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The strategy for the administration of fluid and nutrition management after lung resection is not unusual, as compared to the other ordinal surgeries. However, it should be kept in mind that relative reduction in right ventricular function could occur following lung resection due to increased pulmonary vascular resistance. The surgical trauma such as pulmonary arterial clamp and lymphadenectomy as well as the removal of the lung, and perioperative factors such as single lung ventilation, could also increase pulmonary vascular resistance, all of which could be related to acute lung injury. Regarding the fluid management, excessive fluid administration could cause pulmonary edema, decreased alveolar gas permeability, atelectasis, and hypoxia, while restrictive fluid management could induce complication related to hypoperfusion. Since these adverse effects are highly associated with the main causes of morbidity and mortality particularly in the compromised patients, a proper assessment and monitoring of fluid balance (fluid optimization) would be required. In addition, along with the increasing number of the elderly patients, particular concerns must be given to the patients with the sarcopenia or frailty. The appropriate nutritional support following lung surgery is necessary to reduce surgical morbidity and morbidity especially for the malnourished and elderly patients.

A 39-year-old man was admitted to our hospital with back pain and numbness of the left leg. Computed tomography (CT) showed a giant bulla and tumor in the right lung, mediastinal shift to the left side and lesions suggestive of metastatic sacral tumor. Three days later, the patient visited the emergency room with dyspnea and tachycardia. Chest CT showed the progression of mediastinal shift due to the rapid expansion of the giant bulla, and an emergency surgery was performed. After induction of anesthesia, sudden respiratory and circulatory failure occurred. Considering further expansion of the giant bulla by positive pressure ventilation, veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) was applied. After establishing ECMO, the condition of the patient became stable and the giant bulla could be resected successfully.

Lung cancer invasion of the chest wall is considered to occur in approximately 5% of all patients who had undergone lung cancer resection. Surgical resection is recognized as a standard treatment, and surgical treatment plays a major role because survival is highly dependent on the completeness of the resection. On the other hand, prognosis is still poor in cases with mediastinal lymph node involvement, and the indications for surgery remain controversial in such cases, with increasing number of reported perioperative chemoradiotherapy cases. In addition, the use of minimally invasive surgery combined with thoracoscopy has become widespread in recent years, and indications are being considered for chest wall resection cases. In this paper, we review the results of operation for lung cancer with chest wall invasion other than those for superior sulcus tumors and discuss the role of surgical treatment and surgical resection and reconstruction techniques.

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic disease characterized by hypophosphatemia and skeletal undermineralization. Overproduction of fibroblast growth factor 23( FGF23) from the responsible tumor is reported to be a causative factor. Removing the tumor is the only effective treatment for TIO, but identifying the tumor is sometimes difficult. A 43-year-old man complained of heel pain 4 years earlier, and the pain gradually expanded to the whole body. As a blood test showed the elevation of the serum FGF23 level and hypophosphatemia, he was diagnosed with FGF23-related hypophosphatemia. Chest computed tomography (CT) showed a 10-mm nodule in the right chest wall. Venous sampling for FGF23 revealed considerable elevation of the FGF23 level in the right subclavian vein. Therefore, a chest wall tumor was suspected as the tumor responsible for TIO, and surgical resection was performed. After surgery, hypophosphatemia improved within several days, and the FGF23 level also normalized.

In the management of chest drain after thoracic surgery, it is important to egest fluid and air which accumulate in the pleural cavity and to gain information such as air leakage, bleeding or pus discharge. To achieve these purpose, continuous chest drainage system is necessary for thoracic surgery. In addition, we have to understand the particularity in the pleural cavity and the structure of continuous chest drainage system. Traditional drainage system is based on 3-bottle system. Recently, we can use new drainage system, such as Thopaz, which is called digital drainage system. There are several studies comparing digital drainage system with traditional drainage system, but the superiority of digital drainage system to traditional drainage system is not confirmed.

Minimally invasive surgery is being widely performed for the management of lung cancers owing to rapid technological advances in surgical devices and techniques. In recent times, because chemotherapy and radiotherapy have both become less invasive treatment strategies, therapeutic opportunities for the use of multimodality therapy have been increasing. Minimally invasive surgery is an important component that requires additional improvements to derive the complete benefit of multimodality therapy. We have been actively performing video-assisted thoracic surgery(VATS) for the management of advanced lung cancers, as well as early lung cancers to reduce surgical stress in our patients, thereby enhancing the scope of multimodality therapy. Although some reports have demonstrated the efficacy of VATS for the management of early lung cancers, only a limited number of reports have discussed the advantage of VATS for the management of advanced lung cancers. In this report, we reviewed patients with advanced lung cancer (pathological stageⅡ or Ⅲ) in whom complete resection was performed between January 2011 and December 2016, and we examined the role of VATS as a component of multimodality therapy.

We report a rare case of giant cell tumor of the rib. A 33-year-old man was admitted to our hospital because of a recently appearing mass and pain in the right chest wall. Chest computed tomography and magnetic resonance imaging revealed a heterogeneous mass of 8-cm in diameter arising from and destroying the right 7th rib. The tumor was resected together with the 6th, 7th, and 8th ribs and the adjacent muscle and diaphragm. The pathological diagnosis was giant cell tumor of the bone. The patient has been free from recurrence or metastasis for 4 years after the operation.

Postoperative intrathoracic hemorrhage is sometimes diagnosed in the thoracic cavity, while the patient is in the recovery room after undergoing thoracic surgery such as lung resection with thoracotomy or mediastinal surgery with a median sternotomy. The information from the chest tube is important to identify this kind of postoperative complication. When the condition becomes severe, the patient may develop hemorrhagic shock due to hemothorax and re-exploration to assess for bleeding and hemostasis may be required. The frequency of reoperation required in patients with postoperative hemorrhage is considered to be 1~3%. The bronchial artery, intercostal artery, and the intercostal vein are the most frequent sources of the hemorrhage. In some cases, the source of hemorrhage cannot be identified during re-exploration. However, intrathoracic hematoma removal by reoperation is essential to allow for adequate expansion of the remaining lung. Although a thoracoscope is usually inserted for re-exploration of the thoracic cavity initially, quick thoracotomy might be required to control hemorrhage, if the patient's vitals indicate rapid hemorrhage and subsequent shock.

The mediastinal mature teratoma is uncommon in adult and sometimes ruptures. We present a case of perforation of mediastinal mature teratoma. A 22-year-old man, who had been scheduled for surgery to resect anterior mediastinal teratoma, was referred to our hospital due to sudden chest pain. The enhanced computed tomography findings suggested a perforation of the teratoma and the emergency surgery was performed. Extirpation of the tumor with partial resection of right upper lung, pericardium, and superior vena cava was performed. The histological diagnosis was mature teratoma and the defect of the mediastinal pleura was found to be the site of perforation. The patient was well and discharged from the hospital without complications.

Surgical intervention is routinely employed for non-small cell lung cancer, whenever no distant metastasis is found. However, its surgical results depend on the staging of the lung cancer, and surgery for stage III disease is less effective compared with stage I or II disease. For patients with stage III, some treatments such as induction chemotherapy have been tried to support the surgery. Recently, T3 lung cancer is divided in two category of staging, T3N0 is evaluated to be stage II B and T3N1-2 is stage III A. In this study, we classified T3 diseases by some factors, and examined long-term survival of each group. As a result, we concluded that mediastinal invasion and N2 involvement were risk factors to early failure. On the contrary, patients with adjacent lobe invasion and resection of two lobes led to the prolonged survival rather than lobectomy with partial resection of adjacent lobe.

Home medical care is becoming a greater matter of concern along with the increasing population of elderly persons. The various difficulties in home care are also found in regional care, and it could be said that in Japan regional care serves as an "advanced model" for home medical care. Ohya Town is located in the mountains of northern Hyogo Prefecture. It has a population of about 5,000 of which 32% is elderly people. There is no railroad, and it takes around 30 minutes to travel to the central hospital from the area. The three town clinics are in contact with each other and with the central hospital concerning medical information. The characteristics of Home Parenteral Nutrition in this underpopulated district are discussed and reported in reference mainly to cases in which the 3 way valved peripherally inserted central venous catheter (Groshong Catheter) is used, in comparison with HPN cases in the city university hospital.

We report a case of operation against chronic expanding hematoma developed in the pleural cavity of the patient who were treated as anaplastic anemia. 69-year-old man had been underwent thymectomy because of the thymoma and hemogenic pleural effusion 8 years ago. Then, last year, he was pointed out severe thrombocytopenia and underwent transfusion of thrombocyte. In the same period, chest X-ray examination revealed development of the tumor-like shadow in the left lung field. The abnormal shadow has enlarged, so the patient admitted us. X-ray findings revealed the huge tumor occupied completely the left pleural space. He was also pointed out severe pancytopenia (WBC: 2,600/mm3, RBC: 172 x 10(4)/mm3, thrombocyto: 1.9 x 10(4)/mm#), and the examination of bone marrow revealed anaplastic anemia. Thoracotomy was underwent, and the tumor was resected. Pathological diagnosis of the tumor was huge hematoma. Negative pressure in the pleural space would keep the hemorrhage and make hematoma huge. The hematoma in the pleural space should be resected as soon as the diagnosis is decided.

Airway obstruction due to oppression by the right aortic arch is relatively common in the newborn, but has never been reported in the adult. We reported an aged case of right main bronchial stenosis due to the oppression by the right aortic arch, performed successful bronchodilatation using the stent. A 92-year-old male complained of fever and productive cough and hospitalized with a diagnosis of pneumonia. Close examinations revealed that his right main bronchus was stenotic due to oppression by the right aortic arch. Bronchodilatation was performed successfully using a Gianuturco-type expandable metallic stent. No endoluminal stenosis was found during 12 months follow up. For the treatment of bronchial deformity by the extrabronchial oppression, implantation of the Gianturco-type expandable metallic stent is considered to be very useful method.

A 46-year-old woman complained of a back pain and was pointed the abnormal shadow on chest X-ray by the physician, so she consulted our hospital in January 1987. After a few weeks, the size of the shadow decreased with no treatment, then we followed up her with roentgenograms. Since '91, its size had increased again. Needle biopsy did not give us the diagnosis, but we performed the operation because we suspected some malignant disease. We resected the tumor with the enough surgical margin. Its size was 4 x 3 x 3 cm, its surface was white and smooth. Its was elastic hard and had the pedicle which jointed the visceral pleura. Histological diagnosis was the localized fibrous mesothelioma.

To evaluate the effects of ceftriaxone (CTRX) administered once daily, the biliary concentration of CTRX and daily changes in the bacterial count in bile from an indwelling T-tube were measured concomitantly. The effects on prophylaxis of postoperative infections after biliary tract surgery were also examined mainly due to clinical symptoms. The biliary CTRX levels increased rapidly and were sustained as high as 92.5-219 micrograms/ml in all patients even 24 hours after 2 g of CTRX was infused intravenously once daily. Five of 7 patients whose bile samples were positive for bacteria showed high CTRX levels in bile and almost no bacteria present after treatment. CTRX-sensitive bacteria eliminated 1 or 2 hours after the administration in response to the increase of biliary CTRX levels. The changes in bacteria count of bile may be closely related to CTRX antibiotic activity. As an antibiotic prophylaxis, other 18 patients with biliary diseases received intravenous infusion of 2 g of CTRX once daily for 5-7 days (mean 5.9 days). Thus, once-daily dose treatment of CTRX 2 g may have antibiotic effects on biliary infection and postoperative prophylaxis of biliary infections and it is indicated that the prolonged biliary levels of CTRX are essential for its efficacy.