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Inflammatory diseases of the lung and pleura in children and adolescents cover a broad spectrum, including complicated pneumonia, tuberculosis, mycoses, and hydatid disease. Their frequency strongly depends on the geographical origin. The following article gives an overview - from diagnosis to surgical treatment of these diseases in the paediatric population., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Spontaneous pneumothorax is a potentially life-threatening situation. Therefore, it is mandatory to treat it safely. The incidence is approximately 10 out of 100 000 residents per year. It occurs through an immediate disruption of the visceral pleura that results in an accumulation of air in the pleural space. According to its etiology, spontaneous pneumothorax is divided into 2 groups. Whereas primary spontaneous pneumothorax occurs in healthy individuals without any detectable lung disease, secondary spontaneous pneumothorax occurs in patients with preexisting. Diagnosis of pneumothorax is typically made by chest x-ray. After diagnosis pneumothorax is traditionally treated by an insertion of a thoracic tube.Recently, thoracic ultrasound gained influence in diagnosis of pneumothorax and primarily conservative treatment strategies have been shown to be safe and equally effective in particular groups of patients. This article aims to present and discuss these upcoming strategies., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

We report on a 40-year-old patient who presented with fever, right upper abdominal pain, right-sided chest pain and acute dyspnea. Imaging revealed several liver abscesses, as well as extensive right pleural empyema. Sixteen weeks previously, the patient underwent tooth extraction of the third molars (18, 28, 38, 48) and a first molar (46), and systematic closed periodontitis treatment. Four different species of the physiological microbiota of the oral cavity were detected in the pleura or liver abscess punctate (Streptococcus anginosus, Streptococcus constellatus, Actinomyces odontolyticus, Prevotella denticola). An underlying immune defect was ruled out. Ultrasound-guided drainage of liver abscesses and surgical treatment of pleural empyema by video-assisted thoracoscopy (VATS) and insertion of thoracic suction drains was performed, accompanied by targeted antibiotic therapy. Over a course of 6 weeks, the patient recovered completely. The case report illustrates severe infectious side effects of major dental interventions, and it critically summarizes current dental guideline recommendations on peri-interventional antimicrobial therapy. Therefore, a good clinical follow up after major tooth extractions is imperative., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Unlabelled: Parapneumonic pleural effusion (PPE) occurring in early-stage (stage I) pleural empyema (PE) can be managed by chest tube drainage, which should be performed as soon as possible, to achieve re-expansion of the pulmonary parenchyma. Chronic disease leads to fibrin deposits on both pleural surfaces (stage II), followed by a thickened pleura peel (stage III). A trapped or compressed lung can only be released by surgical decortication, which may be performed with a minimally-invasive approach (video-assisted thoracoscopy) or an open technique (thoracotomy). This article reviews effects on pulmonary function after decortication in chronic empyema patients., Material and Methods: Selective literature research using Medline (key words: pleural empyema, decortication, lung function). A comparative analysis was performed on functional parameters obtained before and after surgical decortication in patients with chronic pleural empyema., Results: Decortication in chronic PE significantly enhanced spirometric parameters (FEV1, VC/FVC) in all analysed studies. Considerable differences were observed regarding the mean follow-up time (early postoperative to several months after surgery). Computed tomography scans were usually analysed after a minimum of 6 months postoperatively. Measurements of anterior-posterior and transverse diameters as well as volume quantification of the operated and non-operated lung were performed in pre- and postoperative imaging. Statistical comparison revealed a significant decrease in thoracic asymmetry. In addition to static and dynamic pulmonary performance, pulmonary perfusion improved significantly after decortication as demonstrated by lung perfusion scans performed immediately after surgery and during a period of 7 to 10 months thereafter., Conclusion: Surgical decortication in chronic pleural empyema improves lung function and increases perfusion. Besides a significant enhancement of spirometric parameters, re-expansion of the diseased lung leads to equalisation of thoracic asymmetry and may even prevent loss of volume in the affected lung., (Georg Thieme Verlag KG Stuttgart · New York.)

Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor disease, which rapidly leads to death if untreated. In Germany the incidence of newly occurring disease is expected to reach a peak in the coming 5 years. An R0 resection for MPM is technically impossible; therefore, the aim of surgical procedures is to achieve the maximum amount of cytoreduction. There are two established surgical techniques for treatment of MPM, extrapleural pneumonectomy and tumor pleurectomy with decortication. The type and extent of surgery are currently controversially discussed. Within multimodal therapy concepts including cytoreductive surgery, long-term remission is possible in selected patients. When choosing the appropriate surgical therapy the high incidence of recurrence has to be borne in mind.

Introduction: Parapneumonic pleural effusions arise from pneumonia and may develop into pleural empyema (PE). PE is defined as collection of pus in the pleural space with secondary inflammation of the visceral and parietal pleura. This review article describes the current treatment strategies for para- and postpneumonic PE both in children and adults., Material and Methods: Selective literature research via Medline (key words: pleural empyema, pleural empyema in children, thoracic empyema) and presentation of our own clinical experience with therapy recommendations., Results: The incidence of postpneumonic PE is increasing in both children and adults. PE is associated with a high morbidity and mortality if it is not treated early and adequate. Progression of PE follows a characteristic morphological course, which is classified in three stages: the exsudative, fibrinopurulent, and organizing phase. Treatment should be adapted to these three phases including systemic antibiotic therapy and drainage of the pleural space. Intrapleural fibrinolysis can be performed with good success independent of age in the transition of stage 1 and 2. In persistent PE (stage 2), thoracoscopic decortication is recommended to avoid progression into the organizing phase (stage 3) with the need of an open decortication. In debilitated elderly patients the increasing use of intrathoracic vacuum therapy (Mini-VAC/Mini-VAC-instill) offers an effective and less invasive therapy option., Conclusion: Para- and postpneumonic PE requires an individualized and stage adapted therapy using a combination of medical and surgical treatment strategies with the aims of removing the source of infection and ensuring re-establishment of lung expansion., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Malignant pleural mesothelioma (MPM) is an aggressive, malignant tumor of the pleural surface and is strongly associated with asbestos exposure. Incidence of MPM will reach its peak over the coming years. Most patients present with advanced tumor stages and therefore surgical options are limited., Patients and Methods: Retrospective analysis of all patients with MPM reported to the tumor centre Regensburg between January 1998 and August 2011., Results: A total of 118 patients (85 % male) with cytologically or histologically confirmed MPM were reported. The mean age at diagnosis was 67 years (range 45-84 years) and 65 % of patients had a history of asbestos exposure. The incidence of MPM at the tumor centre Regensburg was 0.8/100,000 inhabitants with obvious regional differences depending on asbestos exposure. Staging was completed in 81 patients (67 %): stage I 9 %, stage II 22 %, stage III 23 % and stage IV 46 %. Of the patients 87 (74 %) underwent at least one surgical procedure: diagnostic thoracoscopy with biopsy (n = 37, 43 %), debulking surgery or talcum pleurodesis (n = 33, 38 %) and potentially curative resection (n = 17, 19 %). After a mean follow-up of 20 months the overall median survival was 14 months (1 year survival rate 62 %, 3 year survival rate 15 %). Patients had a significantly better median survival of 18 months after curative resection., Conclusions: The distribution of MPM varies according to regional and industrial asbestos exposure. Screening and diagnostics should concentrate on locations with higher incidence of MPM to facilitate surgical therapy in a multimodal treatment regime.

Introduction: Patients with pleural thymoma spread (Masaoka stage IV a) should be treated within a multimodal treatment regime. However, the extent of local surgical resection to achieve optimal tumour control remains controversial., Patients and Methods: Prospective analysis between September 2008 and April 2013 of all patients with a Masaoka stage IV a thymoma, who underwent radical pleurectomy/decortication (P/D) followed by hyperthermic intrathoracic chemotherapy (HITHOC)., Results: A total of 11 patients (male n = 7; mean age 46.5 ± 11.4 years) with a primary stage IV a thymoma (n = 3) or thymoma with pleural relapse (n = 8) were included after successful transsternal thymoma resection. WHO histological classification was: B1 n = 1, B2 n = 6, B3 n = 3 and C n = 1. A radical P/D (5/11; 45 %) was extended with resection of the pericardium and diaphragm in 6/11 (55 %) patients. After surgical resection (91 % complete macroscopic R0/R1-resection) the HITHOC with cisplatin (100 mg/m2 body surface area (BSA) n = 7; 150 mg/m2 BSA n = 4) was performed for one hour at 42 °C. Operative revision was necessary in two patients (chylo- and hematothorax) with one patient also requiring temporary renal replacement therapy due acute renal failure (cisplatin 150 mg/m2 BSA). 30-day mortality was 0 %. Local recurrence (pulmonary n = 1, paravertebral n = 2) was documented in 3/10 (30 %) patients after R0/R1 resection. After a mean follow-up of 23 months the overall median survival was 27 months and 82 % (9/11) patients are still alive at the end of the study period., Conclusions: Masaoka stage IV a thymoma could be safely treated with lung-sparing radical P/D and HITHOC with cisplatin in a multimodality treatment regime. Early results with respect to recurrence and survival are encouraging, but further studies are warranted and we have to await long-term results., (Georg Thieme Verlag KG Stuttgart · New York.)

The role of surgical resection per se and the type of surgery in the management of multimodality treated malignant pleural mesothelioma remains controversial. Patient selection for either extrapleural pneumonectomy or radical pleurectomy depends not only on the cardiopulmonary status of the patient, tumor stage and intraoperative findings but is also strongly influenced by surgeons' preference, experience and philosophy. The aim of this review is to compare extrapleural pneumonectomy and radical pleurectomy with regard to surgical technique, morbidity, mortality and survival.

The increased use of asbestos in Germany in the mid 1970s led occupational physicians, pulmonologists, thoracic surgeons and pathologists to the expectation of an increasing incidence and mortality in patients with pleural mesothelioma up to 2020. Prerequisite for curative surgery is a pathological anatomical tumor diagnosis on the basis of a biopsy and accurate tumor staging. In order to achieve reproducible results in the assessment of malignant pleural diseases, the pathological anatomical diagnosis of malignant pleural mesothelioma should be made according to the guidelines of the international mesothelioma interest group (IMIG). Currently used multimodal thoracic surgery therapeutic concepts present new challenges and problems to the pathological anatomical diagnosis and are discussed in this article.

Trimodality treatment including induction and/or adjuvant chemotherapy, surgical resection and in some cases radiotherapy offers a curative intention in selected patients with pleural malignancies (malignant pleural mesothelioma, thymoma with pleural spread). Nevertheless, locoregional tumor recurrence mainly limits the outcome and the quality of life. A few years ago an additional intraoperative chemotherapy perfusion was developed in order to improve local tumor control and prognosis after surgical resection in a multimodality treatment setting. Cytoreductive surgery with the purpose of a macroscopic complete resection could be achieved by radical pleurectomy or extrapleural pneumonectomy. The concept, techniques and perioperative management of this additional treatment option are presented along with a detailed review of the recent literature.

Recently cytoreductive surgery of primary and secondary pleural tumors has been combined with hyperthermic intrathoracic chemotherapy perfusion (HITHOC) for better local tumor control. In comparison to simple instillation of chemotherapeutic agents into the pleural cavity, the combination of surgical resection of pleural tumors and simultaneous HITHOC seems to be a more effective treatment. Intra-operative perfusion allows an improved distribution of the drug in the pleural space and a higher local concentration of the chemotherapeutic agents in contrast to systemic chemotherapy. Additional advantages of HITHOC are a better response to chemotherapeutic agents and synergistic antineoplastic effects. A prerequisite for safe application of HITHOC is compliance with safety regulations. Due to the reduction in morbidity and mortality this new concept is a valuable alternative for selected patients who do not undergo radical resection (e.g. extrapleural pneumonectomy). HITHOC is an additional therapeutic option in the multimodal treatment of patients with primary or secondary tumors of the pleura.

Parapneumonic pleural empyema has been classified by international societies and by pleural diseases experts into different stages and classes. While the American Thoracic Society (ATS) classification is based on the natural course of the disease, Light has classified pleural empyema according to radiological, physical and biochemical characteristics, and the American College of Chest Physicians (ACCP) has categorised patients with pleural empyema according to the risk of a poor outcome. According to these classifications, the management of the pleural empyema is based on the stage of the disease. The recommended treatment options in (ATS) stage I disease (Light classes I-III, ACCP categories I and II) are therapeutic thoracentesis or tube thoracostomy and antibiotics when necessary. In (ATS) stage II disease (Light classes IV-VI, ACCP category III), thoracoscopy (VATS) is the treatment of choice because it has a higher efficacy than treatment strategies that utilise tube thoracostomy or catheter-directed fibrinolytic therapy alone, whereas in (ATS) stage III disease (Light class VII, ACCP category IV), decortication via thoracoscopy or thoracotomy is the treatment of choice.

Multimodal therapy including neoadjuvant chemotherapy with subsequent extrapleural pneumonectomy and postoperative radiotherapy has been shown to improve the survival of patients with malignant pleural mesothelioma (MPM) if they are selected carefully. Careful patient selection is required in order to administer aggressive multimodal therapy only to patients who will benefit from such a treatment. To achieve an accurate staging (

Solitary fibrous tumours of the pleura can arise from either the visceral or the parietal pleura. Female and male subjects are affected equally; solitary tumours of the pleura are found at all ages with a main incidence in the sixth and seventh decades. The current literature describes the origin of both benign and malign tumour cells as being from multipotential submesothelial fibrous cells. The clinical appearance is unspecific and characteristic symptoms are lacking; cough, feeling of pressure in the thoracic chest or dyspnoea are the main leading symptoms and correlate with tumour size. A CT scan of the chest is the diagnostic tool of choice. Frequently, a solitary tumour of the pleura is found incidentally. Paraneoplastic syndromes are described and hypertrophic pulmonary osteoarthropathia (HPO) is the most common in cases of a solitary fibrous tumour of the pleura. The therapy of choice is complete surgical resection. There are no data supporting a neoadjuvant or adjuvant therapy. There are no known risk factors and complete resection is the only factor of prognostic relevance. Patients with a benign solitary fibrous tumour of the pleura have a far better survival compared to those with the malignant variant. In two recent reviews, the 5- and 10-year survival rates are described as being 97 and 90 %, respectively, for benign tumours compared with 89 and 88 % for malignant fibromas.

Pleural empyema runs in three stages, if untreated. Because it produces uncharacteristic signs, specific diagnosis and adequate treatment is often delayed. The treatment should be early, according to the stage and adapted to the given situation. Expenditure and morbidity of treatment are the higher the longer it is delayed. In the exudative stage 1, drainage--if necessary combined with antibiotic administration--is likely to be successful. In the fibrinous-purulent stage 3, often not clearly demarked from the other stages, video-assisted thoracoscopy (VATS) in its various forms provides the best therapeutic prerequisite. It makes it possible to open all cavities and free pleural layers from the, usually fibrinous or fibrosing, contents. Furthermore, VATS allows targeted drainage placement as essential precondition of effective irrigation. The definitive stage 3 of organization requires the technically demanding empyema excision or decortication.

The solitary fibrous tumor (SFT) is a very rare and usually benign neoplasm. This tumor is mostly located in the thoracic cavity, but it has also been reported in numerous sites including liver, skin, and meninges. Due to its rarity diagnosis is often difficult. Accordingly, histopathological differentiation is of major importance. Solitary fibrous tumors consistently express CD 34 and react negatively to epithelial markers. This absence of expression of epithelial markers, especially cytokeratin, is also useful to distinguish these rare entities from sarcomatous mesotheliomas. The treatment of choice for solitary fibrous tumors is extensive surgical resection. Up to now there is no evidence that radiation and chemotherapy are effective. The local recurrence or onset of metastases depends on histologic parameters. In cases of benign classification (60-80%), the recurrence rate was only 2% after surgical excision. One-half of the patients with malignant tumors can be cured; the rest develop recurrences and metastases more often. Especially in those cases, emphasis should be placed on continual follow-up examination. We report two cases of a 65- and a 75-year-old male patient with huge intrathoracic solitary fibrous subpleural tumors, discovered incidentally on routine chest X-ray.

We present the case of an overweight male patient with a lung hernia caused by a single massive coughing attack. The diagnosis could only be verified by CT-scans. Following a conservative therapeutic approach, surgical intervention was necessary. Lung hernias are easy to detect using radiological diagnostic. Standard X-ray examinations where a subcutaneous air mass can be seen have become, since the inauguration of computed tomography, second line tests. Large traumatic lung hernias should be treated surgically. Spontaneous and especially cervical hernias should be handled conservatively and only must be surgically treated when complications or a progression in size should be observed.

Introduction: Video-assisted thoracoscopic surgery has been used in the treatment of pneumothorax since 1990. There is still no general agreement regarding the procedure to obliterate the pleural space or regarding the indication for wedge resection if no blebs or bullae can be found., Patients and Methods: Clinical records referring to 100 video- assisted thoracoscopic operations for pneumothorax, performed in Berlin-Buch between 1998 and 2001, were retrospectively evaluated with regard to the rate of recurrences and postoperative complications in connection with the operative procedure. There were 70 male and 28 female patients aged from 16 to 78 years. The mean age was 34 years. The statistical significance was evaluated by the McNemar-test., Results: 74 patients showed a regular postoperative course. Severe postoperative complications occurred in 9 patients: re-operation via thoracotomy n=5 (postoperative bleeding n=2, recurrence n=2, persistent air-leak n =1); re-thoracoscopy n=3 (postoperative bleeding n=2, recurrence n=1), pleural empyema n=2. The complication rate was significantly higher (p < 0.001) in patients with underlying pulmonary diseases (secondary spontaneous pneumothorax) or thoracic surgery in their history. Depending on the intraoperative situation, the cause of pneumothorax and the patient's general condition the pleural space was obliterated by the following procedures: apical parietal pleurectomy (n=85), electro-pleurodesis alone (n= 7), electro-pleurodesis and pleural abrasion (n=3), talcum poudrage (n=2). The rate of major complications was lower (p < 0.001) when pleurectomy was performed 8.2 % (7/85) compared to those operations performed without pleurectomy 13.3 % (2/15). The rate of re-operations for recurrences/persistent air leaks or empyemas following persistent air leaks was significantly lower (p < 0.001) when wedge resection 3.75 % (3/80) had been performed compared with operations without wedge resection 10 % (2/20)., Discussion: Apical parietal pleurectomy and wedge resection of blebs or bullae are effective methods to prevent recurrences. Considering the specific complications of parietal pleurectomy alternative methods to obliterate the pleural space should be used depending on the intraoperative situation. Among other factors underlying pulmonary diseases or thoracic surgery in the patient's history strongly influence the postoperative outcome independently of the operative procedure.

Introduction: Fifty-eight patients (mean age 27 years, range 17-44) with primary spontaneous pneumothorax (PSP) underwent resection of apical bullae and partial apical pleurectomy via mini-thoracotomy or thoracoscopy, in 12 cases bilaterally, between 1982 and 1999., Method: After a mean follow-up period of 111 (16-212) months, 26 patients with 31 operated lungs were reassessed by high-resolution CT (HRCT) to demonstrate postoperative morphological changes., Results: Neither relevant clinical symptoms nor recurrence of a pneumothorax were found. However, HRCT revealed new apical bleb formations in 22 (71%) of 31 lungs. Neither the surgical approach, the technique of resection nor giving up smoking could be correlated to the tissue alterations. Surgical excision of the apex of the lung does not stop bleb formation., Conclusion: This study confirms earlier results from a different institution, when blebs recurred in 50% of the cases. The presence of these new apical formations neither influenced the clinical outcome nor predisposed to recurrence of PSP. Parietal (partial) pleurectomy seems mandatory to prevent PSP in the long-term.

Localized fibrous tumor of the pleura is a rare, slowly growing, benign tumor which originates from the submesothelial stem cells of the pleura visceralis. Most of these tumors clinically behave asymptomatically, although tumor-associated hypoglycemia occurs in a few cases and can lead to hypoglycemic coma. Laboratory investigations show significant elevation of paraneoplastic IGF-II with a 2-3 times higher effect on the blood glucose level than insulin. Further, one finds reduced synthesis of IGFBP-3, which inhibits the action of IGF-II by inducing a complex with the paraneoplastic protein. As treatment, surgical resection of the tumor is recommended. We report on the case of a 72-year-old man with diabetes mellitus type II, who complained of recurrent hypoglycemic episodes. Diagnostic evaluation showed a fibrous tumor attached to the right diaphragm. After surgical treatment the hypoglycemic episodes disappeared.

Solitary fibrous tumors of the pleura are rare tumors with unpredictable clinical behaviour. We report about two patients with an incidental finding of an intrathoracic tumor. Preoperative diagnosis was uncertain. In both patients, a solid tumor of the pleura was resected en bloc in combination with a wedge resection of the lung following anterolateral thoracotomy. The postoperative course was eventful. Six months after primary complete resection there were no signs of tumor recurrence.

Solitary fibrous tumors of the pleura (SFTP) are very rare neoplasms. The majority of these tumors are benign, but about 10-20 % fulfill the criteria of malignancy. The clinical presentation varies according to the size and intrathoracic localization. In early stages, often asymptomatic, the tumors may grow to an enormous size and then cause symptoms such as cough, chest pain and dyspnea, but also paraneoplastic syndromes such as hypoglycemia or digital clubbing. Between 1981 and June 1998 we treated in our institution 16 SFTP in 14 patients (4 M, 10 F, average age at first operation 58 years). Eight patients showed symptoms, whereas in the other cases the tumors were found on routine chest X-rays. The usually pedunculated SFTP were completely resected without complications. Two patients developed malignant recurrences, which infiltrated the right upper lung lobe and the diaphragm respectively. In these cases the tumor was resected together with the adjacent structures. Since late recurrences are more often malignant than primary SFTPs long-term follow-up is mandatory even in benign lesions.

Dyspnea and reduced physical capability mean a significant reduction in quality of life of patients with advanced tumor disease. Video-assisted thoracoscopic talc poudrage or alternatively placement of pleuroperitoneal shunts were retrospectively evaluated as procedures for definitive palliation.

Tissue management in minimally invasive surgery plays an important role in the indication for and feasibility of surgical interventions. Hemostasis and sealing of larger areas are possible with minimally invasive tissue gluing in liquid and bandage-bound form. For effective and efficient application of the precoated collagen fleece (TachoComb) a modularly constructed applicator (AMISA) was designed that is suitable for a wide range of indications in MIS and allows selective leak closure (SLC) in parenchymatous tissues with different lesions (Pneumothorax, Chylothorax, rupture of liver/spleen, biopsies, fistulae).

This survey addressed common methods of video-assisted thoracoscopic pleurodesis for spontaneous pneumothorax. A questionnaire asking for frequency, recurrence rate and complications of the different methods of pleurodesis was sent to all hospitals that belong to the German Society for Thoracic Surgery. 19 hospitals reported on a total of 1365 operations. 88 recurrences (6.5%), 26 severe bleeding complications (1.9%), 39 persisting air leaks (2.9%) and two hospital deaths (0.1%) had been observed. Pleurectomy and pleural abrasion were the most common procedures but induced significant (p = 0.01) more bleeding complications (3.1% and 2.6%) than all other methods of pleurodesis (0.4%). Overall recurrence rates depended significantly on the chosen procedure (p = 0.0013). Pleurectomy (4.4%) and coagulation of the pleura (2.7%) showed better results than the average. Due to smaller numbers of operations and the widely differing results this significance cannot be shown for the individual recurrence rates of the different clinics. This survey demonstrated a trend towards lower rates of recurrence and complications after coagulation of the pleura parietalis. The retrospective character of the investigation and extremely different recurrence rates for different hospitals demand cautious interpretation of these results.

Since January 1990 we have treated 49 patients with spontaneous pneumothorax (35 primary and 14 secondary cases) by thoracoscopic operation. All patients entered a prospective trial. Those with secondary pneumothorax are discussed here. There have been no major complications. Conversion rate however has been high with 4/14 (29%). Three more patients (21%) not suitable for thoracotomy suffered from persistent air leaks. The other 7 patients needed postoperative drainage for less than 6 days in average. VATS could nevertheless be an alternative to thoracotomy for avoiding prolonged suction treatment in patients with secondary pneumothorax as patients showed no complications or disadvantage after conversion to thoracotomy.

470 patients underwent either lobectomy, bilobectomy or decortication at our institution between 1980 and 1991. A residual postoperative pneumothorax was observed in 20.7% of the patients at discharge after removal of the chest tubes. There was no significant correlation between the development of a residual postoperative pneumothorax and the patient's age and gender, the type of operation (lobectomy vs bilobectomy vs decortication) and the date of operation (as related to the introduction of stapling devices). This residual postoperative pneumothorax at discharge resolved without any further treatment in 95% of the patients during follow-up. Complete regression was observed in 91% of the patients within one year after the operation and the duration of regression did not correlate with the size of the pneumothorax at discharge. No empyema was observed in any patient with residual pneumothorax during follow-up, which also holds true for patients who underwent resection or decortication for inflammatory disease. We conclude that there is no need for treatment of residual postoperative pneumothorax, either with space-filling maneuvers at the initial operation or repeat chest tube insertions during follow-up, provided there is no evidence of lung collapse.

Over the past two to three years video-assisted thoracic surgery has opened up new possibilities in diagnostic and therapeutic procedures. It is viewed as a sparing and quick alternative to thoracotomy and open operation for a number of indications including the treatment of pneumothorax, obtaining biopsies of undiagnosed diffuse or nodulary lung disease, as well as extirpation of peripheral pulmonary lesions. In oncological thoracic surgery it still remains to be verified whether the criteria of radicality are fulfilled by this new technique. Extipation of circumscribed, extrapulmonary benign tumours and cysts within the thoracic cavity will soon be routine procedures. The advantages lie in the minimally traumatizing surgical technique; as a result of avoiding thoracotomy postoperative pulmonary function is less restricted, there is less pain, earlier mobilization is possible and the period of hospitalization is reduced. In the majority of procedures the operative time is reduced as compared with open surgery. Our experiences in this field with 370 patients are briefly reported. Disadvantages are the loss of the possibility to palpate the lung and the thoracic cavity. The costs of employing this technique is discussed. Video-assisted thoracic surgery has a promising future; it is estimated that 20% to 30% of all thoracic interventions will be performed by this technique.

A report on three HIV-positive patients with recurrent pneumothorax in pneumocystis carinii pneumonia on whom partial parietal pleurectomy and in two cases also a wedge-shaped pulmonary resection were performed. Histology revealed granulomatous necrotising pneumonia involving the visceral pleura, and a partly honeycomb-shaped metaplasia of the pulmonary tissue. A fibrinous and partly granulomatous necrotising pneumocystis carinii pleuritis of both pleural membranes was seen, being the morphological correlate of an in all cases prolonged exudation to the pleural cavity. Conservative treatment remained unsuccessful due to the marked lung and pleura involvement in the inflammatory process, necessitating surgical revision.

The localized fibrous tumors of the pleura are rare neoplasms, also known as "benign pleural fibromas" or "localized mesotheliomas", but those names are inaccurate. The tumors are composed of undifferentiated mesenchymal cells, intermediate and differentiated fibroblasts and collagenous interstitial tissue. Their origin is normally the submesothelial layer of the visceral pleura. Mesothelial differentiation is not present. The grading of malignancy doesn't correlate with final outcome, adequacy of surgical excision being the most important factor. This neoplasm may recur but retain its basical histologic features. The positive results for vimentin and negative results for cytokeratin antibodies help to distinguish the localized fibrous tumors from the mesothelioma. We present too cases and their diagnostic possibilities.

179 patients with penetrating chest wall and thoracic injuries were treated at the University Hospital "Rudolf Virchow" in Berlin between 1982 and 1992. Most patients (72.4%) were successfully treated with closed tube thoracostomy alone. 33 (18.4%) patients required thoracotomy, 14 (7.8%) due to injury of the great vessels and 15 (8.3%) due to cardiac injuries. In 10 (5.5%) patients also abdominal organs were compromised, so that also a laparotomy had to be done. Seven (3.9%) patients died. All but one patients who died, died in the OR or within 24 h of admission. So lethality in the group of cardiac wounds was 44.6% (7 out of 15). This underlines the necessity of most rapid transport to the hospital in case of thoracic injury.

The video shows an endoscopic modification of the established conventional surgical therapy of recurrent or persistent spontaneous pneumothorax: The indications and endoscopic techniques of parietal pleurectomy, ligature of leaking bullae and wedge resection are demonstrated. Our first experience on 50 patients indicates, that minimal postoperative pain and a relatively short hospital stay (mean 3.6 days postop.) are the advantages of minimal invasive techniques also in thoracic surgery. Long-term results are however still lacking.

Recent advances in the technologies for minimal invasive surgery have expanded the indications for thoracoscopic surgery. The thoracoscopic approach is for various operations, including pleurectomy, decortication, pulmonary wedge resection, pericardial window, the approach of first choice. Other operations such as resection of tumors in the mediastinum or thoracic wall, lobectomies or others, can often be performed by thoracoscopy. Indications and technical details are described.

The open parietal pleurectomy is an effective treatment of recurrent or persistent spontaneous pneumothorax with a low recurrency rate of 3.3% in our series. The long-term course reveals very good functional results. A relatively high number of patients complains about chest wall pain or a painful thoracotomy scar. Also remarkable is the rate of dissatisfaction with the cosmetic result of the thoracotomy. Regarding both complaints thoracoscopic pleurectomy should be able to improve the results and the acceptance of this operation.

103 patients with recurrent or persistent pneumothorax have been treated with local application of fibrin and talcum by a thoracoscopic procedure. The method was successful in 97 patients (94.2%) and lead to a stable and complete reexpansion of the lung within 6.3 days. As a direct consequence of the procedure itself only a few and minor complications occurred during a mean hospitalization-time of 10.4 days. The longterm followup over a mean period of 6.4 years revealed a recurrence rate of 15%, although half of the episodes occurred early during the first three months. After 6 years, 80% of the patients were completely asymptomatic and spirometric lung function was restored to normal values. We therefore consider thoracoscopic pleurodesis to be a successful and safe method for treating complicated pneumothorax.

In 33 patients with a recurrent spontaneous pneumothorax, a thoracoscopic pleurodesis with fibrin glue was performed under local anesthesia. During an average postoperative observation period of 4 years the relapse frequency was 39% (13 cases). In these cases thoracotomy was performed and a new relapse of pneumothorax occurred in 3 patients (23%): Application of thoracoscopy with fibrin glue pleurodesis should only be applied in those patients without large emphysema vesicles and without large coalescences. Under these conditions the relapse frequency could be reduced to 26%. The thoracoscopic treatment of recurrent pneumothorax by using fibrin glue and local anesthesia in well selected patients is an alternative procedure to thoracotomy.

Between October and December 1991 we performed videoendoscopic procedures, including resection of lung tissue, on 9 patients in our thoracic surgery unit. A lung measuring 15 x 18 was extirpated in 1 patient and parietal pleurectomy was performed after complicated pneumothorax in 4 patients. In one of these cases it was necessary to close a parenchymal leak and in 3 cases bullae had to be removed. Resection was undertaken in 4 patients for peripheral lung nodules, in one of them for metastases. Two patients proceeded to conventional lobectomy immediately after the frozen section results came through. Closure of lung parenchyma was carried out by means of the new ENDO-GIA stapler. Duration of the procedure was less than one hour except in the case of one patient. In one case it was necessary to use three cannulae. In the other cases two cannulae (one for videoendoscopy and fixating instrument, one for preparation instrument and stapler) sufficed for the operation to be undertaken without difficulty. This new technique brings all the known advantages of minimal invasive intervention to patients requiring thoracic surgery.

A 58-year-old man was admitted to hospital because of exertional dyspnoea and a cardiac murmur not previously heard. For one year he was known to have left-sided fibrinous pleuritis. For 5 years he had been taking methysergide for cluster headaches. From 1950-1980 he had worked with asbestos-containing insulating material. Erythrocyte sedimentation rate was greatly increased to 117/136 mm and there was an hypochromic anaemia (Hb 10.4 g/dl). The cholestasis enzymes were elevated (gamma-GT 88 U/l; alkaline phosphatase 511 U/l). Computed tomography of the thorax demonstrated left-sided pleural thickening of up to 3 cm. Endocarditis was excluded (sterile blood culture; normal echocardiogram). There was no evidence of an infectious, immunological or malignant cause for the pleural fibrosis. One year after pleurectomy and having discontinued methysergide all biochemical tests were normal.