[Massive Hemorrhage from the Delayed Diaphragmatic Injury due to the Rib Fracture after the Blunt Chest Trauma:Report of a Case].

We report a case of delayed diaphragmatic injury caused by lower rib fractures. A 56-year-old male was referred to our hospital due to the fractures of right lower ribs. Chest X-ray revealed pneumothorax, and the patient was hospitalized for follow-up. On the sixth day after the injury, the patient suddenly complained of chest pain and respiratory distress, and then shock status developed. Chest computed tomography (CT) revealed massive pleural effusion. An emergency operation was performed. The injury of the diaphragm was found. Fracture of the lower rib can cause diaphragmatic injury leading to massive hemorrhage.

[Contralateral Pneumothorax after Surgery for Idiopathic Hemopneumothorax;Report of a Case].

A 17-year-old man came to the hospital complaining of right back pain. He had a history of an emergency operation for a left idiopathic hemopneumothorax. A chest X-ray revealed right lung collapse and suggested pleural adhesion at the apex of the right lung. He was diagnosed with right spontaneous pneumothorax and the surgical treatment was performed, because pleural adhesion may cause the hemothorax. During surgery, several pleural adhesion bands were found in the thoracic cavity between the right lung apex and chest wall. Spontaneous pneumothorax with a pleural adhesion at the apex is considered to be the indication for surgery because of the risk of hemothorax.

[Birt-Hogg-Dubé Syndrome Diagnosed with Surgery;Report of Three Cases].

Birt-Hogg-Dubé (BHD) syndrome is an autosomal and predominantly inherited disorder. We report 3 cases of BHD syndrome. Case 1:A 24-year-old man was admitted to our hospital due to left-sided spontaneous pneumothorax. He had a previous drainage history of right-sided spontaneous pneumothorax. In operation, we resected the cyst at segment 8 of the left lung and covered the lung using polyglycolic acid( PGA) sheet. Case 2:A 47-year-old man was admitted to our hospital due to right-sided spontaneous pneumothorax. He had a previous surgical history of right-sided spontaneous pneumothorax and left-sided spontaneous pneumothorax. In operation, we resected the cyst at segment 8 of the right lung and covered the lung using fibrin glue-coated collagen fleece. Case 3:A 60-year-old man was admitted to our hospital due to left-sided spontaneous pneumothorax. He had 2 times of previous drainage history of left-sided spontaneous pneumothorax. In operation, we resected the cysts at lingular division of the lung and covered the lung using PGA sheet. On genetic analysis, all 3 cases were diagnosed with the BHD syndrome.

A neuroendocrine tumor within an anterior mediastinal mature teratoma: a case report.

BACKGROUND: Mature teratomas are benign germ cell tumors. On rare occasions, they have been associated with somatic malignancies and are termed rare germ cell tumors with a somatic-type malignancy (GCTSM). Mature teratomas commonly comprise adenocarcinomas; only seven previous cases of mature teratomas with neuroendocrine tumors have been reported to date. Here, we report a patient with a neuroendocrine tumor whithin a mature teratoma. CASE PRESENTATION: A 26-year-old man visited our department complaining of chest tightness. Contrast-enhanced computed tomography (CT) scans showed a strongly enhanced lesion within a 10-cm encapsulated cystic lesion in the anterior mediastinum. Positron emission tomography (PET) scans showed no areas of significant 18F-fluorodeoxyglucose (18F-FDG) accumulation. He underwent complete tumor resection via the transsternal approach. Histopathological examination of the specimen indicated a neuroendocrine tumor contained within a mature teratoma. CONCLUSIONS: In this case, a neuroendocrine tumor was contained within a mature teratoma. Our patient had no specific symptoms and his serum markers were within the normal range. Although PET is beneficial for diagnosing other GCTSM, it is not useful in detecting a neuroendocrine tumor. Therefore, the preoperative diagnosis of neuroendocrine tumors contained within mature teratomas remains challenging. However, GCTSM should be suspected in patients exhibiting CT findings of a mediastinal tumor, measuring ≥ 6 cm, in addition to characteristic GCTSM findings. Moreover, surgery should be performed carefully in such cases.

Intrapericardial Ectopic Goiter: A Very Unusual Presentation.

Mediastinal ectopic goiter is a thyroid tumor that lies entirely below a plane extending from the superior surface of the first thoracic vertebra to the suprasternal notch, and commonly lies in the vicinity of the thymus. Intrapericardial ectopic goiter is extremely rare. We present an extremely rare case of a 63-year-old woman with an intrapericardial ectopic goiter and review the pertinent literature.

Treatment strategies for chronic expanding hematomas of the thorax.

PURPOSE: To investigate retrospectively the treatment strategies for chronic expanding hematoma (CEH) of the thorax. METHODS: We reviewed the medical records of six patients treated for CEH of the thorax at our institution between October 1996 and October 2006. RESULTS: All of the patients had a history of thoracic surgery or tuberculosis with a latent period of 12-55 years before onset. One elderly patient with ischemic heart disease and in poor general health demonstrated a substantial improvement of symptoms after undergoing arterial embolization twice instead of surgery. The remaining five patients underwent either pleuropneumonectomy or a total capsule excision, following which their clinical condition improved remarkably. All six patients were discharged from the hospital. Arterial embolization was performed before surgery, and the amount of intraoperative bleeding ranged from 905 ml to 6,590 ml (average: 2,396 ml). CONCLUSION: Chronic expanding hematoma of the thorax may occur after thoracic surgery and a tuberculosis infection; however, considering the risk of massive bleeding during surgery, the decision to perform surgery should be made with extreme care.

[Treatment with S-1 and radiation therapy for advanced lung cancer invading chest wall].

The patient was a 63-year-old man, who had been suffering from lung cancer with left chest wall invasion and contralateral pulmonary metastases. Due to the severe pain caused by this advanced lung cancer with poor performance status (PS), oxycodone was administered for treatment. Radiotherapy was used for local tumor control and oral S-1 was given as systemic chemotherapy. The local control rate (near CR) and the PS were improved effectively by this combination of palliative treatment. As a result, he was allowed to return home and followed as an outpatient. Our experience suggests that positive palliative treatment improves the quality of life (QOL) of patients and provides survival benefits.

Pulmonary Artery Pseudoaneurysm Secondary to Lung Inf lammation.

Pulmonary artery aneurysms (PAA) and pseudoaneurysms (PAP) are caused by infections, vasculitis, trauma, pulmonary hypertension, congenital heart disease, and connective tissue disease. Most cases of such aneurysm occur in the trunk or major branches of the pulmonary artery, while the peripheral type is less common. The treatment modalities are medical therapy, surgery, and percutaneous catheter embolization. The mortality rate associated with rupture is approximately 50%. We encountered a case of a 53-year-old man with a pulmonary artery pseudoaneurysm secondary to pneumonia and cavity formation during chemotherapy for acute myeloid leukemia (AML). In diagnosis, contrast-enhanced chest computed tomography (CT) scan and pulmonary angiography were very useful. He was treated with right middle and lower lobectomy. After 1-month follow-up, he could restart additional chemotherapy.

Pulmonary langerhans cell histiocytosis with recurrent pneumothorax.

A 20-year-old woman with recurrent right pneumothorax was admitted to our hospital. A thoracoscopic bullectomy and lung biopsy was performed under general anesthesia. According to the histopathologic findings of permanent sections, a tissue specimen of diffuse lung disease revealed eosinophil infiltration and the presence of fibroblasts. Immunohistochemical stain showed S-100 protein-positive, as well as cluster of differentiation-68-positive large Langerhans cells. As a result, pulmonary Langerhans cell histiocytosis was diagnosed. The patient had an uncomplicated postoperative course and was discharged from the hospital on postoperative day 5. No recurrence was observed during the 6-month observation period.

Thoracoscopic resection of mediastinal bronchogenic cysts in adults.

OBJECTIVE: The aim of this study was to discuss the diagnosis and determine the optimal thoracoscopic surgical treatment of mediastinal bronchogenic cysts. METHODS: From May 1996 to April 2008, 13 consecutive patients with mediastinal bronchogenic cysts underwent thoracoscopic surgery at our institution. There were eight men and five women aged 16-74 years (mean age, 41.5 years). RESULTS: In the majority of patients (69.2%), there were no clinical symptoms and the lesions were found incidentally by chest radiography that was performed as part of physical screening. Lesions were found in the posterior mediastinum in five patients (38.5%) and in the upper mediastinum in four (30.8%). In the histopathological examinations, ciliary epithelium was observed in 13 patients (100.0%), bronchial cartilage in 7 patients (53.8%), bronchial glands in 6 patients (46.2%), and smooth muscle in 5 patients (38.5%). No serious postoperative complications were observed. In 3 patients (23.1%), conversion to open thoracotomy was necessary due to major pleural adhesions and intraoperative vascular injury. CONCLUSION: Thoracoscopic resection of mediastinal bronchogenic cyst is minimally invasive and has no serious postoperative complications, and should therefore be considered as the primary therapeutic option.

Cause and management of recurrent primary spontaneous pneumothorax after thoracoscopic stapler blebectomy.

BACKGROUND: As the number of patients treated by thoracoscopic stapler blebectomy increased, the postoperative recurrence rate had risen unexpectedly. We retrospectively investigated the cause and management of primary spontaneous pneumothorax recurrence after thoracoscopic stapler blebectomy. METHODS: From March 1992 to the end of December 2006, thoracoscopic stapler blebectomy was performed in 357 patients with primary spontaneous pneumothorax at the Nihon University Itabashi Hospital. The causes and management of recurrence were investigated in 30 patients with postoperative recurrence based on items such as the resurgical observations, preoperative chest computed tomography findings, previous operative notes. RESULTS: Among the patients with bilateral pneumothorax, young patients exhibited a higher tendency for postoperative recurrence. The most common cause was new bulla formation (28 slides, 16 of which were apparently related to the staple line and 12 of which were not related to the staple line). CONCLUSION: In thoracoscopic stapler blebectomy for primary spontaneous pneumothorax, the most common cause of recurrence was new bulla formation. It is necessary to establish additional procedures involving either the visceral pleura or the parietal pleura to reduce the recurrence rate.

Desmoplastic small round cell tumor of the lung.

We report a rare case of desmoplastic small round cell tumor, which arose from the left lung. A 25-year-old man was found to have an abnormal shadow during a routine physical examination and was admitted to our hospital. A thoracoscopic tumor biopsy was performed under general anesthesia. According to the histopathologic findings of permanent sections, the tumor was composed of sharply outlined nests, clusters, and trabeculae of small round to oval cells separated by a spindle-shaped desmoplastic stroma. A gene analysis revealed chimera genes of Ewing's sarcoma and Wilms' tumor by reverse transcription polymerase chain reaction.

Surgical treatment of catamenial pneumothorax.

OBJECTIVE: To discuss the aetiology and determine the optimal surgical treatment of catamenial pneumothorax. METHODS: Between January 1980 and December 2007, 17 patients with catamenial pneumothorax were treated at our institution. Regarding the surgical approach, thoracotomy was performed until 1991, and thoracoscopic surgery was performed from 1992 onward. RESULTS: Pneumothorax was on the right side in all but two patients. Surgery was performed on 15 of the 17 patients. The surgical procedure was a diaphragm resection plus a partial bleb resection in eight patients, a diaphragm resection in two patients, a diaphragm resection plus an absorbable polyglycolic acid sheet in four patients, and a partial bleb resection in one patient. Five patients demonstrated a postoperative recurrence (33.0%). However, no recurrence has been observed thus far in the four patients with an absorbable polyglycolic sheet placed on the diaphragmatic surface. CONCLUSION: Although the postoperative recurrence rate of patients undergoing surgical procedures remains high, there were some patients with no postoperative recurrence. Placement of an absorbable sheet on the diaphragmatic surface may therefore prevent recurrence of catamenial pneumothorax.

Staple line reinforcement with fleece-coated fibrin glue (TachoComb) after thoracoscopic bullectomy for the treatment of spontaneous pneumothorax.

BACKGROUND: We investigated the cause of pneumothorax recurrence after thoracoscopic surgery and the effectiveness of staple line reinforcement with fleece-coated fibrin glue (TachoComb) in the prevention of postoperative pneumothorax recurrence. METHODS: From April 3, 1992 to the end of December 2005, thoracoscopic bullectomy was performed on 499 patients of primary spontaneous pneumothorax. The causes of recurrence were investigated on 39 patients on the basis of surgical observations, preoperative chest computed tomography, and so on. The most common cause was new bulla formation (37 cases), 19 of which were apparently related to the staple line (within 1 cm of the staple lines) and 15 of which were not related to the staple line. After 2000, we stopped using forceps to grasp lungs and we have reinforced the staple line by applying fleece-coated fibrin glue. RESULTS: The staple line reinforced with fleece-coated fibrin glue, or sprayed with fibrin glue solution and the untreated group (bullectomy only with staples) were compared, and the recurrence rates were 1.22%, 7.25%, and 10.00%, respectively (P = 0.0006021). CONCLUSIONS: The recurrence rate after thoracoscopic bullectomy with fleece-coated fibrin glue was significantly lowered and we consider this procedure to be the treatment of choice for the management of spontaneous pneumothorax.