Arrhythmias after surgery for lung cancer were noted in 84 of 224 patients (37.5%). This complication occurred most frequently (67.5%) in pneumonectomy cases and within 1 week (88.1%). The most common type was atrial fibrillation (39.3%). Significant differences (p< 0.01) were found between 128 patients without postoperative arrhythmias and 52 patients with postoperative arrhythmias in terms of age (57.3 years and 65.2 years), FEV_1.0% (74.7% and 69.6%), predicted postoperative index (55.2% and 43.2%) and predicted postoperative %VC (77.7% and 66.0%). The respiratory complication rate (53.8%) and hospital mortality rate (13. 5%) in the arrhythmia group were higher (p<0.01) than in the non-arrhythmia group (30.5% and 2.3%). Discriminant analysis revealed that the age and predicted postoperative index have a significant positive correlation with the occurrence of postoperative arrhythmias.

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A 60 year-old male who had been treated with right cavernostomy and open window thoracostomy for pulmonary atypical mycobacterial infection was admitted to our hospital because of stridor and dyspnea. Tracheostomy and careful medication lead to closure of the open thoracostomy window. However, because of the past thoracostomy, coexistent cor pulmonale and bronchial asthma, it was not possible to use conventional thoracoplasty or lobectomy to close bronchial fistulas in the open thoracostomy window.
The omentum was brought up to the open thoracostomy window through a subcutaneous tunnel over the xyphoid process and the bronchial fistulas were successfully closed by the omental pedicle flap. The omental pedicle flap closure method through the presternal route is useful in the closure of bronchial fistulas and produces the least damage to the residual lung.

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Nineteen obese patients who underwent lung resection were evaluated for pre-operative complications, lung function, operative procedures and post-operative complications. The results were compared with those of 27 control patients whose obesity index was within 100 ± 2.
There were no differences in pre-operative complications between the groups. FVC and FRC were significantly lower in the obese group than in the control group (p<0.05; p<0.01). There were no differences in operative procedures between the control group and the obese group. Chest abnormalities and atelectasis occurred more frequently after operation in the obese group than in the control group (p<0.05). Nine patients (36.8%) of the obese group and 5 patients (18.5%) of the control group required suction of their sputum by bronchoscopy after lung resection. Many kinds of bacteria were grown from the sputum after surgery, but many from obese patients with post-operative complications were normal flora of the upper respiratory tract.
Post-operative complications frequently occurred in obese patients after lung resection, presumably because of weakened expectoration due to reduced FRC and ERV secondary to obesity and the post-operative supine position. It was concluded that to prevent post-operative complications after lung resection in obese patients it is important to avoid prolonged bed rest.

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Nine patients experienced postoperative chylothorax during a 5-year period when 931 thoracotomies were performed, for an overall incidence of 1.0%. Seven of the nine had lung cancer : six were treated with lobectomy and one with pneumonectomy. One patient with which malignant mesothelioma and one with metastatic lung cancer underwent pleuropneumonectomy. Mediastinal lymph node dissections were performed in eight patients, but not in the one with metastatic lung cancer.
In six patients chylothorax was caused by node dissection and in remaining three it followed an extrapleural approach. Six patients who had had lobectomy were treated conservatively by fasting, IVH and pleural drainage for an average of 36.3 days. There were no complications of malnutrition or infection. The three patients who had had pneumonectomy required re-operation. Milk taken before operation effectively shows the site of injury in the thoracic duct.
Chylothorax after lobectomy can be treated nonoperatively, but operation should be performed as soon as possible in patients who have had pneumonectomy.

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The patient, a 59 year-old male, had had chronic empyema without fistulas treated surgically with extraperiosteal air plombage (AP). Multiple rib fractures which occurred one year later required additional surgery. The fractures included all the ribs which had been extraperiosteally resected at the time of AP. Several bone fragments and surrounding hematomas were removed. The fractures might have been cause by malnutrition and poor circulation in the ribs due to AP, as well as to poor reexpansion of the lung and contamination of the pleural cavity after AP.
We conclude that additional care and attention are required for the early detection of multiple rib fractures after AP.

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A 27-year-old man was admitted to our hospital for the study of a mass seen on a routine chest X-ray film. The mass was in the dorsallateral area of the right lower lobe and was in contact with localized thickening of the pleura. Bronchography revealed convergence of curved bronchovascular markings around the mass. We suspected round atelectasis, but the mass increased in size gradually, so we performed right lower lobectomy. Pathological examination showed a polykaryocytic granuloma.
Mycobacterium tuberculosis was not found. The family history, however supported a diagnosis of tuberculous pleuritis.
In Japan 20 cases of round atelectasis (including our case) have been reported in the literatures. Our patient is the youngest. The most important problem of round atelectasis is its differentiation from malignant neoplasms. A definite diagnosis can be made from the roentgenographic appearance (predilection for posterior or lateral basal segment, localized pleural thickening, comet tail sign, etc.). If a definite diagnosis cannot be made, biopsy or thoracotomy is recommended.

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The omental pedicle flap is an excellent autologous tissue graft for the induction of neovascularity in avascular areas and the elimination of residual space in infected regions, because it has a dence network of blood vessels and abundant lymphatic drainage. Recently, this flap has been used in chest surgery to wrap sites of tracheobronchial reconstruction and to fill empyematous pleural cavities. Bronchopleural fistulas and empyemas that developed after surgical treatment for lung cancer were successfully closed with omental pedicle flaps in two patients. Both patients had undergone pneumonectomy with pericardiotomy and extensive dissection of regional lymph nodes, followed by postoperative radiotherapy. In order to manage the postoperative fistulas, one patient was treated by thoracoplasty and plombage with intercostal muscle flaps, and the other patient by prior open thoracic drainage. We measured the blood flow in the omental pedicle flaps and mucosa of the closed bronchial stumps by laser Doppler flowmeter before and after surgery. The blood flow in the closed bronchial stump mucosa was 35ml/min/100g on the average, and it gradually increased during the 6 months after surgery in Case 1. In Case 2, we measured the blood flow in the omental pedicle flap and the major pectoral muscle flap during surgery. The blood flow in the omental pedicle flap was 30-60ml/min/100g and was greater than that in the major pectoral muscle flap (16ml/min/ 100 g). The blood flow in the closed bronchial mucosa was 38ml/min/100g immediately after the operation.

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Two patients with thymic carcinoid with infiltration into the SVC were treated surgically. The 49 cases reported in the Japanese literature are reviewed. Case 1 was a 56-year-old man with precardial pressure sensation in whom mediastinal tumor was found by chest radiography. In August 1986, using an intra-SVC shunt, we performed total tumorectomy, including total thymectomy, mediastinal lymph node dissection and partial resection of the SVC. The tumor was 8.5×8×6 cm in size. The pathohistological diagnosis was thymic carcinoid with venous infiltration. Postoperative radiotherapy was performed. The patient is good health without relapse 2 year and 10 months after operation. Case 2 was a 60-year-old man in whom thymic carcinoid was diagnosed by puncture cytologic examination under CT guidance. In May 1989, using a bypass with a ringed e-PTFE from the right atrium to the left brachiocephalic vein, we performed total tumorectomy with total thymectomy, mediastinal lymph node dissection, resection of the SVC, and using a ringed e-PTFE from the right atrium to the right brachiocephalic vein, we reconstructed the SVC. The tumor was 10×10×7 cm in size. The pathohistological diagnosis was thymic carcinoid with metastasis to mediastinal lymph nodes and venous infiltration. The patient is in good health with both grafts patent and without relapse 2 months after operation. Therefore, this tumor, which may have low malignancy but can cause infiltration and/or metastasis, should be resected as early and as extensively as possible, including mediastinal lymph node dissection. Venous replacement by artificial veins is considered to be important since it can increase the radical curability of malignant tumors.

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A 52-year-old male was admitted because of an abnormal lesion of right lung. The total W. B. C. count was 1600 with 19% neutrophils. At surgery, it was found that the thymoma invaded the SVC, innominate vein, pericardium, and right lung. The histology of the tumor showed mixed type thymoma. The patient's neutophile count recovered to a normal level 6 months after surgery. Since then this patient has been admitted to our clinic nine times because of recurrence of the thymoma. CDDP was repeatedly injected into the right bronchial artery and costal artery. Severe anemia developed 33 months following surgery. Bone marrow examination revealed pure red cell aplasia, which responded somewhat to blood transfusions and corticosteroids and chemotherapy. However, the patient died of respiratory failure 46 months after surgery.
With the best of our knowledge, only six cases with invasive thymoma after surgery complicated with pure red cell aplasia, have been reported in the Japanese literatures.

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We used the “Kinchu Method” (extraperiosteal air plombage) to treat chronic hemorrhagic pleural effusion of the compressed mediastinum type in a 65-year-old woman who had artificial pneumothorax therapy for pulmonary tuberculosis 40 years earlier. She was admitted because of exertional dyspnea. Chest X-ray films showed total opacity of the left side and a mediastinal shift to the right. Examination of the bloody pleural effusion revealed no malignant cells.
The “Kinchu Method” was performed. The patient was completely cured 7 months after the operation, pulmonary function was improved : blood gas PaO, rose from 53 mmHg to 68.9 mmHg, PaCO₂ fell from 64 mmHg to 44.9 mmHg, %VC rose from 30.4% to 55.7%, and FEV_1.0 rose from 530 ml to 1030 ml.
The “Kinchu Method” is considered to be the best way to treat chronic hemorrhagic pleural effusion complicated by pulmonary dysfunction.

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A 68-year-old man was admitted because of left anterior chest pain. A diagnosis of neurogenic tumor of the vagal nerve was made, and left thoracotomy was performed. A tumor was found attached to left intrathoracic vagal nerve. It was resected by amputating the vagus trunk. The postoperative course was uneventful. The histological diagnosis was Antoni A and B type schwannoma. Intrathoracic vagal nerve tumors are rare. We found 34 reported cases in the Japanese literature. We conclude that complete resection of the tumor is required because malignant change has been reported.

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The patient was a 61-year old male who had c-III B adenocarcinoma originating in the right middle lobe of the lung. Right sleeve pneumonectomy was performed with R2a lymph node dissection, resection of part of the pericardium, and replacement with a Gore Tex sheet. Omentopexy was used to cover the tracheo bronchial anastomosis, stumps of the great vessels and the Gore Tex sheet.
He developed a wound infection on the 5th postoperative day and empyema on the 6th postoperative day. Empyema was completely cured by chest drainage and irrigation of the infected pneumonectomy space with physiological saline containing antiseptic povidone iodine (Isodine) and minocycline HCI (Minomycin).
The prophylactic omentopexy was very helpful in the cure of empyema at the following points.
1) Just at the onset of empyema, minor leakage was found at the tracheo-bronchial anastomosis, but it healed in a few days.
2) Although part of the pericardium was replaced with a Gore Tex sheet in the infected pneumonectomy space, empyema could be cured with conservative treatment.

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A 60-year-old male was admitted to our hospital because of an abnormal shadow on his chest X-ray film. He had no complaints.
Chest X-ray film and MRI revealed a well-demarcated mass in the right paraspinal gutter at Th 9-10.
The red blood cell count was within the normal range.
Operation was performed for a presumptive diagnosis of neurogenic posterior mediastinal tumor.
Histologically, the tumor showed extramedullary hematopoiesis. The patient was examined for blood disorder, but no abnormalities were found.
Extramedullary hematopoiesis in adults is a compensatory response to either chronic hemolytic conditions or bone marrow replacement, but our patient had no underlying disease. Eleven cases of thoracic extramedullary hematopoiesis reported in the world literature since 1982, including our case, are reviewed.

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We reviewed the records of 150 surgically treated patients with idiopathic spontaneous pneumothorax, with special reference to the clinical features and age at time of first episode. Group A comprised 116 patients under 30 years of age and group B, 34 patients 30 years of age or older. The clinical features of these two groups were compared. In group A there was a higher incidence of bilateral pneumothorax (including non-simultaneous) than in group B. At operation group A patients had more emphysematous bullae & blebs. Group B contained a higher proportion of smokers. A comparison of V₂₅/Ht values suggested that group B had greater obstructive ventilatory impairment than group A.
In conclusion, idiopathic spontaneous pneumothorax showed age-related differences in clinical features at the time of the initial episode. External causes such as smoking were closely associated with spontaneous pneumothorax in the older age group.

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The omentum is currently being used to promote wound healing in chest surgery. A 67-year-old male had a left pneumonectomy through a median sternotomy for primary lung cancer. The p-TNM stage was III B in T₄N₃N₀ classification. Eight weeks later, he developed a cough and hemoptysis. Bronchoscopy showed a bronchial fistula at the bronchial stump. It failed to treat this fistula with fibrin glue through the bronchoscope. An omentum pedicled graft was placed in the left thoracic cage trans-diaphragmatically and fixed over the bronchial fistula. The patient's course has been satisfactory.
We consider the omentum to be a very useful tissue for the repair of bronchial fistula following pneumonectomy.

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Case 1 : A 50-year-old man was admitted in January, 1989, with fever and hemoptysis. A chest roentgenogram showed an ill-defined mass and a faint shadow in his right upper lung field. A chest CT scan showed a cavity in the mass.
Case 2 : A 62-year-old woman was admitted in January, 1989, for evaluation of a well-defined mass with pleural indentations and spicules in her right upper lung field seen in a chest roentgenogram. Lung cancers were suspected. Transbronchial lung biopsy (TBLB) showed plasma cell granulomas.
In case 1. the right upper lobe was resected because of recurrent hemoptysis
In case 2. surgery not was performed, the patient has been asymptomatic for one year.
TBLB was useful in the a diagnosis of plasma cell granuloma.

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