Follicular dendritic cell tumor (FDCT) is an uncommon neoplasm that typically presents as a slow-growing, painless mass without systemic symptoms. Histologically, FDCT is characterized as a proliferation of spindle to ovoid cells having plump eosinophilic cytoplasm with indistinct borders and nuclei with vesicular or granular chromatin and small distinct nucleoli. The immunohistochemical profile of FDCT includes positive staining for CD21, CD23, CD35, vimentin, fascin, HLA-DR, epithelial membrane antigen, clusterin, and D2-40. Follicular dendritic cell tumor occurs primarily in lymphoid tissue; however, involvement of extranodal sites such as the tonsils, spleen, and gastrointestinal tract has been reported. Lung involvement typically represents metastatic disease with, to our knowledge, only 2 prior cases of extranodal primary FDCT of the lung reported. We report the third case of primary pulmonary FDCT arising in a 64-year-old woman.

Background. We have previously shown that intraoperative brachytherapy decreases the local recurrences associated with sublobar resections for small stage la nonsmall-cell lung cancer (NSCLC). In this report, we present the outcomes of sublobar resection with brachytherapy compared with lobectomy in patients with stage Ib tumors.Methods. We retrospectively reviewed 167 stage Ib NSCLC patients: 126 underwent lobectomy and 41 sublobar resection with (125) I brachytherapy over the resection staple line. Endpoints were perioperative outcomes, incidence of recurrence, and disease-free and overall survival.Results. Patients undergoing sublobar resections had significantly worse preoperative pulmonary function. Hospital mortality, nonfatal complications, and median length of stay were similar in the two groups. Median follow-up was 25.1 months. Local recurrence in sublobar resection patients was 2 of 41 (4.8%), similar to the lobectomy group: 4 of 126 (3.2%; p = 0.6). At 4 years, both groups had equivalent disease-free survival (sublobar group, 43.0%; median, 37.7 months; and lobectomy group, 42.8%; median 41.8 months, p = 0.57) and overall survival (sublobar group, 54.1%; median, 50.2 months; and lobectomy group, 51.8%; median, 56.9 months; p = 0.38).Conclusions. Sublobar resection with brachytherapy reduced local recurrence rates to the equivalent of lobectomy in patients with stage Ib NSCLC, and resulted in similar perioperative outcomes and disease-free and overall survival, despite being used in patients with compromised lung function. We recommend the addition of intraoperative brachytherapy to sublobar resections in stage Ib patients who cannot tolerate a lobectomy.

Background. Segmental resection for stage I non-small cell lung cancer remains controversial. Reports suggest that segmentectomy confers no advantage in preserving lung function and compromises survival. This study was undertaken to assess the validity of those assertions.Methods. We retrospectively analyzed patients undergoing lobectomy (n = 147) or segmentectomy (n = 54) for stage I non-small cell lung cancer between March 1996 and June 2001. All patients were included in the survival analysis. Pulmonary function testing was obtained preoperatively and at 1 year and included forced vital capacity, forced expiratory volume in 1 second, maximum voluntary ventilation, diffusing capacity, and stair-stepper exercise. Patients with recurrent disease (lobectomy, n = 32; segmentectomy, n = 10) were excluded in the pulmonary function testing analysis to avoid the confounding variables of tumor or treatments.Results. Preoperative pulmonary function tests in segmentectomy patients were significantly reduced compared with lobectomy (forced expiratory volume in 1 second, 75.1% versus 55.3%; p < 0.001). At 1 year, lobectomy patients experienced significant declines in forced vital capacity (85.5% to 81.1%), forced expiratory volume in 1 second (75.1% to 66.7%), maximum voluntary ventilation (72.8% to 65.2%), and diffusing capacity (79.3% to 69.6%). In contrast, a decline in diffusing capacity was the only significant change seen after segmental resection. Oxygen saturations at rest and with exercise were maintained in both groups. Actuarial survival in both groups was similar (p = 0.406) with a 1-year survival of 95% for lobectomy and 92% for segmentectomy. Four-year survivals were 67% and 62%, respectively.Conclusions. For patients with stage I non-small cell lung cancer, segmental resection offers preservation of pulmonary function compared with lobectomy and does not compromise survival. Segmentectomy should be considered whenever permitted by anatomic location. (C) 2004 by The Society of Thoracic Surgeons.

BACKGROUND:An obstructing primary lung cancer is a challenging disease frequently requiring endobronchial interventional therapy. A variety of interventional modalities, including Nd:YAG laser, stenting, photodynamic therapy (PDT), and endoluminal brachytherapy, are utilized to relieve airway obstruction and bleeding. The aim of this study is to compare the effect on patient survival of bronchoscopic palliation for lung cancer utilizing one interventional modality compared to the use of combination of modalities to relieve the airway problem. METHODS. We reviewed our longitudinal experience with interventional bronchoscopy in 75 patients who underwent 176 procedures for the management of endobronchial lung cancer between 1994 and 2002. Indication for intervention was hemoptysis in 24 patients (32%) and airway obstruction in the remaining. Six patients died within 30 days from the first intervention and were excluded. Forty of the surviving 69 patients (58%) were treated with a single interventional modality (group A). In 29 patients (42%) a multimodality endoscopic treatment was utilized (group B). Single-modality treatment in group A included Nd-YAG laser in 60%, stent in 17%, brachytherapy in 20%, and PDT in 3%. A variety of combinations of the aforementioned modalities were used in group B to enhance airway patency. Patient data were compared with the Student's t-test and chi-square test. Survival analysis and the log rank test were used to compare difference in survival between the two groups. A p-value of 0.05 was considered significant.RESULTS:There were 46 males and 23 females, with a mean age of 67 years. The tumor was located in the trachea 9%, in the carina in 7%, and primary bronchial in 84%. Two patients had complications due to stent malposition. There was no significant difference between the two groups in relation to age, gender, tumor location, histology, and type of previous cancer therapy. There was a significant improvement in survival for the multimodality group (p = 0.04). The 1- and 3-year cumulative survival rate for groups A and B was 51.3% versus 50% and 2.3% versus 22%, respectively.CONCLUSIONS:Improvement in survival can be seen with diligent airway surveillance after interventional bronchoscopy and liberal use of a variety of endobronchial treatment modalities for airway obstruction or bleeding. Physicians involved in the management of this difficult problem should be versed in the use of all available treatment modalities to enhance therapeutic outcome.

OBJECTIVE:This study was undertaken to determine the safety and efficacy of reoperative laparoscopic fundoplication for patients with failed fundoplication.METHODS:Thirty-nine of 612 consecutive patients who had undergone fundoplication underwent laparoscopic reoperative fundoplication for recurrent symptoms, persistent dysphagia, or gas bloat. An additional 15 patients were referred from outside facilities for reoperation. Preoperative evaluation included barium swallow (n = 54), esophagogastroduodenoscopy (n = 54), esophageal manometry (n = 34), and 24-hour ambulatory pH measurement (n = 32). Symptom severity before and after surgery was evaluated with a visual analog scoring scale. The mean follow-up was 22.5 months.RESULTS:The primary symptoms that led to reoperation in the 54 patients were heartburn (n = 26), dysphagia (n = 23), and gas bloat (n = 5). Average time from initial operation to reoperation was 22.7 months. There were 3 conversions to open technique. An anatomic reason for the failure of the initial fundoplication was found in 69% of cases: slipped or misplaced fundoplication (n = 14), disrupted fundoplication (n = 8), transdiaphragmatic herniation (n = 7), achalasia (n = 1), and tight fundoplication (n = 7). Fourteen patients had 15 perioperative complications. Mean hospital stay was 2.3 days. Symptoms such as heartburn, dysphagia, and gas bloat improved significantly after reoperation; 40% to 50% of patients had scores 0 to 2, 21% to 45% had scores 3 to 7, and 9% to 29% had scores 8 to 10. Proton-pump inhibitor use after operation decreased from 88% to 36%. Fifty-two percent of patients completely discontinued any antireflux medications. Three patients had failure of the reoperation and required additional procedures.CONCLUSION:Laparoscopic reoperation for failed fundoplication is feasible and can achieve resolution of symptoms for a significant percentage of patients.

Hepatic metastases due to colorectal carcinoma have often been felt to preclude pulmonary metastasectomy. With the recent advances in surgical options, should patients with both liver and lung metastases be considered for surgical resection? The current study reviews the impact of such aggressive management on disease-free and overall survival (OS). The clinical course of 63 patients presenting with colorectal metastasis to the lung alone (group 1, n = 45) or combined hepatic and lung metastases (group 2, n = 18) were reviewed. All patients underwent complete resection of their lung metastases. Surgical control of hepatic tumor burden was achieved by tumor ablation, intra-arterial therapy, and/or resection. All patients in group 1 and group 2 were available for a mean follow-up of 27 and 24 months, respectively. The presence of hepatic metastases, the resectability of hepatic tumor burden, and the disease-free interval after pulmonary metastasectomy did not significantly influence survival. These findings demonstrate that aggressive surgical management of pulmonary metastases in the presence of liver metastases offers a similar benefit as compared to patients with pulmonary metastases alone. Therefore, hepatic metastatic disease does not preclude an attempt at pulmonary metastasectomy if hepatic metastases can be resected or remains responsive to therapy. Such an approach achieves comparable OS and mean survival when compared to pulmonary metastasectomy alone.

Background: The effectiveness of gastric conduit construction using hand-aasisted laparoscopic surgery (HALS) for esophageal cancer was objectively evaluated.Methods: Twentytwo patients underwent radical esophagectomy, among whom the construction of a gastric conduit was performed by HALS in 12 patients and by open surgery in 10.We evaluated the operative time, blood loss, number of resected abdominal lymph nodes, duration of postoperative ventilatory support, duration of bed stay, postoperative respiratory function and complications.Results: In the HALS group, operative time during the abdominal phase was 120 min, which was significantly longer than that in the Open group at 77 rain (p=0.0009).However, the former data also include early cases when the procedure was not yet totally mastered.In the last 5 cases, the mean operative time was 103 min which was significantly shorter than that in the initial 5 cases, at 136 rain (p = 0.028).No significant differences were noted between the two groups in blood loss during the abdominal phase, number of resected abdominal lymph nodes, duration of ventilatory support or duration of bed stay.On day 7 after surgery, forced vital capacity (VC) was 74 % of the preoperative value in the HALS group which was significantly lower than that in the open group at 46 % (p = 0.002).On day 30 after surgery, however, VC recovered in the Open group to almost the same level as in the HALS group.On day 7 after surgery, forced expiratory volume in one second (FEV1.0)value was also signiflcamly lower than in the Open group at 49 %, as compared to the HALS group at 72 % (p = 0.002), but on day 30, there was no difference between the two groups.In 3 patients of the Open group, severe respiratory complications including pneumonia, pulmonary edema were recognized, but no such complications were found in any cases of the HALS group.Conclusion: We believe that construction of a gastric conduit using HAL S enables the same level of surgery as obtained by open surgery.Not only does it preserve respiratory function by reducing pain, and reducing respiratory complications, it also makes early recovery possible, and is effective in improving quality of life after surgery.

PURPOSE: Benign tracheal stenosis (BTS) can be a life threatening condition for which surgical resection / reconstruction is often considered. Many patients presenting with BTS are poor surgical candidates and interventional bronchoscopy (IB) may be an attractive alternative to surgery in such patients.

BACKGROUND:Laparoscopic antireflux operations (LAP) have become increasingly common for the treatment of gastroesophageal reflux disease (GERD). We sought to determine if routine postoperative barium contrast studies following LAP were clinically efficacious in identifying technical problems and life-threatening complications related to the surgical intervention.METHODS:From January 1996 to December 1997, 112 barium studies were performed following 112 LAP procedures (47 male/65 female patients; mean age, 51 years) (group I). This group was compared to a subsequent cohort of 67 patients who underwent LAP between January 1998 and July 1998 without routine early postoperative barium contrast study (group II).RESULTS:In 111/112 of the barium studies of group I, no radiographic abnormality was identified. The average length of stay (LOS) for these patients was 2.6 days. Routine barium studies were not utilized in group II. The average length of stay for patients in group II was 1.4 days. Twelve group II patients underwent early postoperative barium studies to evaluate suspicious clinical symptoms. None of these 12 postoperative studies identified important problems, nor did they alter the patients' clinical management. However, because of the barium study, their LOS was equivalent to those patients who had undergone routine barium study (2.4 days). There was an increase of $1451.80 in hospital charges in the group of patients who had a barium study, largely as a result of the increased LOS.CONCLUSION:The routine use of these studies results in increased patient charges and a prolongation in the length of hospital stay. Immediate postoperative barium studies following laparoscopic antireflux operations are of little value in determining important postoperative problems among patients undergoing LAO.

Background. True parahiatal diaphragmatic hernias are rare entities that are sparsely accounted for in the literature. The current report is intended to depict the clinical profile and assess the feasibility of laparoscopic repair of parahiatal hernias.Methods. We conducted a retrospective review of all patients diagnosed and treated for parahiatal hernias. Clinical presentation and radiological assessment, as well as operative findings and repair, are discussed.Results. Of the 917 laparoscopic hiatal hernia repairs, 2 (0.2%) patients were identified with a parahiatal hernia. The presenting symptoms and preoperative testing were similar to those with more common paraesophageal hernias. Laparoscopic repair was successful in repairing the diaphragmatic defect and alleviating symptoms up to 4 years postoperatively.Conclusions. Parahiatal hernias of the diaphragm appear to be rare primary diaphragmatic defects. The clinical presentation of parahiatal hernias is often indistinguishable from the more common paraesophageal pathology. Laparoscopic repair of this rare entity can be safely and successfully accomplished in conjunction with antireflux surgical interventions when indicated.

Background. Anastomotic leak from cervical esophagogastric anastomoses is a serious problem after esophagectomy. We explored the efficacy of partial or total mechanical anastomoses accomplished with the endoscopic linear cutting and stapling device as an alternative to hand-sewn anastomotic techniques.Methods. During a 42-month period, 93 patients undergoing either transhiatal esophagectomy or a three-incisional approach to esophagectomy underwent either hand-sewn (n = 43), partial mechanical (n = 16), or totally mechanical (n = 34) cervical esophagogastric anastomoses. The occurrence of postoperative anastomotic leak and the development of postoperative anastomotic stricturing requiring dilation therapy were analyzed between these groups using chi (2).Results. All patients survived esophagectomy and were available for postoperative follow-up. Anastomotic leak developed in 10 patients (23%) with hand-sewn, 1 patient (6%) with partial mechanical, and 1 patient (3%) with total mechanical anastomoses (p < 0.05). Anastomotic stricture development paralleled the occurrence of anastomotic leak rate with 25 patients (58%) with hand-sewn, 3 patients (19%) with partial mechanical, and 6 patients (18%) with total mechanical anastomoses experiencing strictures requiring dilation therapy (p < 0.05).Conclusions. These results suggest that partial or mechanical cervical esophagogastric anastomoses created with the endoscopic stapling device may be superior to hand-sewn anastomotic techniques. (C) 2001 by The Society of Thoracic Surgeons.

Incisional access to pulmonary pathology involving both lungs has often involved bilateral standard thoracotomies, median sternotomy, and, recently, sequential lateral video-assisted thoracic surgical approaches. Significant problems are inherent to each of these approaches. We introduce a hybrid technique of bilateral simultaneous minithoracotomy with video assistance as an alternative to these other surgical approaches.

Background. An extensive posterior-lateral longitudinal tracheal laceration is an uncommon but serious complication of percutaneous dilational tracheostomy (PDT). We report the successful management of three ventilator-dependant patients whose percutaneous tracheostomy was complicated by an extensive longitudinal posterior-lateral tracheal laceration requiring operative repair.Methods. A retrospective review of 134 cases of PDT with concurrent bronchoscopy was performed between April 1997 and July 1999 and compared with a review of 124 cases of open tracheostomy. Tracheal lacerations were primarily repaired and augmented with intercostal muscle pedicle buttress.Results. Three cases of an extensive posterior-lateral longitudinal tracheal laceration that required operative repair were reported in the PDT group. None were reported in the open tracheostomy group. The 3 patients were managed with an adult high-frequency oscillating ventilator or pressure control ventilation during the postoperative period to limit barotrauma, and all healed without evidence of tracheal leak or stenosis.Conclusions. The increasing popularity of PDT, particularly among nonsurgical disciplines, may generate an increasing number of complications requiring operative attention. Thoracic surgeons need to be cognizant of the pitfalls of PDT technique and be prepared to manage these difficult clinical scenarios. (C) 2000 by The Society of Thoracic Surgeons.

UCP-2 and J3-actin primer s were carried out.UCP-2 expression was normalized to J3-actin expres sion .UCP-2 e xpression of HCC and nontumorou s liver tissue will be compared using paired t-test, Results: The ratio of UCP-2 to J3-act in exp ressio n in HCC and in non-tumorou s tissue is 3.00 :': 0. 19 (SO) and 2.30 :': 0.17 (SD)respectivel y.The ratio is higher in HCC than non-tumoro us tissue in 35 patients (76 %).Using paired t-test, the observed differen ce in UCP-2 expressio n between tumor and nontum orous tissue is highly significant (p = 0.00 16).Conclusion: UCP-2 expression in HCC is higher than non-tumorous cirrhotic liver tissue.The progress from cirrhotic liver to HCC is associated with an up-re gulation of UCP-2 gene expression.However, the biological significance of such observation is to be further defined .

Surgical techniques involving the endoscopic evaluation and treatment of diseases of the chest have progressed from their origins in the early 1900s to the modern era of video-assisted, minimally invasive thoracic surgery. As the surgical techniques and instrumentation evolve, the role of video assisted surgery in a modern general thoracic surgical practice continues to be debated and to change accordingly. This review describes the current role of video-assisted thoracic surgery (VATS) in the management of diseases of the lung (bronchogenic carcinoma, emphysema, and interstitial. disease), pleura (pleural effusions and empyema), and mediastinum (humors and cysts, autonomic dysfunction, and pericardial disease).