thoracoscopic surgery for acute empyema. Since January 2015, eight patients with acute empyema after thoracoscopic surgery have received fibrinolytic therapy at our hospital. Thoracoscopic surgery was performed to make the thoracic cavity unilocular, and minimal curettage of the pleura was performed. Fibrinolytic therapy involving the administration of 60,000 units of urokinase into the pleural cavity (1-4 times) was initiated within 48 hours after surgery. The median operative time and blood loss were 61 minutes (48-161 minutes) and 10 mL (10-550 mL), respectively. The median postoperative drainage period and hospital stay were 6 days (4-13 days) and 16 days (10-36 days), respectively. No complications were observed during the perioperative or fibrinolytic therapy periods, and all patients achieved resolution of empyema. In this study, it was suggested that postoperative fibrinolytic therapy can be safely administered to and reduce surgical stress loaded on patients with acute empyema.

Thoracoscopic complex basal segmentectomy of the posterior basal (S10) and lateral and posterior basal (S9+10) segments is technically challenging; the presence of a subsuperior segment makes it even more challenging. Surgical strategies for basal segments are conventionally interlobar fissure or posterior approaches. These approaches lead to difficulty coping with the complex basal segmentectomy involved in the subsuperior segment. Here, we report a surgical case of S9+10 segmentectomy through a pulmonary ligament approach to preserve the subsuperior segment. A man in his 70s who was a smoker with a history of treatment for tuberculosis, chronic obstructive pulmonary disease, and respiratory disability was referred to our department because of a growing lung nodule suspected of being lung cancer. Chest computed tomography showed a 1.6×1.5-cm nodule in the right posterior basal segment. We performed thoracoscopic right S9+10 segmentectomy with lower mediastinal lymph node dissection. The pulmonary ligament was incised up to the inferior pulmonary vein. We identified V6 and the basal pulmonary vein, and peripherally exposed the trunk and branches of the basal pulmonary vein. We dissected the pulmonary parenchyma along the intersegmental septum between the medial basal segment and posterior basal segment, and exposed the pulmonary arteries and bronchi. We dissected V10, B9+10, A9+10, and V9 sequentially. Finally, the intersegmental plane was dissected using surgical staples. He was discharged without any complications. The pulmonary ligament approach facilitates basal segmentectomy of the posterior basal (S10) and lateral and posterior basal (S9+10) segments while avoiding non-essential resection of the subsuperior segment.

The patient was a woman in her 40s with a history of drainage surgery for pulmonary pyogenic disease at the age of 14 years, and a right lower lobectomy for pulmonary sequestration at 17 years of age. Since then, she had been asymptomatic; however, at the time of a comprehensive health check-up, an upper gastrointestinal tract radiograph revealed extravasation of the contrast agent into the bronchial tubes, prompting a referral for further evaluation. During esophagoscopy, an esophageal diverticulum was observed in the middle esophagus, 25 cm from the upper incisor. Subsequent gastrografin contrast imaging from the diverticulum revealed leakage of the contrast agent into the bronchus. On bronchoscopy, a needle-sized fistula was identified approximately 1 cm proximal to the resection margin of the right lower lobe. Based on these findings, a diagnosis of bronchoesophageal fistula was made. Surgical intervention was performed through video-assisted thoracoscopic surgery (VATS) via an open approach with division of the fistula using an automated suture machine, followed by reinforcement of the divided site with a pedicled intercostal muscle flap. During the surgery, minimal inflammation was observed in the vicinity of the fistula. Therefore, although histological analysis of the fistula site was not performed in this case, a congenital tracheoesophageal fistula could not be conclusively ruled out. The fistula site was located in the middle trunk, close to the right B6 resection margin. As the sequestrated lung had been resected, its relationship with the resected lung segments remains uncertain. If congenital, this is an exceedingly rare case, considering the presence of the esophageal diverticula and course of the disease in the patient. This case brings to our attention the importance of considering the rare but possible occurrence of bronchoesophageal fistula when planning treatment for pulmonary sequestration.

A 45-year-old woman with a thymoma complicated by myasthenia gravis underwent extended thymectomy with brachiocephalic vein resection and left upper lobe pulmonary resection via sternotomy. A preoperative thoracoscopic biopsy revealed pleural dissemination of thymoma; consequently, we performed warm distilled water immersion of the left pleural cavity. The final pathological diagnosis identified the thymoma as type B2, classified as stage IVa according to the Masaoka-Koga staging system. The patient chose observation without postoperative adjuvant therapy. During the 6-month postoperative follow-up, a solitary nodule at the left third intercostal level was suspected of pleural dissemination and observed by chest CT. A video-assisted thoracoscopic biopsy revealed the presence of multiple yellow-white nodules on the chest wall, and partial resection was performed. Histopathologically, those nodules were diagnosed as cholesterol granulomas, and the patient has been undergoing follow-up without any recurrence. Cholesterol granulomas of the thoracic lesion are rare. When clinically diagnosed, they can be monitored. However, surgical resection is often considered to differentiate them from malignant tumors in the thoracic region. In our case, the suspected pleural dissemination of thymoma necessitated multimodal therapy, including surgical resection if pleural dissemination of thymoma was confirmed. Differential diagnosis between cholesterol granulomas and pleural dissemination based on imaging remains challenging, emphasizing the need for continued, careful observation.

Background. Cases of primary mediastinal liposarcoma are uncommon. Reported here are details of a case of primary middle mediastinal dedifferentiated liposarcoma.

Case. A 57-year-old female visited a nearby doctor with a chief complaint of coughing. Chest computed tomography (CT) findings showed a 14×10-cm tumor extending from the mediastinum into the right thoracic cavity, and she was referred to our hospital. A CT-guided biopsy was performed and pathological examination results showed signs of myxofibrosarcoma. No findings indicating metastasis were found. Surgery was planned, and tumor resection was performed with a median sternotomy and right fourth intercostal thoracotomy. Although there was no adhesion to the lung, great vessels, or chest wall, the right phrenic nerve and azygos arch were found to be involved with the tumor and resected. The pathological diagnosis was dedifferentiated liposarcoma with myxomatous characteristics. The resection margin was positive and radiotherapy (66 Gy/33 fr) was performed. Now, at seven months after surgery, the patient is currently doing well with no signs of recurrence.

Conclusions. The prognosis associated with dedifferentiated liposarcoma is poor. Herein, findings of the present case are described along with a review of the related literature.

Background. Antifibrotic drugs such as nintedanib and pirfenidone have important roles in the treatment of idiopathic pulmonary fibrosis. Surgery for lung cancers with idiopathic pulmonary fibrosis should be performed with extreme caution because of the risk of postoperative acute exacerbation. Case. A 68-year-old man with double lung cancers with idiopathic pulmonary fibrosis underwent right lower lobectomy and right upper lobe wedge resection 5.5 years ago. Histopathologically, usual interstitial pneumonia was observed in the resected lung. Five years after the operation, treatment with nintedanib was started. At the same time, a metachronous second primary lung cancer was detected in his left lower lobe. We decided to perform surgical treatment. Since nintedanib may delay wound healing and its perioperative safety has not been established, we changed nintedanib to pirfenidone for perioperative management. Then, we performed wedge resection of the left lower lobe. There were no complications in the perioperative period. Conclusion. We encountered a case of lung cancer complicated with idiopathic pulmonary fibrosis, in which the drug was changed from nintedanib to pirfenidone preoperatively.

The patient was a 73-year-old woman who had undergone a left lower lobectomy for a metastatic pulmonary tumor approximately 20 years ago. She was referred to our hospital with a chief complaint of coughing associated with massive sputum. Computed tomography (CT) showed that the remaining left lung parenchyma was destroyed, resulting in a diffuse cavitary lesion and destroyed lung. The patient's general condition was poor; therefore, fenestration of the destroyed lung with open thoracotomy (cavernostomy) was performed for drainage purposes. Subsequently, the patient's symptoms improved significantly. On outpatient follow-up, the patient had decreased pus production, and Mycobacterium culture became negative. However, repeated inpatient treatment was required because of symptoms of infection caused by Pseudomonas aeruginosa. Seven months after fenestration, the patient developed drug-resistant Pseudomonas aeruginosa, and we realized that improving the general condition may be difficult. Therefore, we performed a pleuropneumonectomy and thoracoplasty with resection of the 2^nd-9^th ribs for curative purposes. In respiratory surgery for infectious disease, the best treatment strategy, such as the best surgical method or surgical timing, should be determined depending on the patient's general condition. Here, we report a successful case of two-stage surgical treatment for a destroyed lung.

Lymph node metastasis, in which the pathological diagnosis is inconsistent with lung cancer lesions, may lead to the discovery of other intrapulmonary lesions. Conversely, there are no reports of cases in which oropharyngeal cancer was discovered after lymph node metastasis was diagnosed in the hilar lymph nodes. The patient was a 73-year-old man. Chest computed tomography revealed a mass at the base of the right lung, and transbronchial lung biopsy revealed adenocarcinoma. Lower lobectomy of the right lung and lymph node dissection were conducted. Histopathological examination revealed that the tumor was an adenocarcinoma, but the right main peribronchial lymph node (#Rt10) showed a squamous cell carcinoma (SCC). Postoperative fiberoptic laryngeal examination revealed a neoplastic lesion on the lateral wall of the right middle pharynx. Biopsy results confirmed the diagnosis of moderately to highly differentiated SCC; therefore, lumpectomy was performed. Histopathological examination revealed a morphologically similar lesion to #Rt10. Although it is straightforward to determine multiple lung cancers due to discrepancies between the pathological diagnosis of a tumor and lymph node metastasis, there are few reports of multiple cancers found in other organs, as in the present case. Preoperative diagnosis of patients at high risk of cancer should be performed more cautiously.

A 63-year-old woman was undergoing management with an artificial respirator for respiratory failure from COVID-19, invasive pneumococcal disease, and ARDS. Tracheostomy was performed on the 21st hospital day. Chest CT performed the day before tracheostomy revealed a focal pneumomediastinum in the anterior mediastinum. The emphysema developed from the mediastinum to subcutaneous area, and management by prone positioning could not improve the respiratory hemodynamics, so she was referred to us. We planned mediastinal drainage. An approach from the anterior chest wall was not appropriate because we could not get enough space to insert the thick tube, so we selected the xiphoid process approach. Blunt dissection from the xiphoid to anterior mediastinum was performed and a chest tube was inserted into this space. We cut the side of the drain in four places for additional holes to suction. Chest CT revealed a significant decrease of the pneumomediastinum, and the S/F ratio temporarily elevated. After that however, in spite of management by VV ECMO or prone positioning, respiratory and circulatory conditions did not improve. She died of septic shock due to pneumonia on the 56th hospital day. The mediastinal drainage contributed to an improved respiratory condition, although it was temporary.

Loeys-Dietz syndrome (LDS) is a congenital connective tissue disorder that shares certain typical features with Marfan syndrome. Pectus excavatum is a common skeletal comorbidity in LDS. We report a case of LDS characterized by scoliosis progression following pectus excavatum repair. A 9-year-old boy, who was diagnosed with LDS by genetic tests at the age of 5, was referred to our division for severe pectus excavatum (Haller index: 9.81). He also had mild scoliosis (Cobb angle of 8.5°). The pectus deformity was repaired through a combined Ravitch and Nuss procedure, involving the insertion of two pectus bars beneath the sternum, partially resecting the costal cartilages. Post-surgery, the Haller index reduced to 3.57, but the initial lumbar scoliosis markedly progressed, with the Cobb angle increasing to 34.2°. Treatment with a brace was initiated as scoliosis progressed immediately after the surgery. Scoliosis improved markedly by the 4^th month post-surgery. In patients with pectus excavatum complicated with scoliosis, it can progress after pectus excavatum repair. In this case, due to the background of tissue fragility associated with LDS, excessive spinal deformity occurred due to pectus excavatum repair.

Herein, we present a case of drug fever developing after surgery for MRSA empyema. A 68-year-old man with atopic dermatitis visited a local physician because of mild fever and right chest pain. He was diagnosed with right pneumonia and empyema, and received anti-biotic treatment with ampicillin sodium/sulbactam sodium and thoracic cavity drainage. Methicillin-resistant Staphylococcus aureus (MRSA) was detected from the sputum sample and was considered to be causative of thoracic empyema. After receiving the concomitant administration of vancomycin (VCM), he was referred to our hospital and underwent thoracoscopic empyema cavity curettage. On postoperative day 3, the patient developed pyrexia, followed by erosion of the lips and tongue as well as enanthema on postoperative day 6. These symptoms were considered to be associated with the drug treatment. Thus, VCM, the most suspected drug, was discontinued. Although the fever resolved immediately after VCM discontinuation, erosion of the lips and tongue symptoms took time to resolve. When pyrexia develops after surgery for empyema, differentiating between recurrent infection and drug fever is difficult. When drug fever is suspected, it is critical to immediately discontinue administration of the suspected drug.

Myelolipoma is a benign tumor that typically occurs in the adrenal cortex. Here, we report two rare cases of myelolipoma arising from the posterior mediastinum. The first patient was an 80-year-old male, with an abnormal chest radiograph. Chest computed tomography showed a well-circumscribed and low-density tumor with a diameter of 37×27 mm on the right side beside the ninth and tenth thoracic vertebrae. Extirpation under video-assisted thoracoscopic surgery was performed for this tumor. Microscopically the tumor was composed of fat cells and mature bone marrow cells including normoblastic, granulocytic, and megakaryocytic series. The second patient was a 68-year-old female, also with an abnormal chest radiograph. The tumor on the right side beside the eleventh thoracic vertebra was well-encapsulated and soft, with a size of 27×18 mm, on chest computed tomography. We performed complete resection of the tumor under video-assisted thoracoscopic surgery. Histopathological examination showed that the tumor was composed of hematopoietic elements mixed with mature adipocytes. We diagnosed both tumors pathologically as myelolipoma. We reviewed 15 cases with resected mediastinal myelolipoma in Japan from 2010, and report them along with our 2 cases.

A man in his 60s visited his family doctor with a cough and bloody phlegm. Chest CT showed a mass shadow in the left lower lobe. An anomalous artery with a diameter of 20 mm that branched from the left side of the descending thoracic aorta into the left lower lobe was seen. He was diagnosed with an anomalous systemic arterial supply to the basal segment with obstructive pneumonia, and left lower lobectomy was performed. The anomalous artery branched from near the diaphragm, and its branching site was identified from the thoracic cavity. After suturing the aneurysmal artery with 4-0 polypropylene with felt, the peripheral site of the aneurysmal artery was separated with an autosuture device, and the end of the proximal site was sutured using 4-0 polypropylene with felt. The operative time was 312 minutes, and blood loss was 165 mL. One year and three months after the surgery, there was no evidence of an aneurysm at the transected end of the artery. In the past 11 years at our hospital, abnormal vessels were treated in 7 cases of anomalous systemic arterial supply to the basal segment and pulmonary sequestration. The median diameter of the abnormal artery was 3.3 mm, and the vessels were dissected with laparoscopic coagulating shears or an autosuture device after ligation with non-absorbable thread. The method of ligation and dissection of an aneurysmal artery is an important issue because of the fragility of its vessel.