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Summary: Spontaneous pneumothorax is an extremely frequent pathology. Despite this, there is still no clear consensus on managing these patients. Therefore, we perform a systematic review and meta-analysis of the effectiveness of percutaneous aspiration compared with tube drainage for treating idiopathic spontaneous pneumothorax. Controlled, randomised clinical trials were selected, in which the effectiveness of percutaneous aspiration is compared with that of chest tube drainage, in terms of resolution of the pneumothorax and rates of relapse and hospital admission. Relevant articles were identified by searching electronic databases (e.g., Medline, EMBASE, CENTRAL, mRCT and Pascal), as well as the references of the papers found in this manner, with a cut-off date of April 2009. Quality was assessed by two independent evaluators, using the CASPe appraisal tool. Effectiveness of percutaneous aspiration is compared with that of chest tube drainage, in terms of resolution of the pneumothorax and rates of relapse and hospital admission. [Copyright &y& Elsevier]

Abstract: Objective: This study aims to determine the differences among various diaphragmatic eventration (DE) aetiologies and to compare the outcomes of the operation relative to the use of a diaphragmatic patch. Methods: Between 2003 and 2009, 28 patients with a DE who underwent surgery were classified according to the following aetiology: (a) previous operation or disease, (b) congenital/idiopathic and (c) trauma. Patients who received diaphragmatic patches during their operations (plication+patch, P/P, 19 cases) were compared with the patients receiving sole plication during the operation (P, 9 cases). The operations had been performed through a minimal length lateral thoracotomy incision (12–14cm). Results: The mean age of the patients was 53.3±9.8 years. A high hemi-diaphragm (alone or associated with a blunt sinus or a wide mediastinum) was the most prominent chest X-ray (CXR) finding in 19 patients (68%). The postoperative mean forced expiratory volume in 1s (FEV1) value (2.1±0.7) and the dyspnoea score (1.8±0.7) were better than the preoperative values (1.7±0.6; 3.4±0.9, respectively). The average height of the diaphragm (7.8±3.1cm) was not correlated with the dyspnoea score and the FEV1 value. Postoperative complications (4/28 or 14.3%) were minimal, excluding one respiratory insufficiency. The mean follow-up time was 23.4±17.8 months. Patients with congenital aetiology were younger, had higher diaphragms, had earlier operations after symptoms started and had better preoperative FEV1 values. P/P operations were done later than P operations. The P/P method patients had shorter postoperative hospital stays than the P method patients. Two diaphragmatic events (recurrence and herniation) occurred after the operations were performed with the P method. Conclusions: Buttressing the diaphragm by patch after the plication can protect from recurrence of a DE or any diaphragmatic insufficiency. Previous abdominal interventions may increase the complication rate after a DE operation. [Copyright &y& Elsevier]

Abstract: Objective: Residual air spaces on chest radiographs after pneumothorax surgery are not uncommon. We aimed to study their incidence and impact on surgical outcomes. Methods: Four hundred and twenty-seven patients [283 men and 144 women with a median age of 31 (14–96) years] underwent surgery for pneumothorax from 1995 to 2005 in a single unit. Video-assisted thoracoscopy was used in 225 cases (53%). Outcomes were: duration of intercostal drainage and hospital stay, recurrence, re-operation and referral to chronic pain clinic. Results: Median duration of intercostal drainage and hospital stay were 5 and 6 days, respectively. We found a recurrence rate of 6.6% (n =28), re-operation rate of 2.8% (n =12) and need for referral to pain clinic of 7% (n =30). In 129 patients (30%) a small residual apical space (RAS) was reported on chest radiograph prior to discharge. Hospital stay and duration of drainage were longer in these cases (p =0.002 and 0.02, respectively). On multivariate analysis RAS on chest radiograph was associated with increased risk of recurrence [hazard ratio 3.1 (1.4–6.8 95% CI)] (p =0.005); but no need for re-operation or referral to pain clinic. Re-operation was associated with VATS surgery (p =0.001) and when no abnormalities were identified at operation (p =0.04). Referral to pain clinic was more common after open surgery (p =0.01). Discussion: The risk of recurrence after pneumothorax surgery is low. But the presence of a residual apical space on chest radiography after surgery increases it significantly. Recurrence may be due to the failure to achieve early pleural symphysis. [Copyright &y& Elsevier]

Abstract: Objective: Welding of lung tissue is a new radio-frequency surgical method that allows sealing pulmonary tissue without overheating and damaging the tissue. The objective of the research was to study the results of sealing the lung tissue in a non-resectional procedure for spontaneous pneumothorax comprising ablation of bullae via video-assisted thoracoscopic surgery (VATS). Methods: We present a series of 133 consecutive patients with primary spontaneous pneumothorax, who were operated on during the past 3 years. Among 133 patients, 123 were men and 10 were women, with an average age of 26 years (from 14 to 59 years). Indications for surgery were pneumothorax recurrence (59 patients), contralateral occurrence (13), bilateral pneumothorax (one) and haemopneumothorax (two). Prolonged air leakage for more than 2 days was observed in 58 patients. We used the tissue-welding technology and an original bipolar hand-piece for bullae electroablation and lung sealing. Conventional apical pleural abrasion was carried out in all cases. Chest tubes were removed 48h postoperatively by protocol. Results: Intra-operatively, emphysema-like changes and blebs under 1cm were seen in 29 patients (22%) and bullae of 1–2cm in 48 patients (36%); in 56 cases (42%) the size of bullae exceeded 2cm. In all cases, lung sealing was achieved by tissue welding alone, without using staplers, sutures, glues and sealants. The operating time depended on the presence of adhesions and the number of bullae, but did not exceed 65min. Postoperative air leakage for 1–6 days was observed in six patients. Neither mortality nor major morbidity was observed. There were seven recurrences (5.2%). Conclusions: The tissue-welding procedure is easy to perform through VATS and is efficient for ablation of bullae of any size. Leak-proof sealing is achieved, allowing us to repair the pulmonary–pleural fistula, thus being a non-resectional alternative to wedge resection. No conventional wound-closing devices are needed. [Copyright &y& Elsevier]

Abstract: A 21-year-old male developed significant swelling of his tongue after a respiratory arrest. The patient had a history of Hurler''s syndrome. Magnetic resonance imaging (MRI) angiogram delineated that the swelling was due to compression of his internal jugular veins at the level of the first rib, resulting in thoracic inlet obstruction. The standard surgical treatment of thoracic inlet obstruction was not suitable in this patient''s case due to his short thick neck and his characteristic Hurler''s syndrome body habitus. Therefore, a novel surgical strategy was used to decompress his head and neck vessels. The manubrium was widened using an iliac crest bone graft, stabilised using internal fixation plates and reconstructed with a pectoral muscle flap. [Copyright &y& Elsevier]

The author reflects on a study about pulmonary allograft in the Ross procedure. He mentions that the study attempts to find an alternative to the pulmonary allograft in the Ross procedure. He adds that the attempt aims to improve the results with an alternative surgical technique, the proximal extension of allografts.

OBJECTIVES Recent studies have suggested that postoperative complications could have a potential negative effect on long-term outcome after oesophagectomy for cancer. Because respiratory failures represent the most frequent postoperative complication, we have investigated the prognostic impact of these complications on disease-free survival (DFS). METHODS From a prospective single-institution database of 405 consecutive patients who underwent transthoracic oesophagectomy for cancer, we retrospectively analysed medical charts of all patients with microscopically complete resection (R0, n = 384 patients). Complications were graded according to the modified Clavien classification. Respiratory complications were defined as atelectasis, pneumonia or acute respiratory distress syndrome in the absence of early surgical complications. Patients with grade 5 (postoperative mortality, n = 43, 11%) were excluded from the analysis. The remaining 341 patients were analysed for estimation of DFS according to the Kaplan–Meier method. Logistic regression analysis was conducted to discriminate predictive factors affecting DFS. RESULTS According to the modified Clavien classification, postoperative complications rates were grade 0: 147 (44%), grade 1: 7 (2%), grade 2: 56 (16%), grade 3: 69 (20%) and grade 4: 62 (18%). Five-year DFS rates were not significantly different between grade 0 (no complication, 38%, n = 147) and other grades (grade 1, 2, 3 and 4 (64, 45, 56 and 48%, respectively)). Respiratory complications occurred in 107 patients (31%) and the 5-year DFS in this subgroup was 47% compared with 38% observed in grade 0 patients (P = 0.75). Clavien classification and respiratory complications did not come out in the univariate analysis of factors affecting DFS. On logistic regression, only two variables affected DFS: c-N stage and extracapular lymph node involvement. CONCLUSIONS When postoperative mortality is excluded, postoperative complications do not affect DFS in patients with complete resection. This deserves substantial information regarding the prognosis of subgroup of patients in critical situations where incrementing intensive care is debated. [ABSTRACT FROM AUTHOR]