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Objectives Bronchial stenosis is still a significant source of morbidity and mortality following lung transplantation (LTX) and often mandating placement of a bronchial stent. It has been suggested that although self-expanding metal stents offer excellent early palliation, their long-term complication rates are unacceptably high, and hence, their usage in many transplantation centres has been nearly abandoned. The aim of the study was to assess short- and long-term complication rates and survival in LTX patients with bronchial stenosis treated with insertion of self-expanding metal stents. Methods From January 1997 to March 2013, 435 patients underwent LTX (325 single-LTX and 110 bilateral LTX). Of 503 actual anastomoses at risk (derived by subtracting the number of anastomoses in 30 patients who died within 30 days of LTX), 60 airway complications (11.9%) in 47 patients required self-expanding metal stent insertion. We assessed the early results and long-term outcomes and survival compared with LTX patients in whom stents were not required. Results The median follow-up period ranged from 1 to 132 (median 54) months. Immediate relief of symptoms was achieved in the vast majority of patients (95%). One-, three- and five-year survival in patients who required self-expanding metal stent placement were 77.7, 66.6 and 55.5%, respectively. The corresponding survival rates in LTX patients without stents were 69, 64.9 and 61.1% (P > 0.05). Conclusions Self-expanding metal stents are safe and effective tools in the management of airway complications post-LTX and provide immediate improvement in symptoms and pulmonary function tests in the vast majority of cases. The long-term complication rate is low, and mortality is similar to that in LTX patients who did not require stent insertion.

Pulmonary arteriovenous malformation (PAVM) may occur primarily or in association with hereditary hemorrhagic telangiectasia. We present a case of PAVM in the central lower lobe of the left lung of a 75-year-old woman, which was successfully treated by lobectomy. Contrast echocardiography is an excellent tool for evaluation of this uncommon lesion. Advances in interventional radiology have led to the introduction of obliterative techniques for the treatment of PAVM. However, in the presence of a large solitary malformation centrally located, as in our case, and in high-risk patients, surgery is still a safe and effective first option.

Since Boerhaave’s 1724 report of a fulminant acute mediastinitis, this aggressive disorder has gained recognition because of its often fatal course. The severe mediastinal infections descending via the neck from an oropharyngeal or odontogenic focus or from a peritonsillar abscess triggered research to understand the neck compartments and the way infection was spread. The first experiments started in Europe in the 19th century and by 1940, the anatomy of the neck was established as we know it today. Grodinsky and Holyoke [1] presented the concept of the three fasciae and fascial spaces and showed how an infection in these areas is likely to gravitate to the mediastinum. Cogan [2] identified two different patterns of mediastinitis: suppurative as seen in post-sternotomy cases where an abundant amount of pus is located almost in one compartment and necrotizing as we see when it results from a descending oropharyngeal infection. Here, the tissue planes are violated by a rapid necrotizing process activated always by a combination of aerobic and anaerobic bacteria that run to the danger space, the retrovisceral space. As a result of the invasion of the posterior mediastinum, there is an increased incidence of bilateral pleural effusion. In this issue of the Journal, Kocher et al. [3] present a respectable series of 17 patients with diffuse descending necrotizing mediastinitis, one of the largest ever published. They review the Endo classification [4] that is helpful to determine the surgical strategy. There is also an extensive review of the literature including six of the biggest series of the literature with a total of 228 patients. In all of them, the surgical approach was transcervical only or in a combination with thoracotomy. Surprisingly, the authors report median sternotomy or clamshell thoracotomy as their surgical approach. In my point of view, the best surgical approach is by posterolateral thoracotomy, where we can open the entire mediastinal pleura, wash, clean and drain the cavity and not touch the bones. Sawing healthy bones in the presence of infection is not a correct surgical practice. By thoracotomy, even the anterior purulent collections can be reached and there is no risk of further osteomyelitis. Several times, a second look is necessary, and this can only be accomplished if our patient had a thoracotomy incision. On the other hand, the results presented are very encouraging. Although the morbidity rate is still high, no wound infection was reported and mortality was very low if compared with the data reported in the literature. This is in part a result of better patient support and more potent antibiotics, but we cannot exclude the dedication of the medical team.

Resection of a mediastinal tumor (Fig. 1) in a 57-year-old woman who presented with progressively aggravated dyspnea at rest, productive cough, and a referred vague left chest pain, established the diagnosis of schwannoma (Fig. 2a,b), a benign, slow-growing neoplasm that frequently arises from a spinal nerve root but may involve any thoracic nerve. European Journal of Cardio-thoracic Surgery 24 (2003) 1030 www.elsevier.com/locate/ejcts