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Introduction Advanced non-small cell lung cancer (NSCLC) is still a therapeutic challenge as the 5-year survival is under 30%. The optimal treatment regimen is still under debate. Hypothesis Neo adjuvant (NA) treatment given pre-pneumonectomy does not increase surgical complexity or peri-OP mortality while it has a potential to increase long term survival. Methods We have conducted a retrospective study of 169 patients who underwent a pneumonectomy for NSCLC between January 2005 to December 2015 and focused on stage IIIa patients; a cohort of 51 patients, 30 which received neo adjuvant chemo-radiation (NA group) prior to pneumonectomy and 21 patients who had undergone pneumonectomy followed by adjuvant treatment (Adjuvant group). Surgical complexity and short- and long-term survival were evaluated. Surgical complexity was assessed by surrogates as surgery duration, hospitalization length and interdepartmental transfer. Results While no statistically significant differences were found in surgery duration, hospitalization length, morbidity in the 1st year post-OP and the peri-OP mortality; The long term beneficiary effect among the neo adjuvant patients was clear; while 30% of the NA patients were alive 8 years post-OP, there were no survivors in the adjuvant group 5.5 years post-OP. Conclusion We conclude that while NA treatment has no effect on operation complexity, peri-OP mortality or post-OP morbidity; its impact on long term survival is protuberant, therefore, we believe that NA treatment should be considered as the treatment of choice in advanced NSCLC in need for pneumonectomy.

Background Malignant pleural mesothelioma (MPM) is a rare disease and management of localized disease is controversial. Radiotherapy has been shown to be useful after extrapleural pneumonectomy (EPP), as well as with less aggressive surgery. As no reports of the treatment of this disease have ever been published from Israel, we report our experience with MPM and intensity-modulated radiotherapy (IMRT). Methods The complete medical records of patients treated for MPM at the Rabin Medical Center from 1 August 2007 to 31 March 2016 were reviewed. Twenty-seven patients were treated with IMRT, either post-EPP or without EPP. Patients received 54 Gy in 2 Gy fractions using the restricted field IMRT technique. Chemotherapy was administered sequentially in 26% of patients. Patients were followed up from the date of diagnosis to death or treatment failure. Results Seventy-eight percent of patients had the epithelioid subtype. Nearly all patients were male (85%) and 90% of non-surgical patients were administered chemotherapy compared to 56% of post-EPP patients. All patients completed therapy and only 16% had grade 1-2 radiation pneumonitis, with no incidence of grade 3 or higher. The median follow-up was 22 months and the mean overall survival was 34.9 months. The mean time to progression following radiation therapy was 26.7 months. The mean time to local and distant failure was 19 and 16 months, respectively. Conclusions IMRT for localized pleural mesothelioma is a tolerable and effective therapy both post-EPP or without surgery. These results suggest that future investigation in this area is required.

Background SBRT is standard therapy for early stage lung cancer. Toxicity in central tumors has been a concern. RTOG 0813 showed that central SBRT is safe and effective. We report our experience with central SBRT. Methods We reviewed the records of patients treated with SBRT for central lung tumors (

Advanced non-small cell lung cancer (NSCLC) is still a therapeutic challenge as the 5-year survival is under 30%. The optimal treatment regimen is still under debate.Neo adjuvant (NA) treatment given pre-pneumonectomy does not increase surgical complexity or peri-OP mortality while it has a potential to increase long term survival.We have conducted a retrospective study of 169 patients who underwent a pneumonectomy for NSCLC between January 2005 to December 2015 and focused on stage IIIa patients; a cohort of 51 patients, 30 which received neo adjuvant chemo-radiation (NA group) prior to pneumonectomy and 21 patients who had undergone pneumonectomy followed by adjuvant treatment (Adjuvant group). Surgical complexity and short- and long-term survival were evaluated. Surgical complexity was assessed by surrogates as surgery duration, hospitalization length and interdepartmental transfer.While no statistically significant differences were found in surgery duration, hospitalization length, morbidity in the 1st year post-OP and the peri-OP mortality; The long term beneficiary effect among the neo adjuvant patients was clear; while 30% of the NA patients were alive 8 years post-OP, there were no survivors in the adjuvant group 5.5 years post-OP.We conclude that while NA treatment has no effect on operation complexity, peri-OP mortality or post-OP morbidity; its impact on long term survival is protuberant, therefore, we believe that NA treatment should be considered as the treatment of choice in advanced NSCLC in need for pneumonectomy.

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.

The aim of this retrospective study was to evaluate the mid-term outcome (average follow-up 10 months, range 6-18 months) and value of transaxillary single-port thoracic sympathectomy using a thoracoscope with an operating channel for the treatment of hyperhidrosis. Between December 1992 and October 2002, 176 consecutive patients (94 men, 82 women, mean age 21 years) with hyperhidrosis underwent thoracoscopic sympathectomy via a 12-mm single-port approach. Data on postoperative morbidity and outcome were analyzed to validate the technique. Mean operative time per side was 9 min; there was no conversion to an open procedure. Ninety-five percent of the patients were discharged the next day. Thirty-day mortality was zero. Complications included unilateral transient Horner's syndrome (n=1), residual pneumothorax requiring chest drainage from the port entry (n=4), and segmental atelectasis of the lung (n=4) which was treated conservatively. Complete relief of symptoms was observed in all patients at the 6-month follow-up; 45% experienced compensatory hyperhidrosis. Single-port thoracoscopic sympathectomy produces excellent medical and cosmetic results in patients with hyperhidrosis, and is associated with a short hospital stay and a low risk of complications. Overall satisfaction is high. A few patients may experience compensatory symptoms.

Background: The development of a bronchopleural fistula (BPF) is associated with high rates of morbidity and mortality. We have developed a minimally invasive method of bronchoscopic BPF closure using Amplatzer devices (AD) and Amplatzer vascular plugs (AVP), with excellent short-term results. Objectives: The aim of the present report was to explore the long-term outcome of patients treated by Amplatzer occluders and the durability of this novel modality of BPF treatment. Methods: A total of 31 central BPF in 31 patients (mean age 66.8 years, range 19-91) were sealed under moderate sedation bronchoscopically by either AD (n = 19) or AVP (n = 12). The average follow-up period was 17.6 months (range 1-68 months). Results: The main etiology for BPF was surgery (n = 24), pneumonectomy (n = 14) or lobectomy/segmentectomy (n = 10). The underlying disease was either primary (n = 19) or metastatic (n = 2) lung cancer. The immediate success rate was 96% as symptoms related to BPF disappeared in 30 of the 31 patients. Short-term (Conclusion: Endobronchial closure of BPF using both types of Amplatzer occluders (AD and AVP) is a minimally invasive effective modality of treatment with high safety profile and satisfactory long-term outcome considering the poor prognosis in this particular group of patients.

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.

OBJECTIVE: Bronchopulmonary fistula (BPF) is a severe complication following lobectomy or pneumonectomy and is associated with a high rate of morbidity and mortality. We have developed a novel minimally invasive method of central BPF closure using Amplatzer vascular plug (AVP) device that was originally designed for the transcatheter closure of vascular structures in patients with small BPF. METHODS: Patients with BPFs were treated under conscious sedation by bronchoscopic closure of BPFs using AVP. After locating the fistula using bronchography, the self-expanding nitinol made AVP occluder to be delivered under direct bronchoscopic guidance over a loader wire into the fistula followed by bronchography to assure correct device positioning and sealing of the BPF. RESULTS: Six AVPs were placed in five patients, four males and one female, with a mean age of 62.3 years (range: 51–82 years). The underlying disorders and etiologies for BPF development were lobectomy (two patients), pneumonectomy for lung cancer (one patient), lobectomy due to necrotizing pneumonia (one patient), and post-tracheostomy tracheo-pleural fistula (one patient). In all the patients, the bronchoscopic procedure was successful and symptoms related to BPF disappeared following closure by the AVP. The results were maintained over a median follow-up of 9 months (range: 5–34 months). CONCLUSIONS: Endobronchial closure using the AVP is a safe and effective method for treatment of small postoperative BPF. The ease of their implantation by bronchoscopy under conscious sedation adds this novel technique to the armatorium of minimally invasive modalities for the treatment of small BPF.

Objective: Patients with end-stage lung disease very frequently die while awaiting lung transplantation. The aim of this study was to identify factors associated with mortality in patients referred for lung transplant assessment. Methods:The files of all consecutive patients listed for lung transplantation in Israel between 1997 and 2006 were reviewed and the data were compared statistically between those who survived to transplantation. Results: A total of 229 patients were listed for lung transplantation, of whom 42 (18.3%) died while awaiting transplantation. Comparison of the patients who survived to transplantation with those who did not using univariate analysis revealed that the died-waiting group was significantly older, used steroids to a greater extent, had more IPF patients and less emphysematous, and lower mean oxygen saturation at rest (p = 0.005). There were no between-group differences in comorbid diseases or pulmonary function measurements. The 6 min walk distance was strongly and inversely correlated with risk of death before transplantation (p = 0.005). On multivariate analysis, only oxygen saturation at rest was a significant independent risk factor for death while awaiting transplantation (OR 0.886; C.I. 0.805—0.974). Conclusions: There are several risk factors for death in the Israeli population listed for LTX, including age, steroid use, emphysematous patients and lower saturation at rest.

Objective: Post-transplant diabetes mellitus (PTDM) is a common and potentially serious complication after solid organ transplantation. There are only a few data, however, about the incidence of DM in patients undergoinglung transplantation. Patients and methods:The medical records of 119 consecutive patients who underwent lung transplantation from 1998 to September 2004 were reviewed. Patients were divided in three groups according to their diabetes status, including pre-transplant DM, the PTDM group and those without DM. Patient records and all laboratory data were reviewed and the clinical course of diabetes was monitored. All recipients were treated with tacrolimus based regimen. Results: Mean follow-up for all patients was 25 10. Twenty-three patients had DM in the pre-lung transplantation (LTX) DM group. PTDM developed in 34 of the remaining 96 patients (35.4%) with an incidence of 20%, 23% after 6 months and 12 months post-transplant. No significant difference was noted between 12 and 24 months post-LTX. The patients who developed DM were older (57 15 vs 53 13 years, p = 0.009), had increased BMI (26 5 vs 24 4, p = 0.0001), shorter time from diagnosis to LTX (21 13 vs 28 18 months, p = 0.007) more cytomegalovirus infection and more acute rejection and hyperglycemia in the first month after LTX. Four patients died in the PTDM group compared to nine patients in the no-DMgroup (12% vs 14%; p = 0.72). Conclusions: Post-transplant diabetes is a common complication in lung transplant patients receiving tacrolimus-based immunosuppression. The risk for developing PTDM is greatest among older recipients, those obese, and among recipients with more rejections episodes.

Recent years have witnessed important progress in the use of minimally invasive robotic-enhanced surgical systems in cardiac and general thoracic interventions. We report the first-ever successful use of the Zeus robotic surgical system (Computer Motion, Inc, Goleta, CA) for the excision of an anterior mediastinal mass. Proper positioning of the thoracic ports for the robotic arms to permit a wide range of movement, is the key to the application of the system for intrathoracic cage operations. Other advantages of the system include three-dimensional voice controlled imaging, low-heat surgical field, and good exposure of the structures.

The aim of this retrospective study was to evaluate the mid-term outcome (average follow-up 10 months, range 6-18 months) and value of transaxillary single-port thoracic sympathectomy using a thoracoscope with an operating channel for the treatment of hyperhidrosis. Between December 1992 and October 2002, 176 consecutive patients (94 men, 82 women, mean age 21 years) with hyperhidrosis underwent thoracoscopic sympathectomy via a 12-mm single-port approach. Data on postoperative morbidity and outcome were analyzed to validate the technique. Mean operative time per side was 9 min; there was no conversion to an open procedure. Ninety-five percent of the patients were discharged the next day. Thirty-day mortality was zero. Complications included unilateral transient Horner's syndrome (n=1), residual pneumothorax requiring chest drainage from the port entry (n=4), and segmental atelectasis of the lung (n=4) which was treated conservatively. Complete relief of symptoms was observed in all patients at the 6-month follow-up; 45% experienced compensatory hyperhidrosis. Single-port thoracoscopic sympathectomy produces excellent medical and cosmetic results in patients with hyperhidrosis, and is associated with a short hospital stay and a low risk of complications. Overall satisfaction is high. A few patients may experience compensatory symptoms.

Lung transplantation is a well-established therapeutic option for end-stage lung disease in cystic fibrosis. Although it confers a clear survival advantage, outcome differs among centers according to local experience, patient selection, transplantation procedure, and postoperative care.To evaluate the national Israeli experience with lung transplantation in patients with CF.We reviewed the medical charts of all CF patients who underwent lung transplantation between January 1996 and June 2005 at the two Israeli centers that perform this procedure.Eighteen transplantations were performed in 17 patients. Mean patient age at transplantation was 25.3 +/- 9.1 years, and mean duration of follow-up in survivors (n=14) was 37.2 months (range 1-113 months). The actuarial survival rate was 88% at 1 year and 74% at 5 years. Pulmonary function, expressed as percent of predicted normal forced expiratory volume in 1 sec, improved from 22.4 +/- 8.1% to 76 +/- 16.8% at one year after transplantation. Bronchiolitis obliterans syndrome was diagnosed in 5 patients (29%), of whom 2 died and 2 are currently candidates for retransplantation. Median time to onset of BOS was 34.2 months (range 17-64 months).In Israel, the early and intermediate-term results of lung transplantation for cystic fibrosis are encouraging. BOS remains a major complication that threatens long-term outcome.

Purpose: Paraplegia is an uncommon yet devastating complication following thoracotomy, usually caused by compression or ischemia of the spinal cord. Ischemia without compression may be a result of global ischemia, vascular injury and other causes. Epidural anesthesia has been implicated as a major cause. This report highlights the fact that perioperative cord ischemia and paraplegia may be unrelated to epidural intervention. Clinical features: A 71-yr-old woman was admitted for a left upper lobectomy for resection of a non-small cell carcinoma of the lung. The patient refused epidural catheter placement and underwent a left T5–6 thoracotomy under general anesthesia. During surgery, she was hemodynamically stable and good oxygen saturation was maintained. Several hours following surgery the patient complained of loss of sensation in her legs. Neurological examination disclosed a complete motor and sensory block at the T5–6 level. Magnetic resonance imaging (MRI) revealed spinal cord ischemia. The patient received iv steroid treatment, but remained paraplegic. Five months following the surgery there was only partial improvement in her motor symptoms. A follow-up MRI study was consistent with a diagnosis of spinal cord ischemia. Conclusion: In this case of paraplegia following thoracic surgery for lung resection, epidural anesthesia/analgesia was not used. The MRI demonstrated evidence of spinal cord ischemia, and no evidence of cord compression. This case highlights that etiologies other than epidural intervention, such as injury to the spinal segmental arteries during thoracotomy, should be considered as potential causes of cord ischemia and resultant paraplegia in this surgical population.

We describe a case of takotsubo cardiomyopathy in a 69-year-old woman after right upper lobectomy, without cardiac antecedents. The immediate course of recovery was uneventful. On the first postoperative day, clinical symptoms of acute coronary syndrome developed in association with ischemic electrocardiographic changes and a mild elevation in creatinine phosphokinase levels. Echocardiography showed moderate left ventricular dysfunction, with a typical takotsubo pattern. Coronary angiography revealed no abnormalities. After 2 days of supportive treatment, the patient recovered completely. The clinical presentation, instrumental findings, additional cardiac and noncardiac diseases, and the potential pathomechanism of takotsubo cardiomyopathy are described according to the current medical literature.

Background Video-assisted thoracoscopy with the creation of a pericardial window is a noninvasive method of pericardial drainage. It also allows an excellent view of both the pleural cavity and pericardium and the precise selection of biopsy sites. We review our 3-year experience with this technique. Methods Between January 2001 and February 2004, 18 patients (10 men, 8 women; mean age 57 years) with echocardiographically diagnosed pericardial effusion underwent video-assisted thoracoscopy at our center. Pericardial windows were created under general anesthesia and single-lung ventilation using 2 to 3 trocars. Mean operating time was 46 minutes. A right thoracic approach was used in 16 patients and a left thoracic approach in 2. Results Microbiology and virology cultures of the pericardial fluid were negative. Histologic findings were compatible with tuberculosis in 2 cases and granulocytic sarcoma, infiltrating breast carcinoma, and infiltrating nonsmall cell carcinoma in 1 case each. In the remaining patients, the histologic diagnosis was chronic or subacute nonspecific pericarditis. Talc pleurodesis was performed in 3 patients for concomitant malignant pleural effusion. In 4 patients, the pericardial effusion occurred secondary to cardiac surgery; 3 were receiving anticoagulants after valve replacement, and 1 had a heart transplant. There were no complications of the thoracoscopy technique. Conclusions Video-assisted thoracoscopic fenestration is an effective technique for pericardial drainage and biopsy. Apart from its diagnostic value, it allows the physician to fashion a pleuropericardial window for effective drainage while avoiding the complications of classic surgical procedures. Concomitant pleural and pulmonary disorders may be managed simultaneously.

Inflammatory myofibroblastic tumor is a rare solid tumor that most often affects children and young adults. Although benign, the tumor may be very aggressive locally. We describe a 9-year-old boy with primary inflammatory myofibroblastic tumor of the left upper lobe involving the left atrium.

Objective: Pleural effusions are extremely common in the early postoperative period after lung transplantation (LTX). It occurs in all transplant recipients, and like pleural fluid following other cardiothoracic surgery is bloody, exudative and neutrophil predominant. There was no information, however, on the characteristics of the late (14 ‐45 days) postoperative pleural fluid after LTX. The purpose of this study was to describe the characteristics and the clinical implications of late postoperative pleural effusion after LTX. Methods: Thirty-five patients underwent TX between May 1997 and May 2001. Seven patients (20%) developed late postoperative pleural effusion. Thoracentesis were performed in these patients and the white blood cell counts, cell differential as well as biochemical parameters were determined. Results: The median time for late pleural effusion appearance was 23 days (range, 14‐ 34 days) after TX. The pleural effusions were medium in size (700 ml, range, 100‐ 1300), exudative in all the patients and had lymphocyte predominance. No evidence of fluid recurrence or clinical deterioration was noted in these patients. Conclusion: Late-onset exudative lymphocytic pleural effusion after LTX is not uncommon. When there is no evidence of rejection or infection, it usually has a benign, favorable outcome. q 2003 Elsevier Science B.V. All rights reserved.

Historically, donor age above 55 years has been considered to be a relative contraindication for organ transplantation. The shortage of organs for transplantation has led to the expansion of the donor pool by accepling older donors.To compare the 1 year follow-up in patients after lung transplantation from older donors (50 years old) and in patients after transplantation from younger donors (or = 50 years).The study group comprised all adult patients who underwent lung transplantation at the Rabin Medical Center between May 1997 and August 2001. Donors were classified into two groups according to their age:or = 50 years (n = 20) and50 years (n = 9). Survival, number and total days of hospitalization, development of bronchiolitis obliterans syndrome, and pulmonary function tests, were examined 1 year after transplantation.We performed 29 lung transplantations in our center during the observed period. Donor age had no statistically significant impact on 1 year survival after lung transplantation. There was no statistically significant effect on lung function parameters, the incidence of hospitalization or the incidence of bronchiolitis obliterans between both donor age groups at 1 year after transplantation.Donor age did not influence survival or important secondary end-points 1 year after lung transplantation By liberalizing donor criteria of age up to 65 years, we can expand the donor pool, while assessing other possible mechanisms to increase donor availability.

Video-assisted thoracic surgery (VATS) is widely used for many thoracic surgical procedures. Post-operative pain is less after VATS than after conventional thoracic surgery, but is still significant. The objective of this study was to assess the efficacy of thoracoscopic, internal intercostal nerve block in alleviating immediate postoperative pain.Thirty-two patients underwent VATS bilateral sympathectomy for the treatment of hyperhidrosis. The patients were randomly divided into two groups with similar demographic and preoperative physiologic parameters. Group A (n = 16) was submitted to thoracoscopic, internal intercostal nerve blocks performed at T2, T3, and T4 intercostal levels using 3 cc of 0.5% bupivacain in each intercostal space. The injections were performed bilaterally, immediately after the sympathectomy, through the same port. Group B (n = 16) underwent bilateral thoracic sympathectomy without the block. During the immediate postoperative period, heart rate, blood pressure, respiratory rate, pain score, and analgesic requirements were monitored every 30 minutes.No morbidity was recorded in association with the thoracoscopic, internal intercostal nerve block. The mean heart rates (77 +/- 6 vs 89 +/- 12 beats per minute, p0.001), respiratory rates (15 +/- 2 vs 18 +/- 3 respirations per minute, p0.01), pain score (1.9 +/- 0.6 vs 2.7 +/- 0.5, p0.01), and postoperative analgesic requirements (20 +/- 18 vs 50 +/- 21 mg pethidine HCL, p0.001) were significantly lower in group A. There was no significant difference in blood pressures.Thoracoscopic, internal intercostal nerve block with bupivacain 0.5% during VATS is safe and effectively reduced the immediate postoperative pain and analgesic requirements.

Background . Open lung biopsy (OLB) has long been considered the gold standard for the diagnosis of parenchymal lung disease. With recent advances in computed tomographic imaging and diagnostic techniques (eg, bronchoscopy), we thought it necessary to reevaluate the role of OLB in the management of patients with interstitial lung disease. Methods . We carried out a retrospective analysis of 103 OLBs performed at Hadassah University Hospital, Jerusalem, and Carmel Medical Center, Haifa, between 1980 and 1994. Data gathered included demographic information, underlying condition, indications for biopsy, diagnosis before biopsy, final diagnosis, change in therapy, and mortality. "Benefit" was defined as a change in therapy resulting in survival. Results . There were 45 immunocompetent patients (group 1), 39 immunocompromised patients (group 2), and 26 children (group 3), 7 of whom were included in group 2 for analysis. Overall, a diagnosis was reached after OLB in 85% of patients. An unexpected diagnosis was reached in 52%, and a change in therapy was instituted in 46%. The overall mortality rate was 20%. In group 1, the mortality rate was 13%, and "benefit" from OLB was reached in only 18%. In group 2, the mortality rate was 39%, and "benefit" was achieved in 46%, and in group 3, the mortality rate was 12% and "benefit", 50%. Conclusions . Open lung biopsy is an excellent diagnostic technique. In immunocompetent patients, the "benefit" is relatively low, as therapy (corticosteroids) is frequently used after biopsy. In immunocompromised patients, therapy changes substantially after OLB, but mortality is high. Therefore, OLB should be reserved for patients in whom the diagnosis is likely to lead to a change in therapy and in patients in whom the underlying condition has a reasonable prognosis according to the clinical impression by the attending physician.

The shortage of organs for lung transplantation has led to the growing use of "marginal" donors. Although patients on hemodialysis are still excluded as lung transplant donors because of the possible effects of renal failure on the lungs, recent data suggest that they may be suitable in selected cases. This article describes the successful transplantation of two lungs from a single donor who had been receiving long-term hemodialysis treatment. In the absence of other causes of pulmonary diseases, such as smoking or lung infection, lungs from dialysis-dependent patients may be acceptable for lung transplantation.

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