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Background: Selective sinus replacement seems a reasonable option in cases requiring replacement of one or two sinuses of Valsalva, especially with acute aortic dissection and high bleeding risk., Methods: Six patients (average age 58±17 years;five males) underwent selective replacement of the right sinus of Valsalva with right coronary artery bypass grafting (n=5) in 2015-2023. Five patients developed acute aortic dissection and one developed aneurysm of the right sinus of Valsalva., Results: All patients survived the operation, and there were no cases requiring re-exploration for bleeding. Intraoperative transesophageal echocardiography showed trivial or less aortic regurgitation (AR) in all patients. Cardiopulmonary bypass time, aortic cross-clamping time, and lower body circulatory arrest time were 214±28 min, 159±22 min, and 31±6 min (n=5), respectively. During follow-up of 55±44 (4-104) months, all patients were asymptomatic. AR was mild or less in four patients, mild-moderate in one patient, and severe in one patient. All patients had normal cardiac function without left ventricular enlargement, and so no reoperation was required., Conclusions: Although this method appears to be relatively safe and effective, some patients developed late AR. Long-term follow-up of larger numbers of patients will be necessary to confirm its effectiveness.

We report a case of huge aortic root aneurysm 19 years after aortic valve replacement. A 58-year-old woman was referred to us for aortic root dilatation. She underwent aortic valve replacement with mechanical valve due to severe aortic regurgitation of tricuspid aortic valve 19 years ago. We performed graft replacement of aortic root preserving prior mechanical prosthetic valve. Histological examination of aneurysm showed myxomatous change in medial layer. Aortic root dilatation after aortic valve replacement is caused by bicuspid valve, aortic dissection, Marfan syndrome, tissue disorder disease, aortitis, and dilated Valsalva sinus at the time of prior operation. It is important to follow-up a patient for root dilatation after aortic valve replacement.

Meningitis has not been described to the same extent as other neurological complications of infective endocarditis(IE). The appropriate selection and dosing of antibiotics for patients with IE and meningitis do not exist. Herein, we described an instructive surgical case of mitral valve endocarditis and meningitis caused in a patient with atopic dermatitis, that was successfully treated using a multi-disciplinary approach.

We report here our experience with a case of anaphylactic shock caused by fibrin glue. A 51-year-old male underwent a thoracoscopic surgery for refractory pneumothorax under local anesthesia. Bullae were revealed, and subsequently covered with fibrin glue and a polyglycolic acid sheet. Twenty-minutes after application of the fibrin glue, sudden drop of blood pressure less than 80 mmHg and a skin rash appeared. Since the patient was not administered any other drugs prior to the reduction in blood pressure, anaphylactic shock was considered to be caused by fibrin glue. The patient recovered after the treatment by dopamine and steroid.

Although nonstructural dysfunction of a bioprosthesis caused by pannus formation or native valve attachment has been well described, structural valve deterioration( SVD) caused by calcification or tear of a bioprosthesis, especially a bovine pericardial valve, is very rare in the tricuspid position. We report a case of redo tricuspid valve surgery for SVD 14 years after tricuspid valve replacement( TVR) using a Carpentier-Edwards Perimount (CEP) pericardial valve. A 71-year-old woman was referred to our hospital because of exertional dyspnea and pre-syncope. She had undergone mitral valve replacement with a St. Jude Medical mechanical valve and TVR with a CEP pericardial valve 14 years previously. Transthoracic echocardiography revealed tricuspid valve stenosis with a mean trans-tricuspid valve pressure gradient (TVPG) of 7.3 mmHg. Redo TVR using a CEP Magna Mitral Ease valve was performed under cardiac arrest. Severe calcification was observed on the ventricular side of the leaflets of the explanted valve. The mean TVPG decreased to 3.2 mmHg after surgery, and the patient's postoperative course was uneventful.

A 69-year-old woman was diagnosed with a germ cell tumor in the anterior mediastinum. Following 3 years follow-up, she experienced chest pain and an enlarging of the anterior mediastinal tumor and bilateral lung metastases were detected by chest X-ray. The tumor was diagnosed as a primary malignant mediastinal non-seminomatous germ cell tumor by needle biopsy. After initial radiotherapy (12 Gy/4 Fr), she was subsequently treated with EP chemotherapy which achieved a partial response. Complete resection of the residual tumors in the mediastinum and right lung was performed. No recurrence has been noted for 5 years post-operatively.

We performed salvage surgery after chemoradiotherapy(CRT) in a patient with thymic basaloid cell carcinoma. A 46-year-old man with an abnormal chest shadow on X-ray findings was referred to our hospital. Computed tomography revealed a partially solid tumor along with a multilocular cyst in the anterior mediastinum with mediastinal lymph node swelling infiltrating to the superior vena cava(SVC). Positron emission tomography revealed FDG accumulation (SUVmax 7.94)in the tumor. Pathological findings of a tumor biopsy specimen obtained by thoracoscopy led to a diagnosis of thymic basaloid cell carcinoma. Following CRT (ADOC+RT:60 Gy), a complete resection (R0)with replacement of the SVC was performed. The postoperative course was uneventful, and the patient was alive at 20 months after surgery with metastasis to the cervical lymph nodes and bone.

A 66-year-old woman who had had coughing and worsening dyspnea for 3 weeks was admitted to our hospital. Echocardiography showed a solid round mass (72×49 mm in diameter) attached to the tricuspid septal annulus with a short stalk. A right atrial myxoma was suspected and operation was performed under cardiopulmonary bypass after heart failure symptoms subsided. The tumor was extirpated along with the tricuspid valve annulus. We performed reconstruction of the tricuspid annulus, tricuspid valve replacement with a bioprosthetic valve and pacemaker implantation. The histopathologic diagnosis was myxoma. The postoperative course was uneventful, and no recurrence has been noted for 1 year after surgery.

A 41-year-old female with hereditary deficiency of antithrombin III (ATIII) was diagnosed with atrial septal defect( ASD) and scheduled for the closure of ASD. She had been taking warfarin since she suffered from deep vein thrombosis 10 years ago. Preoperative management of anticoagulation included discontinuation of warfarin, and supplementation of antithrombin with heparin infusion. On the day of operation, antithrombin activity was maintained above 80% by administering antithrombin, and closure of ASD was carried out under standard cardiopulmonary bypass support using heparin. Heparin infusion was continued with antithrombin supplementation until prothrombin time-international normalized ratio(PT-INR) recovered to around 2.5 with warfarin. Her intra-and postoperative courses did not show any thromboembolic events, and she was discharged 20 days after the surgery.

A 71-year-old woman was referred to our department for a nodular lesion in the left lung. She had been followed by urology department in our hospital for 6 years since right nephrectomy for ureter cancer. Chest X-ray and computed tomography (CT) scan demonstrated a small nodular shadow in the left lower lobe. The lung tumor was removed by wedge resection, and pathologically diagnosed during the operation as a metastasis from the ureter cancer. The lung tumor consisted of clear cells similar to the ureter cancer. However, the final pathological diagnosis changed to a primary lung cancer based on the findings of stratified differentiation and cancer cell nests in the tumor. Immunohistochemical staining for ureter epithelium-related antigens confirmed the diagnosis. Although we recommended left lower completion lobectomy, the patient refused additional surgery. She is suspected to have local recurrence in the left lower lobe 18 months after the surgery.

Lower body ischemia due to bending of a stented graft at the thoracic aorta was rare, particularly when it occurred in several days after surgery. We experienced this complication and performed the 3rd-time thoracic endovascular repair( TEVAR).A 49-year-old man with a chronic aortic dissection of Stanford type B underwent TEVER;however we failed to close the entry because of the tortuously bended distal arch of the aorta. Then it was decided the patient undergo a hybrid treatment with arch replacement and frozen elephant trunk. Seventeen days after the surgery, the blood pressure of the patient's lower limb was reduced rapidly and his renal function deteriorated. Bending of the stent was revealed by computed tomography( CT). The patient underwent the 3rd-time emergency TEVAR, and his symptoms improved.

We retrospectively analyzed surgical approach to cystic thymic lesions based on 25 cases. We classified to 4 groups as follows, 12 thin-wall solitary cysts with low uniform density, 7 solitary cysts with ununiform density, 5 cysts with tumor lesions and 1 multiple cysts. Preoperative image diagnoses were 10 thymic cysts, 7 cystic thymomas, 4 mature teratomas, and 1 each of multilocular thymic cyst and thymic lymphoma. Twenty cases were indicated to video-assisted thoracic surgery( VATS), the other 5 cases were operated by sternotomy. The reasons for thoracotomy were adherence with left brachiocephalic vein(LBCV)3, huge cyst compressing superior vena cava (SVC) 1, diffuse multiple cysts and tumors in hypertrophic thymus 1. Three cases were converted to open thracotomy from VATS because of dense adhesions around LBCV and malignant diagnosis. Final diagnosis are 16 congenital cysts, 3 thymomas, and one each multilocular thymic cyst, mature teratoma, thymic cancer, thymolipoma, venous hemangioma and mucosal associated lymphoid tissue( MALT) lymphoma. Thin-wall solitary cysts with low uniform density are able to diagnosed congenital thymic cysts by computed tomography( CT)/magnetic resonance imaging (MRI) appearances. On the contrary un-uniform density cysts or cysts with tumor lesions are difficult to achieve correct diagnoses by images. These lesions may contain thymoma or thymic cancer, so that rapid pathological examination should be prepared during surgical operation. Cysts adhering to LBCV should be operated by thoracotomy to avoid accidents of massive bleeding.

Optimal timing of surgical repair for traumatic aortic injury (TAI) is still controversial. We have experienced 3 cases of TAI. The 1st one suffered from severe multisystem trauma in addition to TAI, so we performed graft replacement of the proximal descending aorta electively 31 days after the injury. The 2nd one had massive pleural effusion on admission and we performed urgent operation. They recovered uneventfully. The last one died of aortic re-rupture during anesthetic induction despite attempting emergent operation. In patients with serious multisystem trauma besides TAI, surgical repair can be delayed as long as there are no signs of on-going rupture and/or bleeding, however close observation, serial computed tomography( CT) check-ups and strict control of blood pressure are needed.

We report a rare case with severe intestinal ischemia due to chronic aortic dissection. A 75-year-old man was admitted to our hospital with abdominal and right leg pain. The patient had a history of aortic dissection (Stanford type B) 12 years before admission and had been treated medically. Although a throaco-abdominal aneurysm due to aortic dissection (Crowford type III) had been diagnosed 1 year before admission, he had rejected the operation. Computed tomography (CT) revealed an increased diameter of the aneurysm (6 cm). As abdominal pain was increased, emergent surgery was performed on day 1 after admission. Although perfusion of the superior mesenteric artery and marginal artery was maintained, intestinal ischemia was worsening and general condition was deteriorated during surgery. Bypass surgery and/or resection of colon were not indicated because of peripheral colon artery ischemia, and he expired day 1 after surgery.

Cylothorax is one of a hazardous complication after thoracic aorta replacement. In this paper, we report effectiveness of octreotide acetate for postoperative persistent cylothorax. A 59-year-old female was referred to our hospital for chest pain. Previously she underwent arch reconstruction following aortic root replacement due to aortic dissection. Computed tomography (CT) revealed acute dissection on dissected descending aorta. Urgent descending aorta replacement was performed. After surgery, massive chylothoracic pleural fluid was drainaged. Although conventional medical treatment was not effective, drainage of chylothoracic pleural fluid significantly decreased after administration of octreotide acetate. Although mechanism has not been fully investigated, octreotide acetate was effective for persistent cylothorax after descending aorta replacement.

The successful key of video-assisted thoracic surgery (VATS) to mediastinal tumors (MTs) should be the correct choice of surgical approach according to anatomical positions and relationships between large vessels and tumors. The middle and posterior MTs are good indications of VATS with intercostal approach under lateral position. The superior MTs are usually not indicated to VATS because of anatomical complexity of nerves and vessels of this area Thymus is the most frequent site of MTs and is in the narrow anterior mediastinum between sternum and heart. So that VATS to the anterior MTs needs some sternal lifting devices to get working space with appropriate combinations of intercostal, infrasternal and cervical approaches under supine position. Benign neurogenic tumors and congenital cysts are good indications of VATS. Thymic cyst, benign thymic tumor. such as mature teratoma, and small thymoma [noninvasive, diameter less than 5 cm, caudal position from left brachiocephalic vein (LBCV)] are now also indicated to VATS. Vessel sealing system LigaSure V is a computer control bipolar electric scalpel and be able to seal and cut safely up to diameter 7 mm vessels. LigaSure is suitable instrument for thymic vein handling, for esophageal muscle cutting, and for inflammatory teratoma dissection. This device is an essential device for VATS of MTs. The cases of mature teratoma and esophageal cyst were presented.

A 72-year-old man was admitted to our hospital due to abnormal shadow in the right hilum by a routine chest X-ray. When we had another look at a chest X-ray that had been taken 6 years before, we had found a pulmonary nodule of 18 mm in size. The chest X-ray and computed tomography (CT) taken at admission showed a round nodule with calcification in the same site, with increasing in size to 30 mm. The tumor could not be clinically diagnosed and the surgery was scheduled because the nodule had grown and the possibility of a malignant tumor was suggested. At surgery, the tumor was easily enucleated and the pathological diagnosis was chondromatous hamartoma. Although pulmonary hamartoma is a benign tumor, operation should be performed when the tumor had grown.

The patient was 70-year-old man. He had complained of general fatigue and hoarseness for 5 months. Chest computed tomography scan demonstrated a large anterior mediastinal tumor. The diagnosis of high grade malignant sarcoma was established with needle biopsy and the complete resection through median sternotomy was conducted. The tumor was histopathologically diagnosed pleomorphic liposarcoma. Six months after operation, right supraclavicular lymph node metastasis was noted. Radiotherapy was performed, but the liver metastasis appeared subsequently 16 months after operation. Pleomorphic type is considered one of the poorest prognostic liposarcoma and should be required special attention.

A 77-year-old woman was transferred as traumatic thoracic aortic dissection with subarachnoid hemorrhage soon after a traffic accident. Her consciousness was slightly compromised and cardiogenic shock was developed. Serial computed tomography (CT) scans revealed an unchanging subarachnoid hemorrhage and a progressive mediastinal hemorrhage and pericardial effusion due to traumatic type B aortic dissection. An emergency distal arch replacement was performed under cardiopulmonary bypass 4 hours after the injury. She woke up 3 days after the operation without progression of subarachnoid hemorrhage on a cerebral CT scan. She was discharged 36 days after the injury.

Airway obstruction due to compression by the thoracic great vessels or their branches sometimes appears in patients with congenital heart disease. However, to make a definitive diagnosis may not be easy, because respiratory symptoms are common and stem from a variety of causes in this cohort. Thus, some invasive evaluation, including angiography, bronchial fiberscopy, and bronchography has usually been required. We employed multi-slice helical computed tomography (MSCT) and 3-dimensional (3D) image reconstruction in 7 cases (median age, 107 days ; range, 21 days to 6 years) who were suspected of complicating external vascular compression as a cause of respiratory symptoms. The CT scan clearly showed detailed anatomy of the thoracic vessels and interrelationship with the airway systems. It also disclosed a culprit artery compressing the trachea or bronchus. Different from other invasive or noninvasive examination modalities, MSCT allows precise evaluation of 2 independent organ systems, such as vascular and respiratory systems. We conclude that MSCT with 3D image reconstruction represents a reliable less-invasive technique for assessment of symptomatic airway obstruction caused by vascular compression.

Electro-surgical device is an essential instrument for bloodless surgery after the 1st introduction by Harvey Cushing in 1926. Basal mechanisms of electric scalpels (monopolar and bipolar), current waveforms (cut, coagulation and blend), high-frequency currents and electrical shocks were commented. After 1990s, several new electro-surgical devices such as argon beam coagulator, bipolar scissors and vessel sealing system (LigaSure) were developed and introduced in chest surgery. Argon beam coagulator is useful in sealing and hemostasis of bleeding from chest walls after extrapleural dissections. Bipolar scissors can seal small vessels less than diameter 2 mm and is useful in mediastinal lymphnode dissections. Vessel sealing system is able to seal and cut vessels up to diameter 7 mm. LigaSure V is the most suitable instrument for thymic vein handling in thoracoscopic thymectomy. Clinical applications of these new surgical devices in chest surgery are discussed.

We report a case who had undergone operation of very early malignant pleural mesothelioma (MPM). A 58-year-old woman admitted to first visited hospital because of pleural effusion of the right side. She received a diagnosis of epithelial type MPM which had been confirmed from a pleural biopsy spacemen obtained by thoracoscopy under local anesthesia. An abnormal change of the pleura could not be detected on chest X-ray and thoracic computed tomography (CT) scan after chest drainage. She was referred to our hospital for surgery, and was undergone an extrapleural pneumonectomy followed by postoperative treatment with cisplatin puls gemcitabine. Pathologically, the disease was diagnosed as stage IA based on the classification of International Mesothelioma Interest Group (IMIG). There is a no evidence of the relapse 9 months after the operation. An early diagnosis of the MPM is very difficult. The thoracoscope with local anesthesia was very effective for early diagnose of a MPM.

A 14-year-old boy with a left ventrivular outflow tract obstruction (LVOTO) after the repair of double outlet right ventricle (DORV) at the age of 7 months was successfully treated with an extended septoplasty. A significant pressure gradient occurred between the left ventricle and the ascending aorta of 70 mmHg in spite of the previous surgery for LVOTO with muscle resection and the ventricular septal defect (VSD) patch enlargement at the age of 5. An extended septoplasty was performed including extensive resection of the conus muscle and the previously placed patch, long incision on the interventricular septum toward the apex, and reconstruction of the outflow tract using a Hemashield patch. The cathterization 10 months after the operation revealed an effective relief of LVOTO with left ventricle (LV) and aorta (Ao) pressure of 115 and 103 mmHg, respectively. An extended septoplasy is effective for the relief of LVOTO, but further follow-up is mandatory of both the left ventricular function and mitral valve function.

A rare case of recurrent Castleman disease is reported. A 49-year-old man was referred to our division under the suspicion of mediastinal tumor. We performed tumor resection successfully, and the tumor was shown to be Castleman disease by histology. The patient had a past history of this disease, therefore it was suggested that the tumor recurred at the same site 20-years after removal.

We investigated surgical complications and prognosis of bronchoplasty and bronchoplasty with pulmonary angioplasty (broncho-angioplasty) for lung cancer. Between October 2000 and October 2007, 37 bronchoplastic procedures were done in 572 patients who underwent lung resections for lung cancer. Eleven (29.7%) bronchoplasties were done with pulmonary angioplasty. There was no operative mortality and 1 hospital mortality (2.7%) causing by myocardial infarction. Six of 11 postoperative complications were bronchial complications and 2 additional lung resections were needed. The 5-year survival for all patients was 55.2% and for bronchoplasty was 57.8%. Though the 5-year survival of broncho-angioplasty was not able to calculate at present, the 3-year survival of which was 72.9%. There was no death of patients with adenocarcinoma after introduction of pre-operative assessment by FDG-PET for lymph node metastasis. These data suggest that bronchoplasty and broncho-angioplasty are safe operative procedures and could provide acceptable intermediate survivals with modern multimodality diagnostic and therapeutic tools.

Primitive neuroectodermal tumor of the sternum is rare. A 59-year-old woman referred to our department with anterior chest pain and a tumor in the sternum. The patient was diagnosed as primitive neuroectodermal tumor of the sternum by core biopsy of the lesion. She received 2 cycles of preoperative chemotherapy with vincristine, doxorubicin, cyclophosphamide, ifosfamide, etoposide. She underwent a total sternectomy with resection of adjacent bilateral costal cartilages and sternal ends of the clavicles. The skeletal defect of chest wall was reconstructed by polypropylene mesh-resin sandwich. The myocutaneus defect was reconstructed by the pedicled latissimus dorsi myocutaneus flap and the bilateral breast flaps. The postoperative course was uneventful and adjuvant radiotherapy was started 6 weeks after the operation. She died of distant metastases 3 months after the operation, although this patient was free from local recurrence.

The shortage of donor organs has been 1 of the major obstacles to solid organ transplantation. Typical lung donor criteria include clear lung field on chest radiograph, adequate oxygenation, acceptable lung compliance, and satisfactory bronchoscopic findings. To extend usage of available donors, liberalization of donor lung selection criteria has been facilitated, however, marginal donor lungs must be used with discretion, because donor lung injury, especially that related to infection, has a potential leading to early post-operative death of the recipient. From March 2000 to December 2006, we evaluated 15 braindead donors and at least 1 of the lungs from 9 donors was judged suitable for transplantation. One of 9 recipients developed severe pneumonia cased by carbapenems-resistant Pseudomonas aeruginosa possibly originating from the donor lungs, eventually leading to death. The chest radiograph and oxygenation of the donor had been satisfactory, however, a moderate amount of mucopurulent secretions was observed by bronchoscopic inspection and the donor had been given a cefozopran for 9 days before the procurement operation. Remaining 8 recipients were free from air-way infection in the early postoperative period. We discuss the status and problems of donor lung evaluation for transplantation with regard to donor lung infection.

Combination of congenital cardiovascular and other anomalies are often found. Combined operation is needed for some of these cases. We report 3 cases who underwent combined operations by combined team of cardiovascular and general surgical units. Case 1: A 10-month-old boy with VATER association was complicated with tetralogy of Fallot, double aortic arch and so on. He underwent division of left aortic arch for vascular ring by cardiovascular surgical unit and esophagogastrostomy for esophageal atresia by general surgical unit. Case 2: A 15-day-old girl with patent ductus arteriosus and eventration of the diaphragm underwent ligation of ductus arteriosus by cardiovascular surgical unit and plication of left diaphragm by general surgical unit. Case 3: An 8-month-old boy with tracheobronchomalacia and atrial septal defect underwent atrial septal defect (ASD) closure by cardiovascular, and extra tracheobronchial stenting on cardiopulmonary bypass by cardiovascular and general surgical unit. These 3 operations were successful, and we consider that combined operation is useful for certain surgical congenital multiple anomalies.

Blunt bronchial injury is rare but crucial injury. A 17-year-old female was admitted due to traumatic injury. She was diagnosed with bilateral lung contusion, multiple rib fractures, spleen damage and the suspicion about the complete transection of the left main bronchus on X-ray and computed tomography (CT). She was brought to our hospital at 30 hours later from injury. Bronchoscopy revealed the complete transection and the edema of the left main bronchus. She underwent a resection of the disrupted portion and end-to-end anastomosis of left main bronchus without lung resection. We should be an immediate and accurate diagnosis of tracheobronchial disruption by X-ray, CT and bronchoscopy whenever we evaluate patients with blunt chest trauma.

A 60-year-old woman, who had undergone aortic root replacement with composite graft 5 months previously, suffered from anemia and slight fever. Transthoracic echocardiography showed pseudoaneurysm in the aortic root, and blood culture was positive. She was diagnosed with prosthetic valve endocarditis, and surgical intervention was planned. Intraoperatively necrotic tissue and dehiscence of the suture line in the aortic annulus were found. Re-aortic root replacement with Freestyle bioprosthesis and re-hemiarch graft replacement were performed with the omentopexy around the aortic root and the new graft. Antibiotics were administered intravenously for 6 weeks postoperatively. At 7 months after the operation, no prosthetic valve infection had recurred. Although the long-term results of Freestyle bioprosthesis have not been determined, it might be a valuable option for aortic root infection as an alternative to an aortic homograft. In addition, omentopexy might also be effective in the prevention of recurrent prosthetic valve infection.

We retrospective reviewed minimally invasive video-assisted thoracoscopic surgery (VATS) to thymic diseases. These procedures were performed using intercostal and infrasternal approach with a sternum-elevator. Indications of this method are benign thymic lesions [mature teratoma, thymic cyst and myasthenia gravis (MG)] and small thymoma (non-invasive Masaoka stage I-II, less than 5 cm in diameter and nontouching to the left brachiocephalic vein). Fifty patients underwent VATS for 13 hemithymectomies (7 thymomas, 5 mature teratomas and 1 thymic cyst) and 37 extended thymectomies (25 nonthymomatous MGs and 12 thymomatous MGs). Conversion to sternotomy was required in 3 cases of nonthymomatous MG because of bleeding from thymic vein in 1 case and pleural adhesion in 2 cases. Four cases of thymomatous MG were successfully treated with partial lung resection and/or small pericardial resection by VATS. New bipolar vessel sealing system (LigaSure V) is safer and more useful than metal clip and ultrasonic coagulator in VATS for thymic vein sealing, extraction of upper poles of thymus and incision of mediastinal pleura near phrenic nerve. VATS thymectomy should be useful from the standpoint of less invasive, less pain, rapid recovery, and good cosmetic results.

Unlabelled: We here presented 2 cases of interstitial pneumonia with lung adenocarcinoma incidentally diagnosed by partially resected lung for diffuse pulmonary disease. CASE 1: A 78-year-old female was admitted to the hospital complaining of productive cough and general fatigue. The chest computed tomography (CT) revealed diffuse honey comb pattern in bilateral lung field especially in the right lower lung. Video-assisted thoracoscopic lung biopsy was performed and was diagnosed as diffuse spreading well differentiated adenocarcinoma. CASE 2: A 59-year-old male was admitted to the hospital complaining of dyspnea and general fatigue. The chest X-ray revealed right pneumothorax and chest CT revealed diffuse honey comb pattern and bullae in bilateral lung field and fibrous tumor-like lesion in the right middle lung. Video-assisted thoracoscopic lung biopsy was performed and was diagnosed as pulmonary fibrosis with papillary adenocarcinoma., Conclusion: It is important to examine carefully the specimen obtained from thoracoscopic lung biopsy even if interstitial pneumonia is strongly suspected.

The infarct exclusion technique with a xeno-pericardial patch which Komeda and associates firstly reported in 1990 is one of the best procedure to close ventricular septal perforation. A large patch can protect the perforation and the surrounding weak tissue from the internal left ventricular pressure. However, suturing this large patch to the left ventricular wall through the small incision is not technically easy because of the patch design in the ventricle. We modified the design of the patch. This round shaped bovine pericardial patch was sutured continuously to the left ventricular wall. Then, excessive part of the patch was trimmed to make a corn shape. Finally, the corn shaped patch fit the left ventricular wall naturally.

Left ventricular myxoma is particulary rare. Our case is a 77-year-old female. Transesophageal echocardiography showed a giant tumor in the left atrium. An urgent operation was performed. A giant mass was excised en bloc via a transinteratrial septal approach. Histopathologically it was myxoma. As a transthoracic echocardiography at 1-year postoperation showed a tumor in the left ventricle. A mass was excised en bloc via a vertical approach. Histopathologically it was diagnosed again as myxoma. We looked at the earliest transesophageal echocardiogram again, and found the small tumor on the same area under the posterior mitral leaflet. At the diagnose of cardiac tumor, possibility of multiple formation should be always considered.

We developed new surgical technique of pulmonary segmentectomy by ultrasonic scalpel to sever intersegmental pulmonary tissue and absorbable sealing materials to cover the cut surface of lung. This method is expected to preserve more anatomical lung volume than the segmentectomy with surgical stapler. Two cases of post surgical recurrent lung cancer, 3 cases of pulmonary metastasis and 4 cases of primary lung cancer were applied this technique to preserve function. Among 3 materials examined, best result was obtained with polyglycolic acid felt (PGAF:Neoveil). PGAF is a very soft and thin (0.15 mm depth) new absorbable material that is able to closely adhere to irregular sections of the lung with fibrin glue and effectively seals air leakage. Mean chest drainage period after surgery in 6 cases with PGAF was 3.3 days. Excellent lung expansion was obtained immediately after the surgery and PGAF was disappeared completely on chest CT within 1 year. Although the possible superiority of this method is suggested in the present study, further comparative study is necessary to clarify the advantage of this new technique.

Papillary fibroelastoma is one of the commonest benign tumor in the heart. In almost all of cases, symptoms never develop and the tumors are usually discovered coincidentally. Even though papillary fibroelastoma is a benign tumor, surgical extirpation is usually indicated for reason of productive serious complications. The tumors may cause left ventricular outflow obstruction, cerebral embolic infarction, myocardial infarction and even sudden death. The case we reported here is unusual case, because the patient developed symptoms and complaints such as palpitation, feverish and general fatigue. We measured tumor markers, interleukin 6, serotonin and histamine, but none of those was elevated in the blood samples. Surgical removal of the tumor attached to the base of posterior papillary muscle was carried out without causing mitral incompetence, and the pathological findings were compatible with papillary fibroelastoma. After the operation, the both symptoms and complaints disappeared unexpectedly.

We have performed pulmonary metastasectomy on 97 patients with various malignant tumors. We analyzed the outcome of surgical treatment and prognostic factors. Survival of patients undergoing metastasectomy was significantly different according to the type of malignant tumor. The patients with carcinomas had a good survival when they had 3 years or longer disease free interval (DFI) and no other lesion except the lungs. Those with sarcomas were good survivors, who had a solitary pulmonary lesion, 1 years or longer DFI, and had no symptom originating from pulmonary metastases. Survival of patients with germ cell tumors was significantly superior to other 2 types, and factors such as an existence of extra-pulmonary metastatic lesions, respiratory symptoms and a length of DFI had no impact on the chance of their survival. These results suggest that we should decide the indication for metastasectomy on patients according to their types of malignant tumor.

In order to establish an appropriate treatment for thymic carcinoma, clinical courses of 15 patients with type C thymoma of WHO classification were reviewed. Five-years survival rate in all patients was 37.6%. In cases underwent complete resection, survival was 48.5%. The induction chemotherapy was done in 7 cases, and complete resection was possible in all these cases, suggested the possibility of improving the survival by the induction therapy. Upper mediastinal lymph node dissection each performed in 9 cases, and they showed significantly better survival than those without lymph node dissection. In conclusion, we have found that induction chemoradiotherapy and complete tumor resection with lymphnode dissection would contribute to improvement of the results in treatment for thymic carcinoma.

Although lobectomy is the standard surgical treatment for primary lung cancer, it is unclear whether lobectomy will be benefit for patients with metachronous lung cancer. The purpose of this study is to evaluate the difference of benefit between lobectomy and limited resection at second lung resection. Forty-eight patients, who had already undergone lobectomy due to primary lung cancer, undergoing second lobectomy (n = 30) or limited resection (n = 18) for metachronous lung cancer were investigated. The over-all 5-year survival rate of second operation was 51.9%. Although there was no significant difference of 5-year survival rates between lobectomy and limited resection, 50.4% and 49.4%, respectively, lobectomy for T1N0 subset prolonged the survival compared to limited resection, 5-year survival rates, 69.6% and 31.7%, respectively. However, lobectomy resulted in more postoperative complications and less preservation of lung function. Lobectomy should be considered the surgical procedure of choice for patients with metachronous T1N0 lung cancer when lung function is preserved.

Cardiopulmonary bypass (CPB) and diseased lung ventilation were presented as new methods of oxygenation during carinal reconstruction. Two cases of left sleeve pneumonectomy (SP) were performed for bronchial gland carcinoma through clamshell incisions. Adequate oxygenation and excellent operative fields were provided by CPB in both patients. The postoperative courses of these patients were uneventful, although they developed temporary pulmonary edema that needed mechanical ventilation and appropriate diuretics for several days. One case of patient with squamous cell carcinoma after chemotherapy was successfully treated by right SP through midline sternotomy. Adequate oxygenation and excellent operative fields was obtained by diseased right lung ventilation in this patient. The postoperative course of the patient was uneventful without mechanical ventilation support. These procedures of oxygenation in this paper are considered to be safe and effective methods for carinal reconstruction.

Reconstruction of chest wall using myocutaneous flap has been performed in 2 cases. A 72-year-old female referred to our hospital for locally recurrent left breast cancer without any distant metastases. The other patient was a 77-year-old female, having locally recurrent liposarcoma of the left lateral chest wall. Chest wall was resected with wide margin of normal tissue, and myocutaneous flaps of latissimus dorsi were used for reconstruction of skin defect (13 x 8 cm and 14 x 10 cm) in both cases. Although additional split-thickness skin graft was required for one of them, myocutaneous flaps were useful for the reconstruction of widely defected chest wall. By using this technique, wider margin can be obtained, which could decrease the risk for local recurrence of malignant tumor.

Poly (L-lactide) sternal coaptation pin has been developed as an assistant material for the fixation of sternum. We used the novel material to a patient who underwent median sternotomy. A 21-year-old male was suspected to have invasive thymoma in the anterior mediastinum. The median sternotomy was indicated as an approach for the resection of tumor. Tumor was completely resected and there was no invasion to sternum. For the fixation of sternum, three poly (L-lactide) sternal coaptation pins were inserted in the bone marrow of sternum and five stainless steel wires were used as conventional procedure. Sternum was adapted without slippage and no complication from the material was observed in the post-surgical period. The application of poly (L-lactide) sternal coaptation pin is a good option for ensuring the fixation of sternum.

A 21-year-old female was admitted to our hospital because of high fever, neck swelling, and dyspnea. She was diagnosed as descending necrotizing mediastinitis (DNM) extended from odontogenic infection. On the day of admission, she underwent cervical drainage. Next day, the CT scan showed an abscess below the tracheal bifurcation and bilateral pleural effusion. Mediastinal drainage was performed through a right thoracotomy, and a left thoracic tube was inserted. Anaerobic Peptostreptococcus was found with bacteriological culture. After the mediastinal drainage, bilateral thoracic irrigation was performed through the thoracic tubes. Left thoracic tube was removed on the 8th day and right one was removed on the 20th day after the thoracotomy. She was discharged on the 42nd day. DNM is relatively rare, but it is lethal disease with high mortality. Immediate and sufficient mediastinal drainage is indispensable for the disease.

The feasibility of the complete systematic nodal dissection by the video-assisted thoracic surgery was prospectively assessed in 22 cases of clinical stage I lung cancer (16 right, 6 left cases). Resection of the designated lobe with the mediastinal lymph node dissection was carried out by the small thoracotomy with the aid of the thoracoscope, followed by the standard surgery to verify the completeness of systematic nodal dissection. Although residual lymph nodes were found in 14 of 22 cases, the residual rate was 2.9% and 2.7% by the number and 2.3% and 2.1% by the weight in right and left cases, respectively. Average time and hemorrhage for performing the procedure were 196 minutes, 216.7 minutes and 157.5 g, 145 g in right and left cases, respectively. As a consequence, sufficient systematic nodal dissection in lung cancer was suggested to be feasible by VATS lobectomy.

To clarify the pathway of the metastases from each pulmonary lobe to mediastinal nodes, we examined the pattern of mediastinal nodal involvement in 462 resected pN2 non-small cell lung cancer. Carcinomas of the right upper lobe frequently involved #3 (78/133) and #4 (70/133) nodes, whereas those of the right middle or lower lobe frequently metastasized to #7 nodes (18/23 and 86/113, respectively). On the other hand, carcinoma of left upper lobe frequently involved #5 nodes (81/118), whereas those of the left lower lobe most frequently metastasized to #7 nodes (50/75). Of 462 pN2 patients, 95 (20.6%) had skip metastases to the mediastinal nodes. Skip metastasis was observed more frequently in carcinomas of right upper and middle lobe. One of the reasons of skip metastasis may be the direct lymph drainage through subpleural space to mediastinum.

We investigated interstitial pneumonia, one of the most severe postoperative acute complications of respiratory surgery. In sixteen years, from 1982 through 1997, 2,453 cases underwent thoracotomies caused by lung cancers, in our institute. There were 20 cases (0.79%) who died within 30 days after surgery (operative death). Six out of 20 cases died of interstitial pneumonia, one of the most frequent postoperative complications. We examined these six patients and 2 patients with postoperative interstitial pneumonia who died within 32 days. Preoperative lung function tests, laboratory data, chest CT and/or chest X-ray films cannot predict development of postoperative interstitial pneumonia. Those who acquired postoperative interstitial pneumonia had continuous high fever after surgery following reticular shadows on their chest X-ray and increase in LDH levels. We could not detect any characteristic viral infections. Although, they were treated by steroid, elastase inhibitor and/or immune suppressant, they died within 32 days. In conclusion, development of postoperative of interstitial pneumonia cannot be predicted from preoperative laboratory data and/or lung function tests.

Eight years ago, A 29-year-old woman was admitted by complaining with facial edema and dyspnea. A chest x-ray film and computed tomography showed an anterior mediastinal tumor that invaded to the superior vena cava and the trachea. A bronchoscopic biopsy revealed that the tumor was a thymoma. We performed radiotherapy and chemotherapy because a surgical operation was not possible. The size of the tumor was slightly reduced after those therapies roentgenographically. We followed up the subsequent of history of the patient. Eight years later, July, 1995, chest computed tomography showed bilateral disseminations of invasive thymoma. The disseminated tumors were removed by two-stage video assisted thoracoscopic surgery (VATS), to preserve collateral veins so that collateral venous circulations were preserved. She discharged 20 days after second VATS uneventfully.

We experienced two cases of lung cancer with terminal tracheostomy. Conventional double lumen tubes such as the Broncho-Cath or the Robertshaw were not applicable for one-lung anesthesia for these cases because of anatomical reasons due to the total laryngectomy. One left lower sleeve lobectomy and a right middle lobectomy were performed under one-lung ventilation using an occlusion balloon catheter that was introduced through a seath placed in the spiral type tracheostomy tube through a plastic connector. This method has three advantages: 1) a spiral type tracheostomy tube is easily fitted for the deformed trachea. 2) an occlusion balloon catheter with an extra lumen at its tip enables the airway aspiration and the inflation of the lung. 3) air leakage around a catheter is completely prevented by the use of a catheter introducer. The present method was concluded to be superior to the prior technique with the Forgaty catheter as an endbronchial blocker.

Seventeen cases with surgical treatment for pulmonary metastases of osteosarcomas have been experienced for past 20 years in our institute. Disease free intervals, tumor doubling time, the number of metastatic lesions, the size of metastatic lesions, pathological features on nuclear findings were assessed in relation to their prognosis. These parameters were concluded to have no significant relations to the survival outcomes after the surgery for pulmonary lesions except for the number of metastatic lesions less than 20 in total which is likely to be associated with long survivals, supporting previous reports on the resectability of pulmonary metastatic lesions as an only reliable prognostic indicator. It was also stressed from our experience that the meticulous follow-up after each surgery for both primary and metastatic lesions is absolutely necessary for the early detection of recurrent pulmonary lesions in order not to overlook curable cases with aggressive treatment.