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Objective: Solitary fibrous tumours (SFT) of the pleura are rare tumours originated from the mesenchimal tissue underlying the mesothelial layer of the pleura. This tumours present unpredictable clinical course probably related to their histological and morphological characteristics. Methods: Twenty-one patients affected by SFT of the pleura were referred to us for surgical resection from September 1984 to April 2000. They were 15 males and six females with median age of 51 (range 15‐73) years. Nine patients (43%) were symptomatic and predominant clinical symptoms or signs were dyspnoea (19%), coughing (14.3%), chest pain (28.5%), finger clubbing (14.3%) and hypoglycaemia (14.3%). Hypoglycaemia was related to a pathological incretion of insulin-like growth factor 2 by the tumour. Chest radiograph and computed tomography of the chest revealed intra-thoracic homogeneous sharply delineated round or lobulated mass sometimes associated with ipsilateral pleural effusion (19%) or causing pulmonary atelectasis with opacification of the complete hemithorax (19%). Surgical excision required 14 posterolateral thoracotomies, six anterior thoracotomies and one video-assisted thoracoscopy. Thirteen tumours arose from visceral pleura and wedge resection was performed, seven tumours arose from parietal pleura and extrapleural resection was carried out without any chest-wall resection, one tumour growth within the upper left lobe and required lobectomy. Tumours weighted from 22 to 1942 g and measured from 22 £ 12 £ 8 to 330 £ 280 £ 190 mm. At cut section seven cases (34%) revealed focal necrosis and hemorrhagic zones and on light microscopy six cases (28.5%) were characterized by high mitotic count: characteristics related with uncertain clinical behaviour. Immuno-histochemical reactions were in all cases positive for CD34. Results: In all our patients resections were complete. Paraneoplastic syndromes like hypoglycaemia and clubbing receded after surgery. No intraoperative or perioperative medical or surgical complications occurred. Median chest-drain duration timed 3 (range 2‐5) days and median hospital stay was 5 (range 4‐7) days. Perioperative mortality rate was 0%. Median follow-up was 68 (range 2‐189) months: during this period patients were submitted to chest Xray with 6-months interval to evaluate possible local recurrence. Only one patient experienced tumour recurrence after 124 months followup: the tumour was suspected after observation of finger clubbing. The tumour was detected and excised by redo-thoracotomy. Conclusions: Surgical resection of benign solitary fibrous tumours is usually curative, but local recurrences can occur years after seemingly adequate surgical treatment. Malignant solitary fibrous tumours generally have a poor prognosis. Clinical follow-up and radiological follow-up are indicated for both benign and malignant solitary fibrous tumours. q 2001 Elsevier Science B.V. All rights reserved.

A 71-year-old male was referred to us after a steer-wheel blunt trauma of the chest. Computed thomography scan of the chest revealed a posttraumatic pulmonary hernia associated with right haemothorax (Fig. 1). Anterolateral right thoracotomy was performed and herniation through the chest wall of the anterior segment of the upper lobe of the lung was detected. The herniated lung was reduced into the pleural cavity and the chest wall was reconstructed by a Prolene mesh. European Journal of Cardio-thoracic Surgery 19 (2001) 360

Objective: Interstitial lung diseases (ILD) require lung biopsy for the diagnosis in more than 30% of patients. Open lung biopsy (OLB) was generally considered the most reliable method of biopsy and tissue diagnosis. This study tests the diagnostic accuracy and safety of the videothoracoscopic lung biopsy (VTLB) in the diagnosis of ILD. Methods: During the last 5 years, 58 patients were submitted to VTLB under general anesthesia. The mean age was 49:6 ^ 12:0 years (range 21‐69). All the biopsies were performed by an endostapler EndoPath 30 or 45. Conversion to minithoracotomy was necessary in only one patient because of extensive pleural sinfisis. All the specimens were sent to the microbiology and pathology department for microbiological and histopathological diagnosis. One chest-tube (28F) was positioned and connected to a drainage-system and placed on suction. Results: The histopathological diagnosis was obtained for all patients and therefore the diagnostic accuracy of the procedure was 100%. No postoperative haemothorax occurred and only two patients experienced a prolonged air-leakage (3.4%). The median duration of the chest-drain was 3 days (range 1‐7) and the median hospital stay was 4 days (range 2‐7). Conclusion: VTLB provides adequate specimen volume for histopathologic diagnosis and achieves a very high diagnostic accuracy (100% in our series). The postoperative morbidity and mortality rates are lower than those related to OLB. We conclude that VTLB is an effective and safe procedure in the diagnosis of ILD. q 1999 Elsevier Science B.V. All rights reserved.

We have read the paper by Dr Elsayed about a life-threatening haemothorax complicating a mediastinoscopy [1]. We think many points must be discussed. First, the author states that they have closed a patient submitted to mediastinoscopy with demonstrated active (even if very mild) mediastinal bleeding associated with iatrogenic opening of the parietal pleura. This is not cautious behaviour by a thoracic surgeon. It is well known that even mild bleeding may be the cause of massive haemothorax when the negative intrapleural pressure is transmitted to other opened neighbouring compartments, such as the mediastinum. Second, when postoperative right-sided haemothorax was demonstrated by a reduction of the haemoglobin levels and chest X-ray (Fig. 2a of the cited paper [1]) they inserted – as stated – a basal chest drain without significant improvement. The chest X-ray demonstrated the presence of right-sided thoracic clotting in the upper and medial third of the chest without involvement of the basal region. Unfortunately, the patient was well-known preoperatively to have a raised right hemi-diaphragm, explained by a history of right lower lobe pneumonia with postpneumonic scarring and traction on the diaphragm. These are all indirect signs of the presence of basal pleural adhesions, confirmed by the presence on the chest X-ray of a bloody effusion without basal involvement. The basal chest drain was very hazardous in this case, with inherent risk of further damage. After a 24 h observation period, video-assisted thoracoscopic surgery was attempted, with demonstration of many pleural adhesions (obviously), so the video-assisted procedure was converted into right thoracotomy with evacuation of 1800 ml of clotted blood. Why, on the basis of the previous chest X-ray, was a limited axillary right thoracotomy not performed at the third intercostal space with easy pleural access and eventual control of bleeding at the well-exposed upper mediastinum? Third, but not last, during the procedure to control the iatrogenic bleeding secondary to mediastinal lymph nodal biopsy, the surgeons performed a mediastinal lymphadenectomy and attempted a decortication of the right inferior lobe. These procedures are debatable, because they are not directly related to the primary indication of the reintervenction and because they may significantly increase the operative risks. Moreover, the chest X-ray at discharge revealed that decortication resulted in no improvements. Our personal opinion is that an intervention of pleural access and haemostasis via the axillary route should have been attempted first without basal pleural drain insertion, and no other collateral procedures should have been carried out because the relative risks were not justified, in particular when the diagnosis of the primary disease was still unknown (lymph nodal enlargement due to sarcoidosis). The reported paper concerns a rare, life-threatening complication of mediastinoscopy that has been managed in a dangerous manner. We think that the procedures described are the perfect example of ‘how not to do it’.

(a) Were the authors able to obtain the parietal pleurectomy by VATS in all cases or was it unpractical in some patients, because the tumour was too adherent or too bleeding? (b) Doesn’t it seem to the authors that a palliative decortication of a not expandable lung, obtained via thoracotomy, perhaps is a too severe operation, considering that the persistent air leak rate, longer than 7 days, was 15%, and the 6-week mortality rate was 14%?

Objective: Two hundred consecutive patients undergoing resection surgery of the lung during 1999 were retrospectively reviewed to define prevalence, type, clinical course and risk factors for postoperative supraventricular arrhythmias (SVA) with particular reference to atrial fibrillation or flutter (AF). Methods: Records of 200 lung patients were collected and analysed with particular attention to preoperative physiologic values and associated pathologies, lung functional status, electrocardiogram registration, extent of surgical resection of the lung and were also analysed to confirm or exclude correlation between them and postoperative AF; three patients were excluded as they were affected preoperatively by SVA. Results: Forty-five episodes of SVA, 41 of AF were identified in 197 patients (22%) and were more prevalent in several groups of patients such as those with increased age, pneumonectomy and superior lobectomy. Rhythm disturbances were most likely to develop on the second day after surgery. Ninety-eight percent of AF disappeared within a day of discharge and sinus rhythm was restored with digitalis or other antiarrhythmic drugs in all patients except one who was discharged with persistent atrial fibrillation. Arrhythmias were not direct causes of any in-hospital deaths. There is a tendency in the difference of the AF rate between pneumonectomy and upper lobectomy patients versus inferior lobectomy ones, probably related to the different anatomic structure of the proximal trunks of the upper and inferior veins of the lung, respectively. Conclusions: Statistical analysis revealed that increased age, extent and type of pulmonary resection, such as pneumonectomy and superior lobectomy were significant risk factors. Despite these factors, arrhythmias after lung surgery could be managed easily and were not closely related to higher mortality. Direct cause of AF after lung resection surgery remains unclear; anatomical substrate such as surgical damage to the cardiac plexus or to the proximal trunks of the pulmonary veins covered by myocardial sleeves with electrical properties are to be considered. q 2001 Elsevier Science B.V. All rights reserved.

Objective: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. Methods: Between April 1994 and April 2000, 13 patients, mean age 39.23 ± 18.47 (median 38, range 16-67) years with DNM were submitted to surgical treatment. Primary odontogenic abscess occurred in six, peritonsillar abscess in five and post-traumatic cervical abscess in two patients. Diagnosis was confirmed by computed tomography (CT) of the neck and chest All patients underwent surgical drainage of the cervico-mediastinal regions by a bilateral collar incision associated with right thoracotomy in ten cases. Results: Six patients out of 13 required reoperation. Two patients previously submitted only to cervical drainage required thoracotomy: four patients, which have been submitted to cervico-thoracic drainage, underwent contralateral thoracotomy in two cases and ipsilateral reoperation in two cases. Ten patients evolved well and were discharged without major sequelae; three patients died of multiorgan failure related to septic shock. Mortality rate was 23%. Conclusion: Early diagnosis by CT of the neck and chest suggest a rapid indication of surgical approach to DNM. Ample cervicotomy associated with mediastinal drainage via large thoracotomic incision is essential in managing these critically ill patients and can significantly reduce the mortality rate for this condition, often affecting young people, to acceptable values.