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We report a relatively rare surgical treatment for two cases of inflammatory pseudotumors of the lung. In case 1, a 52-year-old male with a history of left chest pain was admitted to our hospital for an abnormal nodule with an irregular margin that was detected in the left upper lung field. The nodule, measuring 15 mm in diameter, was larger than the one observed six months earlier, which had been removed by a thoracoscopic resection. In case 2, a 64-year-old female with a history of chronic cough and hemoptysis was admitted to our hospital, and an abnormal nodule with pleural indentation was detected in the lower left lung field. The nodule, measuring 8 mm in diameter, was also removed by a thoracoscopic resection. In both cases, the histologic examination enabled us to diagnose the lesion as an inflammatory pseudotumor. In general, it is very difficult to differentiate inflammatory pseudotumors from malignant tumors of the lung. The best treatment for inflammatory pseudotumors is usually early and complete surgical resection, since it can lead to improved survival. Therefore, we consider thoracoscopy-aided surgery to be less invasive and more useful than other surgical methods in the diagnosis and treatment of inflammatory pseudotumor of the lung.

We report a very rare and successful surgery for primary malignant tumor of the sternum. A 73-year-old male, previously healthy, was admitted to our hospital because a chest computed tomography scan detected an abnormal shadow that suggested a sternal tumor destroying part of the sternum body. Aspiration needle biopsy demonstrated a primary sternal chondrosarcoma measuring 3 x 4 cm in diameter. The sternum below the second intercostal space was resected along with a 1-cm width of cartilage below the third rib on each side. Sternal reconstruction was performed with Composix mesh, titanium mesh, and Marlex mesh, using a right pectoralis major muscle flap translation. The patient was extubated just after surgery, and the postoperative course was uneventful. This procedure may be useful for repairing the detect after wide sternotomy.

We report on the rare and surgical treatment of a case of primary mediastinal liposarcoma. A 64-year-old male complained of hoarseness for one month and was admitted to our hospital because of an abnormal shadow, which was postulated to be an anterior mediastinal tumor on a chest computed tomography (CT) scan. Horizontal T1-weighted magnetic resonance imaging (MRI) showed an anterior mediastinal round mass with a signal intensity similar to that of subcutaneous fat, which was 6.5 cm in diameter. An operation similar to extended thymectomy was perfomed through a median sternotomy. Histological examination of the resected specimen revealed that the tumor was composed of well-differentiated liposarcoma and pleomorphic malignant fibrous histiocytoma and the tumor was diagnosed as a de-differentiated liposarcoma. We discuss it with reference to a collective review of the Japanese literature for surgical cases of primary liposarcoma of the mediastinum.

We report on the rare and surgical treatment of a senile patient of infected intralobar pulmonary sequestration. A 56-year-old male who had complained of headache, vomiting, cough, sputum production, and high fever was admitted to our hospital. Chest computed tomography (CT) showed an infected intralobar pulmonary sequestration as an 8x6 cm cystic mass with multiple air-fluid cavities in the left lower basal segment and severe pneumonia in the left upper and lower lobes around the mass. A 3-D CT showed an aberrant artery entering the consolidation from the descending aorta. A standard lower lobectomy was performed with a ligation of the aberrant artery with a diameter of 1 cm supplying the posterior segment of the left lower lobe. A histological examination of the lung revealed acute and chronic broncho-bronchiolitis with cystic dilatation consistent with intralobar pulmonary sequestration. We discuss the characters of senile patients compared with juvenile patients, with reference to a collective review of patients older than 50 reported in the literature.

Purpose: A study was undertaken to evaluate the validity and efficacy of video-assisted thoracic surgery (VATS) for the diagnosis of indeterminate pulmonary nodules., Materials and Methods: Between April 2001 and November 2004, 57 adult patients (31 males, 26 females) with a clinical diagnosis of pulmonary nodules by preoperative chest computed tomographic (CT) scanning were included in this study., Results: A definitive tissue diagnosis was obtained in all 57 patients. The mean age of the patients was 66+/-9.8 yrs. The mean size of the tumor was 1.76+/-0.67 cm. 38 patients (67%) had malignant disease. Twenty eight patients (49%) had primary lung cancer and 10 patients (18%) had metastatic lung cancer from an extrathoracic primary neoplasm. The rate of malignancy was 65% in the tumor sizes equal to or less than 2 cm. Among primary lung cancer, most patients had primary adenocarcinoma (24 cases)(86%). Pathologic staging showed T1N0 (stage IA) in 18 cases (69%), T2N0 (stage IB) in 4 cases (15%), T2N1 (stage IIB) in 1 case (4%), and T1N2 (stage IIIA) in 3 cases (12%). In 10 patients (18%) who required preoperative placement of a localization hookwire with a string near the nodule, the rate of malignancy was 70%. In 7 patients with positive positron emission tomography (PET) imaging with F-18 fluorodeoxyglucose (FDG), the rate of malignancy was 57% and proved to be falsely positive in 3 cases (43%). There was no operative mortality and no significant morbidity in all cases., Conclusion: We proposed that VATS, which is safe and offers virtually 100% sensitivity and specificity, should be performed for most small (<3 cm in diameter) and all indeterminate pulmonary lesions on the basis of these results.

We report on the rare and successful surgical treatment of a case of spontaneous rupture of the ascending thoracic aorta resulting in a mimicking pseudoaneurysm. A 72-year-old male who had complained of sudden onset of severe chest pain was admitted to our hospital. Initially, acute type A closing aortic dissection was suspected because computed tomography (CT) showed a small ulcer-like projection (ULP) in the posterior aspect of the ascending aortic wall, but it also revealed no intimal flap, false lumen or aortic aneurysm. CT and magnetic resonance imaging (MRI) indicated a change in the radiographic aspect of the ULP and revealed a mimicking saccular-type pseudoaneurysm and gradual increasing size of the pseudoaneurysm. Surgery was performed after considering the risk of pseudoaneurysmal rupture. We replaced the ascending aorta and diagnosed it as a spontaneous aortic rupture by histological examination of the rupture site after failing to observe an aneurysm or dissection. We discuss these results with reference to the literature, including our pathological and radiographical findings.

A 61-year-old male had complained of cough and dyspnea on effort, with right pleural effusion. Computed tomography demonstrated a calcific pericardium surrounding the entire heart, with thickening of 10 mm. Cardiac catheterization showed no coronary disease, but a dip-and-plateau of the pressure curve of both ventricles. We diagnosed congestive heart failure due to chronic constrictive pericarditis, and performed a subtotal pericardiectomy, using an Ultrasonic Scalpel through a median sternotomy combined with anterior left thoracotomy at the level of the fifth rib, without cardiopulmonary bypass (CPB). After the subtotal pericardiectomy, his postoperative recovery was uneventful and his functional status improved. We consider that our surgical technique is a useful method for treatment of chronic constrictive pericarditis, and advocate the use of the Ultrasonic Scalpel for a safe and easy pericardiectomy.

We report a 58-year-old man who underwent surgical treatment of primary lung cancer arising from the wall of a giant bulla. Chest roentgenography and computed tomography revealed multiple emphysematous bullae in the bilateral upper lobes, and a right upper giant bulla with a mass measuring 6 cm arising on the bulla wall. Right upper lobectomy was performed, the postoperative pathological diagnosis was large cell carcinoma arising from the wall of a giant bulla. Although the postoperative course was uneventful and he was discharged, he underwent partial resection of the jejunum for recurrence of carcinoma in the jejunum, and postoperative chemotherapy, and he was alive 20 months after that operation. In general, patients with both pulmonary bullous disease and primary lung cancer have a very poor prognosis, because they receive treatment when the tumor is at an advanced stage. On the basis of our review of the literature, we recommend that middle-age male patients with a giant bulla who smoke should have annual chest roentgenography and/or chest computed tomography to screen for lung cancer arising in or close to the bullous disease, and that a giant bulla should be resected in patients older than 50 years because of the high incidence of coexisting cancer and bulla, to improve the prognosis of this disease.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.

The performance of cardiac surgical procedures via median sternotomy in a patient with a tracheostomy can result in difficult problems, such as mediastinitis, stoma necrosis or inadequate operative exposure. We present a case of successful treatment for aortic valve regurgitation in a patient with a tracheostomy using a T-shaped sternotomy instead of a usual median sternotomy. This approach permitted adequate surgical exposure for cardiopulmonary bypass and aortic valve replacement. After surgery, the patient had a good clinical course without any complications and he was discharged on the 65th postoperative day. We consider this procedure to be applicable in consideration of the favorable results obtained.

We report a very rare case of primary malignant lymphoma arising in the pleura with no history of persistent pyothorax. A 72-year-old male was hospitalized with dyspnea on effort and chest CT demonstrated a mass along the right chest wall. Right thoracotomy with complete en bloc resection of the pleural tumor was performed. Immunohistochemical examination of the pleural tumor showed that the histology was marginal zone B-cell malignant lymphoma. We considered that this tumor had originated from the soft tissue in the chest wall based on radiographical and surgical findings. As diagnosis and treatment of pleural malignant lymphoma seems to have been difficult in most cases reported in the literature, it is thought that early active and accurate biopsy with large-bore needles, or, if possible, surgical incision for early diagnosis and aggressive surgery to achieve complete resection combined with radiation therapy and/or chemotherapy would be very important for a good prognosis.

We report a 58-year-old male treated with surgical drainage by mediansternotomy using a pedicled omental flap for descending necrotizing mediastinitis (DNM). The patient recovered from DNM after five months of mechanical respiratory support. In deciding upon the most appropriate surgical approach for mediastinal drainage, the level of infection is a good landmark and should be investigated by CT scan. We also review the 43 cases of successful surgical treatment of DNM reported since 1989 in Japan, including our own patient, who were diagnosed with DNM by CT scan according to the classification proposed by Endo et al., and discuss the most appropriate surgical approach for mediastinitis based on the literature. In the treatment of DNM localized to the upper mediastinal space above the carina, a transcervical approach may be appropriate. In diffuse DNM extending into the lower anterior mediastinum, a mediansternotomy or a thoracotomy may be useful, and in diffuse DNM extending into both the anterior and posterior lower mediastinum, a thoracotomy may be the best approach for debridement of the lower posterior mediastinum, in addition to early complete debridement of the entire cervical area.

We report a rare successful surgical repair of a common atrium (CA) with mild tricuspid valve (TV) regurgitation due to valvular annulus enlargement in a 39-year-old man, who had a complete atrial septum defect (ASD) without the characteristic of an endocardial cushion defect. The left-to-right shunt ratio was 85 percent and the Qp/Qs was 6.7 due to the CA. Left ventriculogram revealed no evidence of typical goose-neck deformity and no mitral valve regurgitation. The operation consisted of making a new atrial septum with an autologous pericardial patch and tricuspid annuloplasty (DeVega) using extracorporeal circulation. There was no evidence of a cleft on the anterior leaflet of the mitral valve or the septal leaflet of the TV. The postoperative echocardiogram showed no residual shunt flow through a new atrial septum and no TV regurgitation, and atrioventricular (AV) dissociation did not occur. We consider this procedure to be widely applicable in consideration of the favorable results obtained after surgical treatment.

A 42-year-old man was admitted to another hospital complaining of acute abdominal pain that was induced by eating. Abdominal computed tomography and selective angiography revealed an intimal flap separating true and false lumens that was located 3 cm from the origin of the superior mesenteric artery (SMA). Emergency surgery was performed because of the sudden recurrence of diffuse abdominal pain after eating and abdominal aorta-SMA bypass grafting was done using a radial artery graft. Postoperative angiography revealed that the graft showed good patency. The postoperative course was uneventful and abdominal pain no longer occurred after eating. This excellent result was achieved by early diagnosis using CT scanning and angiography plus an aggressive surgical repair with a radial artery bypass graft for isolated dissection of the superior mesenteric artery.

A 53-year-old man crashed his motorcycle into a vehicle and was transported to our hospital by ambulance after about 30 min. Echocardiography revealed cardiac tamponade. Pericardiocentesis was immediately performed using a 5 Fr catheter via the subxiphoid approach and the results suggested cardiac injury. Surgery was commenced via median sternotomy about 2.5 hours after the accident. Patients with cardiac rupture who reach hospital alive can be saved by rapid transport, early detection, and early surgery. In particular, rapid echocardiography and pericardiocentesis via the subxiphoid approach under ultrasonic guidance are easy and helpful methods of making a diagnosis and achieving hemodynamic improvement prior to surgical intervention.

Spontaneous and isolated dissection of the limb arteries without involvement of the aorta is extremely rare. We present a 36-year-old male who has 95% tapering stenosis and dissection of the left external iliac artery with abrupt onset with total thrombosis in the false lumen until the level of the inguinal ligament. We also suggest that endovascular stent graft placement is a useful treatment for isolated arterial dissections prior to operation in consideration of the technical ease and safety of guiding intravascular ultrasound like in this case.

A 21 year-old woman was admitted to our hospital because of chest and back pain after blunt chest trauma. On admission, consciousness was clear and a physical examination showed labored breathing. Her vital signs were stable, but her breathing gradually worsened, and artificial respiration was started. The chest roentgenogram and a subsequent chest computed tomographic scans revealed contusions, hemothorax of the left lung and multiple rib fractures. A transthoracic echocardiography (TTE) revealed normal left ventricular wall motion and mild mitral regurgitation (MR). TTE was carried out repeatedly, and revealed gradually progressive MR and prolapse of the posterior medial leaflet, although there was no congestive heart failure. After her general condition had recovered, surgery was performed. Intraoperative transesophageal echocardiography (TEE) revealed torn chordae at the posterior medial leaflet. The leaflet where the chorda was torn was cut and plicated, and posterior mitral annuloplasty was performed using a prosthetic ring. One month later following discharge, the MR had disappeared on TTE.