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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: 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.

Paralysis of the diaphragm may cause life-threatening respiratory distress in infants and young children because of paradoxical motion of the affected diaphragm and contralateral shift of the mediastinum during expiration. Phrenic nerve injury (PNI) may follow chest operations. 10 children with diaphragmatic paralysis and severe respiratory distress underwent plication of the diaphragm. Ages ranged from 14 days to 5 years. 9 had PNI after operations for congenital heart disease and 1 after resection of an intraspinal cervical lipoma. The right side was affected in 7, the left in 3. Indication for surgery was inability to wean from mechanical ventilation, which had ranged from 11 to 152 days (median 35). 8 underwent plication via a thoracic approach and 2 via an abdominal approach. There were no complications directly related to the operation. The interval from plication to weaning from mechanical ventilation ranged from 2 to 140 days (median 4). 1 patient died 2 hours after plication due to severe heart failure and 2 after prolonged hospitalization due to sepsis and multi-organ failure. 6 were extubated 2-8 days (median 4) after plication and 1 only after 40 days. Early diaphragmatic plication is simple and avoids more serious surgery. While effective in ventilator-dependent infants and young children, it should not be used in those with multi-organ failure. Early plication may prevent the complications of prolonged mechanical ventilation.