Objective: In a previous study, we have shown that the sequence of vessel interruption (SVI) during lobectomy has no impact on tumor recurrence. The aim of the present study was to determine whether SVI has an impact on the amount of blood retained in the resected lobe. Patients and methods: A non-randomized prospective study including 30 patients undergoing lobectomy for neoplasms. Group A-1'st had all lobar arteries ligated before interruption of the lobar vein and group V-1'st had a reverse sequence. Generous exclusion criteria were used, so as to include only patients with straightforward lobectomy, attempting to isolate SVI as the only factor that could affect blood loss. Lobar weight was recorded immediately after lobectomy. All ligatures and staplers were removed; blood drained from the lobe, collected and measured, and thereafter the lobe was weighed again. Results: Sixteen patients entered group A-1'st and 14 group V-1'st. The groups were similar in age, sex, body surface, histology, prior therapy, stage, FEV1%, length of operation, and number of segments resected. The amount of blood drained from the lobe was 31.4 +/- 13 and 34.2 +/- 14.8 ml in group A-1'st and V-1'st, respectively. The lobar weights before and after blood drainage were 177.6 +/- 56.9, 141.7 +/- 49.1 g and 201.5 +/- 74.2, 161.6 +/- 69.7 g, respectively. The amount of blood divided to the lobar weight was 0.178 +/- 0.052 in group A-1'st and 0.177 +/- 0.099 in group V-1'st. All of these figures did not differ statistically. No patient required blood transfusion during or after surgery. Conclusions: In straightforward lobectomy the amount of blood retained in the resected lobe is small. This amount is not affected by the sequence of hilar vessel interruption. (c) 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

OBJECTIVESThis study was undertaken to determine the incidence and outcome of major bleeding complicating deep sternal infection after cardiac surgery, to identify predisposing factors and means of prevention, and to clarify management options.METHODSThis was a retrospective study of 10,863 consecutive patients, of whom 213 (2.18%) acquired deep sternal infection. With 43 additional referrals, the total number of patients with deep sternal infection was 280. Deep sternal infection was managed by a two-stage scheme. Major bleeding was considered to be bleeding that occurred during or after operation for deep sternal infection from the heart, great vessels, or grafts, or bleeding requiring urgent exploration.RESULTSFifteen patients (5.36%) had major bleeding. The incidences of deep sternal infection and bleeding were highest among patients undergoing coronary artery bypass grafting. Thirteen patients had underlying diseases (type 2 diabetes in 9 cases). Deep sternal infection was diagnosed a median of 15 days after reoperation. Bleeding originated from the right ventricle in 9 patients. In 4 patients bleeding was iatrogenic during surgery for wire removal (n = 2) or reconstruction (n = 2). In 11 it occurred 15 minutes to 15 days (median 2 days) after wire removal, as a result of shearing forces in 7 cases and of infection only in 4 cases. Three patients died immediately. The other 12 were operated on, 6 with complete cardiopulmonary bypass, 2 with femoral cannulation, and 4 without cardiopulmonary bypass. The immediate mortality was 26.7%; the overall mortality was 53.3%. The median length of hospitalization of surviving patients was 38 days.CONCLUSIONSThe probability of development of major bleeding in patients with deep sternal infection was unrelated to the primary operation. The mortality associated with this complication was high. Meticulous technique during wire removal may decrease the risk of major bleeding. The impacts of cardiopulmonary bypass and of the technique and timing of sternal reconstruction remain undetermined.

Objective: During pulmonary resections for non-small cell lung cancer, the pulmonary vein is traditionally interrupted first to prevent seeding of malignant cells and consequently decrease metastatic implantation. This hypothesis was never confirmed scientifically. The aim of the present study was to determine whether the sequence of vessel interruption during lobectomy (lobar vein or lobar artery first) affects disease recurrence.Methods: A historical prospective study was performed of 279 consecutive patients with complete follow-up, who survived lobectomy for non-small cell lung cancer during 1992 to 1998, in a single center. Pre-, intra-, and postoperative variables were collected from the medical records; recurrence and vital status were obtained from follow-up files, central population registry, and personal confirmation, updated to December 2000. Comparison of recurrence rates by sequence of ligation and other independent variables was assessed by univariate and multivariate logistic regression analyses.Results: A total of 133 patients (48%) had vein interruption before the artery (V-first) and 146 (52%) had artery interruption first (A-first). The distribution of demographic, clinical, and other characteristics was similar between the 2 groups, except for the operated side and performing surgeons. The morbidity, blood requirement, and length of stay were equal for both groups. The total recurrence rate (A-first, 53%; V-first, 51%) was similar. Multivariate analysis (controlling for the effect of the performing surgeon) revealed elevated risk for recurrence among patients with high disease stage (odds ratio = 2.54), male gender (odds ratio = 1.59), intraoperative lung manipulation (odds ratio = 2.72), and blood transfusion (odds ratio = 1.49). Sequence of vessel interruption was not found as a risk factor for recurrence (odds ratio = 1.29; 95% 0.73 to 2.29, P =.4).Conclusions: Our results did not show that sequence of vessel interruption during lobectomy plays a role in tumor recurrence. A prospective study with randomization in selection of method as well as surgeons for each patient is needed to confirm these results.

Helical computed tomography (CT) has an important role in the evaluation of a wide range of congenital and acquired thoracic abnormalities. The development of advanced computerized reformations enables the generation of bronchographic and bronchoscopic images of the tracheobronchial tree, as well as angiographic images of pulmonary arteries and veins. Additionally, it provides coronal and sagittal reconstruction imaging of parenchymal abnormalities. This information is obtained by a 20-30 s procedure on a typical single channel system, which makes helical CT an optimal technique for the evaluation of patients undergoing major upper airways and thoracic interventions. The recent introduction of multisection CT scanners allows faster imaging of patients with thinner collimation, thus improving spatial resolution along the longitudinal (z) axis of the patient along with reduction of motion artefacts [1]. This article demonstrates the use of dual and quad-section helical CT in the postoperative evaluation of patients undergoing laryngo-tracheal and thoracic interventions, including laryngoplasty, tracheal endoscopic laser ablation, lobectomy, pneumonectomy, lung transplantation, sleeve resection, pulmonary angioplasty, and pulmonary artery thromboendarterectomy. Emphasis is given to the additive value of using computerized reformations over axial images, especially for delineation of complex postoperative anatomical details in the tracheobronchial tree and pulmonary vasculature. Konen, E. et al. (2003). Clinical Radiology 58: 341-350. (C) 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.

We report a case of chronic empyema and bronchopleural fistula after lobectomy for tuberculosis. The patient had undergone four different surgical procedures to correct his bronchopleural fistula during an interval of seven years. Finally, he had a successful closure of the fistula using the transsternal transpericardial approach.

Background: A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury.Methods: A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated.Results: One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication.Conclusions: Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults.

BACKGROUND:Video-assisted thoracoscopic surgery has become routine worldwide. On the basis of accumulating experience and technologic improvements, more complex operations can be performed. Until recently, thoracoscopic lobectomy has not been performed in Israel.GOALS:To describe the initial experience with thoracoscopic lobectomy in Sheba Medical Center, and discuss the advantages, disadvantages and indications for its use.MATERIAL & METHODS:From June 2000 to January 2001, five patients (3 male, 2 female) 22-72 year-old underwent thoracoscopic lobectomy. Four had malignant neoplasms (3 lung primary) and one a benign process. Preparations for surgery, anesthesia and monitoring were standard as for open lobectomy. Surgery was done through 3 ports and a 5-7 cm auxiliary thoracotomy. The majority of the operation was performed with staplers. In patients with lung tumors the regional lymph nodes were sampled. Pulmonary function tests were evaluated prior to surgery and in the immediate postoperative period.RESULTS:Lobectomy was completed in all patients according to preoperative planning without conversion to open thoracotomy. Operative time was 120-160 minutes. Blood transfusion was not required in any patient during or after the lobectomy. There was no operative mortality and only two minor complications in one patient. Narcotic requirement did not exceed 40 mg of morphine in any patient. Pulmonary function tests revealed a smaller than expected decrease compared to open thoracotomy. The cosmetic results were excellent.CONCLUSIONS:Thoracoscopic lobectomy is feasible in Israel too. It is an acceptable alternative for patients needing this operation. Thoracoscopic lobectomy causes less surgical trauma, better functional result and expectance for lowered mortality and morbidity. Its main disadvantage is its high cost.

BACKGROUND:Malignant neoplasms involving the pleura have a poor prognosis. In some cases the main symptoms and the cause of death are due to local spread, whereas metastases, if at all, develop late. The preferred treatment of these tumors is not clear.GOALS:To evaluate whether regional therapy that includes resection, local chemotherapy and hyperthermia is feasible, safe and effective for tumors with pleural spread.MATERIAL & METHODS:Forty-three patients undergoing surgery and hyperthermic pleural perfusion were studied retrospectively. The majority had mesothelioma, or thymic malignancies with pleural spread. Twenty-five patients received previous treatment. The extent of resection was dictated by tumor type and patients condition. Perfusion was performed with a roller pump and heat exchanger plus cisplatinum in a dose of 60-200 mg.RESULTS:Intrapleural temperature exceeded 40 degrees C in all patients. There were no hemodynamic, or respiratory problems related to perfusion. There was neither intraoperative mortality nor hematologic, renal or systemic toxicity. Three patients died (7% mortality) and 14 had complications. The overall 1, 2, 3, and 5-year survival rates ware 78%, 72%, 50% and 36% respectively. The best survival was for thymoma patients--70% after 3 and 5 years, and the worst for metastatic tumors--31% 3-year survival. Among 39 patients followed-up for more than 1 year (24 alive, 15 dead), 28 (72%) were free of ipsilateral pleuro-pulmonary recurrence.CONCLUSIONS:Surgery and hyperthermic pleural perfusion is feasible and relatively safe. This method offers a good chance of complete midterm local eradication of neoplasms with pleural spread. A survival benefit over other modalities is suggested in patients with thymoma. Other drugs, alone or in combinations, should be studied.

Background. Thymoma and thymic carcinoma with pleural spread have a high rate of locoregional recurrence and poor prognosis. Maximal debulking coupled with aggressive local treatment could offer a chance for cure. This study evaluates the early and midterm results of operation and hyperthermic pleural perfusion with cisplatinum for thymic malignancies.Methods. Fifteen patients (11 men), 20 to 67 years old (10 thymoma, 4 thymic carcinoma, 1 carcinoma in thymic cyst) underwent resection and hyperthermic pleural perfusion between 1995 to 2000. All had pleural spread proven before or intraoperatively. Six of the thymoma cases were recurrent. Current operation included resection without pleurectomy (9 patients), resection with pleurectomy (5), and extrapleural pneumonectomy (1 patient) with intraoperative hyperthermic pleural perfusion in all. Intrapleural temperature reached 40.3 degreesC to 43 degreesC. The total dose of cisplatinum was 150 mg or more in 14 patients.Results. Complete resection (RO) was achieved in 10 patients, subtotal (R1) in 3, and partial (R2) in 2. There was no operative mortality, no hemodynamic or respiratory disturbances during perfusion, and no hematologic, neurologic, or renal complications. Complications consisted of significant bleeding (2 patients), fever (2), and air leak (1 patient). Two patients with thymic carcinoma died after 27 and 34 months, and 1 is alive with no evidence of disease at 54 months. Two patients with thymoma died after 7 and 36 months. Eight are alive after 9 to 70 months. Four patients (all RO) are alive without local recurrence more than 60 months after operation and hyperthermic pleural perfusion.Conclusions. Operation and thermochemotherpy is feasible and safe in patients with thymic tumors. This method seems to offer excellent local control for patients with stage IV-a thymic malignancies. Midterm results suggest that operation plus hyperthermic pleural perfusion may lengthen survival in stage TV-a thymoma. (C) 2001 by The Society of Thoracic Surgeons.

Background. The preferred treatment for patients with pleural tumors or tumor's with pleural extension has not been determined. Systemic and local modalities were studied, including intrapleural chemotherapy and hyperthermia, which mainly have been investigated separately. The objective of this study was to investigate the feasibility, toxicity and early results of a multimodality treatment consisting of surgery, chemotherapy, and hyperthermia in one session for the treatment of patients with pleural malignancies.Methods. From November 1994 to September 1998, 26 patients (7 patients with mesothelioma, 11 patients with thymic neoplasms, and 8 patients with other tumors) underwent intraoperative hyperthermic pleural perfusion (HPP). Perfusion was performed with a roller pump and a heat exchanger. Cisplatin was added when the temperature stabilized to a mean of 40.8 degreesC (range, 40.2-41.5 degreesC). Dosages of cisplatin used were 60 mg in 2 patients, 100 mg in 2 patients, 120 mg in 1 patient, 150 mg in 18 patients, and 200 mg in 3 patients. The patients underwent the following associated surgeries: extended extrapleural pneumonectomy in 8 patients, resection of tumor without pleurectomy in 4 patients, resection of tumors with pleurectomy in 10 patients, and exploration and HPP only in 4 patients (thoracotomy in 2 patients and video-assisted thoracoscopy in 2 patients).Results. There were no technical problems during the perfusion period. The systemic temperature rose to a maximum of 38 degreesC. There was no renal or hematologic toxicity, except in one patient who experienced thrombocytopenia. One patient died from complications related to a technical error. Eight patients had complications; the most bothersome were in four patients with empyema (early in two patients and late in two patients). The median postoperative hospital stay was 7 days (range, 2-50 days). Ten patients were alive 28-69 months after surgery. The overall 1-year, 2-year, and 3-year survival rates were 72%, 65%, and 44%, respectively. Complete ipsilateral pleuropulmonary control was achieved in 17 patients (9 patients who are alive and 8 patients who have died).Conclusions. Intraoperative HPP with cisplatin is feasible, easy to perform, and relatively safe. This method may offer excellent local control for patients with pleural tumors. Cancer 2001;92:2197-203. (C) 2001 American Cancer Society.

A 30-year-old nonsmoking man underwent a left lower lobectomy with bronchoplasty for an obstructing lesion of the left lower lobe. Pathology results demonstrated a psammomatous melanotic schwannoma, a rare pigmented neural tumor of which only 25 cases have been reported as originating in the respiratory tract.

Ten patients with diaphragmatic paralysis and severe respiratory distress. 14 days to 5 years old, underwent plication of the diaphragm Nine of the patients had PNI after operations for congenital heart disease and one after resection of an intra spinal cervical lipoma. The right side was affected in 7, the left in 3, Indication for surgery in all patients was inability to wean from mechanical ventilation. The duration of ventilation before plication was 11 to 152 days (median 35 days). Eight patients underwent plication through a thoracic approach, 2 via an abdominal approach. There were no complications directly related to the operetion. The interval from plication to extubation was 2 to 140 days (median 4 days). Three patients died two hours to 51 days after plication due to causes related to the cardiac condition. Seven patients were extubated. One - 140 days following plication and six after 2 to 8 days (Median 4 days).We conclude that diaphragmatic plication is a simple and safe operation. It allows rapid weaning in infants and young children with phrenic nerve injury who are ventilator dependent. Patients with multi organ failure should not be selected for the procedure. Plication may prevent the complications of prolonged mechanical ventilation and should therefore be performed as early as possible.

A 17-year-old boy presented with spontaneous hemothorax due to a puncture wound of the diaphragm by an inward facing exostosis of the rib. Diagnosis was made by computed tomographic scan, and the patient underwent a video-assisted thoracoscopic procedure to remove the exostosis. This is only the eighth reported case of an exostosis causing hemothorax.