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Percutaneous or transbronchial markings are performed to localize pulmonary nodules preoperatively. We present a novel intraoperative procedure that utilizes virtual thoracoscopic imaging-assisted pleural marking. In this procedure, a virtual thoracoscopic image is created preoperatively, and the coordinates of the pleural point above the tumor are determined. The pleural marker is intraoperatively placed on the coordinates, and dye is transferred to the visceral pleura with two lung ventilations. We present the specific procedures and countermeasures for cases when nodules are not palpable. Additionally, we present a comparison between the various methods of preoperative marking and this method.

Introduction: The decrease in the postoperative recurrence rate after thoracoscopic bullectomy for spontaneous pneumothorax is an issue that should be tackled even at this moment. We presently make sure to do the reinforcement of the visceral pleura around between the staple line on bullectomy and the common sites of the new-born bullae such as apex, top site of S6, interlobar fissure to prevent postoperative recurrence., Purpose: We evaluated the latest efficacy of preventing postoperative recurrence by widely covering the staple line and the common sites of the new-born bullae with a polyglycolic acid( PGA) sheet after bullectomy., Methods: Retrospective analyses were performed for 1,097 patients with spontaneous pneumothorax who received thoracoscopic bullectomy at our hospital between January 2011 and December 2020. The 1-year, 3-years, 5-years postoperative recurrence rates of 229 patients with spontaneous pneumothorax were respectively calculated with the Kaplan-Meier method., Results: The 1-year, 3-years, 5-years postoperative recurrence rates of spontaneous pneumothorax were 0.9%, 3.6%, 4.0%, respectively., Conclusions: Combination treatment with bullectomy and wide coverage of the staple line and the common sites of the new-born bullae with the PGA sheet reduced satisfyingly postoperative recurrence rates of spontaneous pneumothorax.

Purposes: Here, we present the tips and pitfalls of video-assisted thoracoscopic( VATS) total pleural adhesiolysis( TPA), determined on an empirical basis., Patients and Methods: From 2012 to 2020, VATS-TPA was performed in 33 patients undergoing pulmonary anatomic lung resection at our institute. The basic procedure was as follows:after peeling off the area of pleural adhesion surrounding the surgical ports using the fingers, the thoracoscope was inserted into the thorax and the adhesions in other areas were peeled off under thoracoscopic guidance., Results: The adhesiolysis group had a longer operating time, greater blood loss, and higher rate of conversion to thoracotomy compared to the non-adhesiolysis group. However, the results were acceptable considering the extra manipulation for adhesiolysis., Conclusions: VATS-TPA is a necessary component of the standard surgical procedure for general thoracic surgeons in cases of total pleural adhesion.

The adhesion between the visceral and parietal pleura makes video-assisted thoracoscopic surgery (VATS) difficult or impossible. When performing VATS without conversion to thoracotomy due to pleural adhesion, it is important to( ⅰ) evaluate the presence and extent of the adhesion preoperatively, (ⅱ) carefully perform detachment, and( ⅲ) adequately repair the injured visceral pleura. We evaluate visceral sliding with the help of chest ultrasonography and plan the best approach to make utility inci-sions, camera port, and third-port incisions. Considering the difficulty in repairing the injured visceral pleura under VATS, we perform extra-pleural detachment of adhesions around the injured visceral pleura, which can facilitate the repair of the pleural injury. For repairing pleural injury, we use free mediastinal fat tissue as biological pledgets to support suturing. In this report, we present the approaches and techniques we follow to perform VATS for patients with pleural adhesion.

Pseudomyxoma peritonei (PMP) is a condition characterized by production of a large amount of mucopolysaccharides by neoplastic epithelium, with intraabdominal cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) known to be viable treatment options. Pleural extension from an PMP is unusual and thought to be related to diaphragmatic perforation during surgery or transdiaphragmatic spreading of the disease through the lymphatic lacunae. Here, we report a patient with PMP with pleural extension of a mucinous tumor for whom CRS was performed twice. A 57-year-old female with PMP infiltrating the right chest cavity was scheduled for two separate CRS and hyperthermic chemotherapy procedures, because of the highly invasive characteristics of the surgery. For the first operation, we performed intra-abdominal surgery under general anesthesia combined with epidural anesthesia. To assess fluid and blood transfusion responsiveness, and reactions to vasoactive medication, we utilized an arterial pressure-based cardiac output monitor and central venous oximetry catheter. The second operation was performed 5 months later under general anesthesia with differential lung ventilation combined with epidural anesthesia. The operation and anesthesia for both surgical procedures were uneventful.

Malignant pleural mesothelioma (MPM) is a rare tumor and associated with very poor prognosis. The median survival time( MST) was 8.9 months for those treated by palliative care only. For a radical treatment, total removal of the tumor is the main therapy as well as other solid tumors, but these diffuse and infiltrate growth pattern of tumor make it difficult. The MST was 13 months for patients treated by surgery only. On the other hand, MST using pemetrexed/cisplatin was 12.1 months. There are negative opinions for invasive surgical treatment such as extrapleural pneumonectomy (EPP). Currently surgical treatment of mesothelioma is conducted as part of the multidisciplinary treatment combined with chemotherapy and radiation therapy.

A 45-year-old man experienced dyspnea on effort and was hospitalized due to severe mitral valve regurgitation and atrial fibrillation. He also had alcoholic cirrhosis. After he was stabilized, mitral valve plasty and Maze procedure were performed. The postoperative clinical course was satisfactory. During the follow-up period, he began to suffer from persistent left pleural effusion, which amounted to about 2,500 to 3,000 ml, and required intercostal tube drainage weekly. Therefore a pleuro-peritoneal shunt was implanted. The pleural effusion decreased, and he obtained significant relief from dyspnea. After one year, we confirmed that pleural effusion had not reoccurred, and removed the pleuro-peritoneal shunt.

A 75-year-old woman who had been treated for pulmonary Mycobacterium intracellulare infection was admitted to a nearby hospital because of hemoptysis, right pneumothorax, and empyema. She had been treated by thoracic drainage and pleural lavage, but was reffered to our hospital because of refractory empyema. Her chest radiograph and chest computed tomography( CT) showed right chronic empyema of which pleural aspirate was smear positive for acid-fast bacilli and positive for the polymerase chain reaction method(PCR)-Mycobacterium intracellulare. Serum levels of white blood cell and C-reactive protein(CRP) were found to be slightly elevated. She was treated with combined use of ethambutol, rifampicin, clarithromycin, and kanamycin and with pleural curettage by thoracoscopic surgery. After surgery additional treatment was done using urokinase which was administered into the thoracic cavity via an thoracic tube. Chronic empyema gradually improved with the treatment and the pleural effusion became bacterial free, enabling the patient to discharge from hospital without thoracic drainage.

Secondary spontaneous pneumothorax (SSP) such as lymphangioleiomyomatosis (LAM), bronchiolitis obliterans (BO) is intractable or repeated the recurrence of pneumothorax. The most effective chemical pleurodesis for intractable pneumothorax is talc poudrage and so on that is associated with a reduction in the rate of pneumothorax recurrence. However, severe and broad pleural adhesion due to the pleural interventional procedures sometimes cause serious bleeding when the patients undergo lung transplantation. We must be considered for new approaches to these intractable secondary pneumothoraces which replaced traditional conservative and surgical approaches. We had proposed new 2 approaches of total pleural covering (TPC) and awake surgical intervention (ASI) for intractable pneumothorax. We applied the TPC modified with coverage of air leak points with polyglycolic acid (PGA) sheet to 5 patients with intractable bilateral pneumothorax to reduce the risk of excessive bleeding by chemical pleurodesis in lung transplantation. The bilateral pneumothorax was well controlled, and no recurrence has been observed. TPC is reliable procedure for management intractable bilateral SSP. For 12 high-risk patients with other underling pulmonary diseases on general poor conditions, a surgical intervention was performed in awake condition. The air leaks were stopped in 11 cases except for 1 case. The recurrence of pneumothorax after surgery was 2 cases. ASI for intractable secondary pneumothorax can be applicable to selected patients with deteriorated general condition.

Background: In our hospital, a new mode of operation was introduced in pleuropneumonectomy from 2004. We studied how these changes had affected postoperative management of patients after pleuropneumonectomy., Methods: We retrospectively reviewed 22 patients who had undergone pleuropneumonectomy for malignant pleural mesothelioma from 2001 to 2008. They were divided into two groups; those before 2003 (n = 6) and those after 2004 (n = 16)., Results: After 2004, the amount of infusion, amount of blood transfusion and bleeding until POD1 were less, and the amount of urine output was more than that before 2003. But no significant complications were observed., Conclusions: The new mode of operation produced great improvement in immediate postoperative management. It is necessary to investigate if the new mode of operation improved prognosis and prevented perioperative complications.

Because extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) suffers from unsatisfiable risk/benefit ratio, very careful consideration on its indication should be required. EPP is a complicated, multi-step surgery that includes pleural dissection, division of hilum, resection of a block of pleura, lung, diaphragm and pericardium, and reconstruction of diaphragm and pericardium. Therefore establishment of surgical images of whole procedures before starting surgery is essential. Dissection of parietal pleura is a particularly important procedure of EPP, because it determinates operating time, surgical blood loss, surgical morbidity/mortality and curability. Technical difficulty of pleural dissection strikingly differs according to the degree of pleural thickening, pleural adhesion and the severity of pleural invasion of the tumor. Although good surgical view is essential for safety, excessive thoracotomy may lead to postoperative pain and respiratory disorder. Underestimation of clinical stage is rather common in MPM even after vigorous preoperative assessment. Surgeons sometimes encounter T4 (i.e., unresectable) MPM such as diffuse chest wall invasion, vascular invasion, peritoneal invasion, and positive pericardial effusion that have not been detected preoperatively. Therefore, potentially-T4 site should be 1st processed for possible discontinuance of operation.

In this report, the results of conventional pleuropneumonectomy in malignant diffuse mesothelioma are reviewed, and the role of this aggressive surgery in multidisciplinary treatment is discussed. The surgical results may improve owing to recent advances in medical technology, although the postoperative survival time after pleuropneumonectomy has remained nearly the same for the past 40 years. The problems with pleuropneumonectomy are high mortality and morbidity rates, high local recurrence rates, and almost the same survival rates as seen after pleurectomy. The indications for this aggressive surgery are limited to stage I, II, and III disease based on an accurate staging system, with induction therapy for macroscopic radical resection and postoperative chemoradiation therapy. In addition, patients must be monitored for the development of major complications perioperatively. The natural history of this disease should be clarified to determine the effectiveness of various forms of therapy. Precise analysis of the accumulated data from many institutions will help to improve the results of pleuropneumonectomy.

The recent development of thoracic surgery has depended on the progressive advances of surgical materials. For the reconstruction of the pleura, the chest wall, the diaphragm, the pericardium and other cardiac structures, materials of high quality are indispensable, and their appropriate use is also important.

Reinforcement of the visceral pleura along the stapled line and prevention of lung-chest wall adhesion is supposed to decrease the recurrence rate of video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax. Covering over the stapled line with an absorbable mesh; polyglycolic acid and regenerative oxidized cellulose mesh, and a fibrin glue is recognized useful for that, although, it tends to be troublesome in VATS procedure. In this article, we present the knack of the covering method: (1) installation of the absorbable mesh on the visceral pleura; a folded absorbable mesh is hold with the endoscopic autosuture or grasping foreceps and placed on the pleura without curling up; (2) installation of a fibrin glue over the pleura and the mesh using a rubbing device (U-rod); each of the fibrinogen solution and the thrombin solution are applied and rubbed on the pleura and the mesh. Surgeons can perform them without any complicated technique.

Twenty-one patients (15 men, 6 women, median age 67) were given a diagnosis of malignant pleural mesothelioma between March 1998 and December 2007 in our hospital. There was apparent occupational exposure of asbestos in 11 patients and suspicion of asbestos exposure in 5. Mean period recuired for diagnosis was 60 days with VATS and percutaneous needle biopsy. Eight patients underwent pleuropneumonectomy. Their median survival was 14.4 months, and the 2-year survival rate was approximately 30%. Seven other patients received chemotherapy, another patient underwent palliative radiotherapy and the remaining 5 patients received best supportive care. One patient had long survived (41.6 months) with gemcitabine-based chemotherapy. In the Senshu district, in the southern part of Osaka, there have been many asbestos spinning mills, so environmental exposure might occur. We should try to diagnose malignant mesothelioma for patients with pleural effusion even if they apparently do not have a history of asbestos exposure.

Based on a hypothesis that the most effective target area for controlling malignant pleural effusion is the parietal pleura, the author has selectively carried out the multimodality treatment with limited operations combined with parietal pleurectomy (PL) followed by paclitaxel administered by 24-hour intrathoracic infusion and systemic chemotherapy. Seven patients with carcinomatous pleuritis were enrolled in the study. During a median follow-up period of 22 months, malignant effusion was controlled successfully in all patients. Although the imbalance on assessment and small sample size render the results inconclusive, the interim results presented here suggest that the tactic of targeting PL warrants further study in a less-invasive manner.

A 67-year-old man with a history of surgical resection of the superior lobe of the left lung and thoracoplasty due to pulmonary tuberculosis occurring approximately 40 years previously, was admitted to the hospital due to recurrent hemoptysis. X-ray films and computed tomography (CT) scans of the chest showed the left thoracic cavity to be filled with empyema, compressing the inferior lobe downward. Since three unsuccessful attempts were made at bronchial artery embolization for hemostasis, yielding hemoptysis of approximately 1,000 ml, emergency surgery was performed. To prevent massive intra-operative hemoptysis, the left pulmonary artery was blocked by median sternotomy. A transverse incision was then made, and thus pleuropneumonectomy could be safely performed. Since it allows early blocking of blood vessels surrounding the hilum of the lung and the main bronchus, anterior approach is useful in treating hemorrhagic empyema and wet pleurisy with internal fistula.

A 49-year-old woman with myasthenia gravis who underwent left panpleuropneumonectomy for an invasive thymoma that disseminated through the left thoracic cavity. After six year, radiotherapy was conducted on the recurrent tumor in the left anterior chest wall. Two years later, the recurrent tumors in the intrapelvic and intrathoracic cavities were resected. It was thought that long-term survival was obtained by combining radiotherapy and surgical treatment in view of the patient's general condition, and of the recurrent invasive thymoma present in this case.

Between 1987 and March 2000, we have operated on eight patients for malignant mesothelioma which consisted of four of localized type and four of diffuse type. We have aggressively resected mesothelioma combined with chemotherapy whether the tumor was primary or recurrent, and concluded the following. 1) In localized malignant mesothelioma, en-bloc primary tumor resection was possible and additional resection for recurrence was effective and useful for long time survival. 2) In diffuse malignant mesothelioma, complete tumor resection was impossible to even perform pleuropneumonectomy accompanied with partial resection of pericardium and diaphragm and, therefore, the prognosis was poor in four patients and all died around one year. 3) Because recurrent pattern for localized type was diffuse type, diagnosis and surgical treatment in early stage was essential for long time survival.

A 58-year-old man was admitted to our hospital because of chest pain and dyspnea on July 15, 1999. A chest X-ray showed left pleural effusion, and a chest CT revealed left pleural effusion and diffuse pleural thickening. Because pleural fluid cytology and percutaneous needle pleural biopsy were negative for malignancy, thoracoscopic biopsy was performed on July 28. The biopsied specimen revealed malignant pleural mesothelioma (epithelial type). An operation was performed on August 16. First, mediastinal lymph node dissection was performed and we identified that there was no lymph node metastasis by frozen section diagnosis. Then panpleuropneumonectomy with combined resection of the diaphragm and pericardium was performed.

A 73-year-old male was admitted with dyspnea and cough. The chest X-ray showed left massive pleural effusion and diffuse pleural tumor in the left thorax. It was diagnosed as epithelial-cell type mesothelioma by pleural needle biopsy. After conforming the regression of the tumor from conducting two courses of combined treatment with cisplatin and doxorubicin, panpleuropneumonectomy was performed. He died from sepsis on the thirty second day after operation due to complication of postoperative diaphragmatic hernia and gastric perforation. When conducting a panpleuropneumonectomy to diffuse pleural mesothelioma, the most appropriate approach must be taken to the combined with resection and reconstruction of the diaphragma.

Three cases of chronic thoracic empyema treated by decortication are reported with special reference to the indications for surgery. The first patient was a 68-year-old man who had right chronic thoracic empyema with a bronchopleural fistula. He underwent open thoracostomy, and decortication was performed after 8 months. The second patient was a 74-year-old man who had right chronic empyema without bronchopleural fistula. Open thoracostomy was also performed and decortication was done after 2 months. Postoperative pulmonary function was significantly improved in both patients. The third patient was a 66-year-old man who had left chronic empyema with a bronchopleural fistula. He underwent open thoracostomy and left lower lobectomy, and then decortication and the omental pedicle flap method were performed after 4 months. All three patients are still doing well currently. It is concluded that decortication significantly improves pulmonary function in properly selected patients, and that computed tomography is helpful for assessing the re-expansion ability of the collapsed lung.

A 46-year-old woman was admitted to our hospital with chest pain. Chest X-ray and CT revealed an anterior mediastinal mass as well as several small masses attached to the left chest wall. Thymoma was diagnosed by percutaneous biopsy. The serum level of anti-acetylcholine receptor antibody was 30.3 pmol/ml. At operation, the thymoma was found left in the anterior mediastinum, extending to the upper lobe of the lung. There were also numerous tumors of various size in the left parietal pleura. Thymectomy, partial resection of the upper lobe of the lung and pleurectomy were performed. One month later, she developed myasthenia gravis. After a complete remission of myasthenia gravis brought about by anti-choline esterase therapy, the patient was treated with irradiation. She has been well for more than five years after the operation but her serum anti-acetylcholine receptor antibody level is still higher than normal.

A 53-year-old male was admitted with cough and chest pain. A chest X-ray film showed left pleural effusion and a chest CT revealed irregular thickening of the pleura. Pleural fluid cytology and percutaneous needle biopsy were negative for malignancy. Thoracoscopic findings revealed fibrin network with pleural effusions and yellow-white pleural thickening, but neither nodules nor masses were found. The thoracoscopic biopsy specimen from the pleural thickening resulted in the diagnosis of malignant pleural mesothelioma. Left pleuropneumonectomy with mediastinal lymph node dissection was performed. Since detailed inspection of the pleural cavity and taking large biopsy samples under thoracoscopic examination are possible, we consider thoracoscopic biopsy to be a useful method for obtaining diagnosis of malignant pleural mesothelioma. Pleuropneumonectomy and systematic lymph node dissection of the pulmonary hilum and mediastinum were believed to be necessary for the surgical treatments.

In total 19 cases of non-Hodgkin lymphoma originating from the wall of chronic tuberculous empyema, pleuropneumonectomeic were performed since 1979, with the aim of total cures for not only lymphoma but empyema in 11 cases. Of these cases extraresections (5 of thoracic cages, 4 of diaphragms, 2 of axillar lymph nodes, each of adventitia of descending aorta and esophagus, of the liver, of the left adrenal grand) were added to extirpate tumors completely. The mean operating time was 6 degrees 55', the mean blood loss during operations was 3090 ml, but in the 3 most recent cases it was less than under 1000 ml using electrocartesy-cutting technique under direct observation. Although preoperative radiations were done to 4 cases to decrease invasive area of tumors and postoperative radiation was done to 1 case, there were no adjuvant chemotherapies. The indicative limitation for resections from the point of ventilatory functions was the same as that of pleuropneumonectomy for ordinary chronic tuberculous empyema. There were 2 cases with serious postoperative complications. One suffered from ARDS and died on the 14th postoperative day, and another developed acute respiratory failure and MOF. But the other 9 cases kept good postoperative courses with a few recurrences of minor empyema. The prognoses for 10 remaining cases is excellent. Only one case died from local recurrence in of lymphoma 27 months later, but all other 9 cases have revealed no recurrence in any places, and the 5 year survival rate based on Kaplan-Meier method of 10 cases is 85.7%. By the way no cases could survive one year later in unresected group. So under the poor prognosis of treatment with radiation or chemotherapy for non-Hodgkin lymphoma originating from chronic tuberculous empyema, we conclude that the complete resection of tumor and empyema, so called pleuropneumonectomy, is the best way to cure this disease.

Transverse sternotomy was performed in a 39-year-old man having bilateral lung metastatic lesions of yolk sac tumor. This approach provided an excellent operative field. Bilateral partial lobes including parietal pleura and diaphragma were readily resected. As described in this paper, transverse sternotomy is one of the beneficial method in the thorough surgical treatment for metastatic bilateral lung lesion.

We report a case of diffuse malignant mesothelioma discovered by thoracoscopic examination undertaken while formulating a preoperative diagnosis. A 61-year-old male complained of coughing and sputum production, and was admitted because his chest roentgenogram indicated an abnormal shadow. Chest CT scanning demonstrated right pleural effusion and multiple nodules sited on the diaphragm. Because aspiration biopsy of such nodules was difficult, we performed a thoracoscopic examination. The thoracoscopic findings demonstrated bloody pleural effusion in the right thoracic cavity and multiple nodules on the diaphragm, parietal and pulmonary pleura. They were white and 0.5 to 2 cm in size. By excisional biopsy, these were diagnosed as epithelial-type diffuse malignant mesothelioma. We therefore performed panpleuropneumonectomy. Even though we completely resected the canal of thoracoscope and drainage tube, microscopic findings showed invasion of mesothelioma cells into this thoracoscopic canal. Although we suggest that, in preoperative diagnosis of pleural tumor, thoracoscopy is efficient to perform a pathological examination and confirm the extension of tumor, in the actual operation, we believe that the thoracoscopic canal should be resected.

A felt-like bioabsorbable prosthesis (Polyglycolic Acid (PGA) pledget and sheet; Medifit feft) was used for pulmonary fistula in a total of 10 patients. "Fibrin glue A" was absorbed into the PGA prosthesis previously. And next, the part of pulmonary fistula was coated with "Fibrin glue B", and then covered with the fibrin-absorbed PGA prosthesis. The prosthesis adhered to the diseased part of pulmonary pleura immediately, and therefore, in all these 10 patients, the post-operative air-leakage was stopped up to 4 days and neither side effect nor complication was observed.

We studied the influence of pleurotomy during harvesting IMA for CABG on postoperative pulmonary function. Ninety nine cases underwent CABG surgery from January 1991 to July 1992, were divided into three subgroups, 45 patients (subgroup AY 2) having bilateral IMAs graft with pleurotomy, 45 patients (subgroup AY 1) having unilateral IMA graft with pleurotomy, 9 patients (subgroup AN) having unilateral IMA graft or vein grafts without pleurotomy. Frequencies of chest X-rays abnormality such as elevation of diaphragm and accumulation of pleural effusion before discharge around 2 weeks after surgery, were not significantly different among three subgroups. 58 cases without chest X-rays abnormalities were divided into three subgroups in the same way. There was no case with late extubation or with postoperative pulmonary complication. At first we compared pre-with postoperative pulmonary function in each subgroups. Pulmonary function (VC, FEV1.0, peak flow, MMF, V50, V25) was significantly deteriorated in the patients with pleurotomy, while VC, FEV1.0, peak flow significantly decreased, and MMF, V50 and V25 tended to decrease in the patients without pleurotomy. Moreover, magnitude of change of pulmonary function from pre- to postoperative period were not different significantly among three subgroups. In conclusions pleurotomy itself didn't appear to influence postoperative morbidity.

A 71-year-old female was seen with a complaint of chest pain and cough, and a history of tuberculous pleurisy and artificial pneumothorax 40 years ago. The diagnosis of empyema with carcinoma was made by chest X-ray and CT scans. The examination of lung function showed a restrictive disorder. The value of the predicted postoperative FEV1 0.75 l encouraged to perform operation. A left pleuropneumonectomy and combined resections of the invasive portion of the pericardium and left atrium was performed. Histological examination revealed large cell carcinoma of lung (pT 4 N 1 M 0). The literatures are reviewed concerning the thoracic malignant tumor arising in chronic empyema cavity on Japanese cases.

A 52-year-old woman of diffuse malignant mesothelioma of the right pleura with metastasis to right supraclavicular lymph nodes underwent extended extrapleural right pneumonectomy and neck dissection. For this resection we selected the new approach: median sternotomy with hemi-collar incision. Through this approach systematical dissection of the cervical-mediastinal lymph nodes was performed together with resection of the right lung, parietal pleura, the pericardium and the diaphragm. As a result of this en bloc resection, she is alive without recurrence for one year after the operation.

Atypical mycobacterial infection mostly develops in the lung and its occurrence outside of the lung is very rare. We report a case of mycobacterium avium complex (MAC) infection found with chronic empyema piercing out of the thoracic wall, to which surgical treatment was very successful. A 72-year old male had been treated for an abscess of right thoracic wall. MAC was isolated from thoracic effusion. Thoracic window and pan-pleuro-pneumonectomy was performed. No recurrence of MAC infection was found up to 1 year and 4 months when he died of accident.

Two cases of re-expansion pulmonary edema following decortication of a tuberculous empyema are presented. The period of compression of the whole lung by empyema was relatively short in both cases. One case showed incomplete expansion of the whole right lung after preoperative drainage, and re-expansion pulmonary edema of the whole right lung after decortication, which was treated by mechanical ventilation and steroid therapy. The other case showed incomplete expansion of the right middle and lower lobes after preoperative drainage, and re-expansion pulmonary edema of the right middle and lower lobe after decortication, which was treated by steroid therapy. In cases of tuberculous empyema with a relatively short course, re-expansion pulmonary edema may occur in a lung incompletely expanded by preoperative drainage.

We reported a successful pleuro-venous shunt operation (Pl-V shunt) for a patient of liver cirrhosis with secondary hydrothorax. A 78-year-old female was admitted to our hospital because of severe dyspnea and palpitation. Chest x-ray film revealed right sided massive pleural effusion. Over several weeks the chest tube drainaged about 1,500 ml of transudative fluid per day. We performed Pl-V shunting and pleural effusion subsequently decreased in amount and dyspnea disappeared. This Pl-V shunting is thought to be useful for such a patient with massive pleural effusion which failed to respond to medical therapy.

Open biopsy and pleurectomy were performed in 2 cases of asbestos exposure with bloody pleural effusion. Pathological examination revealed marked proliferation of fibrous tissue containing tumor cells. The tumor was diagnosed as malignant pleural mesothelioma on the basis of histochemical staining and transmission electron microscopy. Almost complete excision of tumor tissue was performed, and malignant mesothelioma had not relapsed 10 and 12 months after the operation. We recommend open biopsy and pleurectomy for cases of exposure with bloody and intractable pleural effusion.

Bioabsorbable PGA non-woven fabric sheets were used to treat 103 patients who underwent pulmonary surgery in three hospitals, and their handleability, applicability, drainage time after surgery and subsequent side effects were studied. For suture reinforcement, these sheets showed satisfactory handleability, applicability and effectiveness for hemostasis and prevention of air leakage at the suture sites. Since this material has good compatibility with fibrin glue, use of these two materials in combination reduced both the operation time and postoperative drainage period. For small fistula and pleural defects, attachment of the sheets with fibrin glue to create an artificial pleura was sufficient for prevention air leakage without suturing. No side effects or complications were observed, and the postoperative courses of all 103 patients were uneventful. These findings suggest that PGA sheets are acceptable for suture reinforcement in the pulmonary surgery, and that when used with fibrin glue, can simplify surgery for emphysematous lung disease and shorten the period of postoperative air leakage.

Twelve patients of non-small cell lung cancer with carcinomatous pleuritis were subjected to panpleuropneumonectomy between June 1981 and December 1988. The median survival time was 13 months. One-year and 3-year survival rates were 52% and 26%, respectively. There was no significant difference in prognosis compared with the results of other modality therapies such as pleurodesis with talc and tube drainage for pleural effusion. After panpleuropneumonectomy the patients were divided into the group with only pleural dissemination and the one with pleural effusion. The median survival time in the group of pleural dissemination was 14 months. The three-year survival rate was 50%. The one patient survived for 51 months and the other for 45 months. The median survival time of patients with pleural effusion was 4 months without over 1-year survivor. The statistically significant difference was found between the two groups (p less than 0.05). We concluded that panpleuropneumonectomy is indicated only for the patients of non-small cell lung cancer with diffuse pleural dissemination and no pleural effusion.

Among surgically resected 192 lung cancer cases, eleven with a interlobar pleural involvement (p 3) were studied to clarify their characters. The five year survival rate of interlobar p 3 was 12.5% (15.6% in case of excluding death of other diseases), which was better than that of the other parietal p 3. Result of surgical treatment of lobectomy + partial resection for interlobar p 3 had better tendency compared with that of bilobectomy or pneumonectomy. But, unfortunately it was necessary for interlobar p 3 to care the local recurrence in the future. We hope that the general rule of the treatment for interlobar p 3 was carefully discussed furthermore, including the safety margin in the partial resection or the classification on T factor.

Nine patients were diagnosed as suffering from localized pulmonary aspergillosis associated with restrictive ventilatory impairment. Eight cases reportedly received a combination of thoracoplasty and cavernoplasty, while one case received only cavernoplasty. The following postoperative courses were observed in these nine patients: of the eight patients having combined thoracoplasty and cavernoplasty, seven patients were cured as the result of successful cavity closures. Cavernotomy was required for the remaining patient whose cavity failed to close. An attempt was made to close the cavity of the one patient reported to have only cavernoplasty, but the cavity failed to close on the first attempt. The cavity was successfully closed in a later attempt using thoracoplasty. Although the application of thoracoplasty and cavernoplasty is useful and safe to the treatment of patients being unable to undergo resection and/or having pulmonary dysfunction, it is very important to reduce the number of ribs being resected because pulmonary function may be more worsened after operation. A combination of extraperiosteal detachment and cavernoplasty seems to be a useful alternative. A lower limitation of the postoperative ventilation function, evaluated as a ratio of FEV1.0/VCpr is thought to be 20%.

A 63-year-old female was admitted to our hospital with chief complaint of exertional dyspnea. Right massive pleural effusion was found. After chest drainage was performed, chest CT scan and MRI showed several masses in the anterior mediastinum and on the diaphragma. Mesothelioma was suspected for needle biopsy. Pleuropneumonectomy with combined resection of diaphragma, superior vena cava and pericardium was performed. Histologically, the Tumor was mixed thymoma. She is well and alive for three years after operation. Pleuropneumonectomy may be a choice of effective treatments for invasive thymoma with pleural dissemination.

Three cases of catamenial pneumothorax were presented. A 42-year-old woman with intrapelvic endometriosis had recurrent right-sided pneumothorax with menstruation more than six times. At the operation only a bleb was noted at the apex of the right lung. In a 16-year-old woman who already had been operated on for recurrent right-sided pneumothorax one year ago, left-sided pneumothorax occurred on the day of the beginning of each menstruation four times. A small bleb was noted at the apex. A 29-year-old woman with cesarean section at the age of 25 had recurrent right-sided pneumothorax occurring on the day before the beginning of menstruation three times. Though the operation was performed during her menstrual period, neither air leakage nor any lesions were found. In all cases each lesion was resected and did not prove endometriosis, and partial parietal pleurectomy was performed for pleurodesis. No pneumothorax has recurred.

A case of invasive thymoma with pleural disseminations, treated with pleuropneumonectomy and thymectomy , is presented. A 30-year-old woman was admitted with abnormal shadows in left lung field and mediastinum. On chest CT examination, the tumor shadows were located anterior mediastinum and left chest wall. Thymoma with pleural disseminations was the most likely consideration by the needle biopsy specimen of the tumor under left chest wall. Preoperative radiotherapy for anterior mediastinum mass was effective. Pleuropneumonectomy and thymectomy combined with partial resections of intercostal muscles and diaphragm were performed. Histologically, the tumor was arranged in lobular structure, composed of epithelial cells, with poorly infiltration of lymphocytes, and invaded into intercostal muscles or lung. Postoperative radiotherapy for mediastinum and left chest wall was added. Tumors may be removed completely by pan-pleuropneumonectomy and thymectomy for invasive thymoma with pleural disseminations.

Pulmonary function was evaluated in patients who were operated on for chronic empyema between October 1973 and October 1988. Fourteen patients underwent decortication, 61 were treated by the Kinchu method, 20 were treated by muscle flap and thoracoplasty, and one underwent pleuropnemonectomy. With decortication or the Kinchu method, significant postoperative improvement was noted in both percent forced vital capacity and FEV1/predicted initial capacity. However with muscle flap and thoracoplasty, percent forced vital capacity decreased. Ventilation and perfusion lung scan showed that pulmonary function improved in patients with good re-expansion of the lung who had suffered from short term lung collapse and no pathological changes in collapsed lung parenchyma.