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Objective: Video-assisted thoracic surgery (VATS) lobectomy was introduced over 25 years ago. More recently, the technique has been modified from a multiport video-assisted thoracic surgery (mVATS) to uniportal (uVATS) and robotic (rVATS), with proponents for each approach. Additionally most lobectomies are still performed using an open approach. We sought to provide evidence-based recommendations to help define the optimal surgical approach to lobectomy for early stage non-small cell lung cancer., Methods: Systematic review and meta-analysis of articles searched without limits from January 2000 to January 2018 comparing open, mVATS, uVATS, and rVATS using sources Medline, Embase, and Cochrane Library were considered for inclusion. Articles were individually scrutinized by ISMICS consensus conference members, and evidence-based statements were created and consensus processes were used to determine the ensuing recommendations. The ACC/AHA Clinical Practice Guideline Recommendation Classification system was used to assess the overall quality of evidence and the strength of recommendations., Results and Recommendations: One hundred and forty-five studies met the predefined inclusion criteria and were included in the meta-analysis. Comparisons were analyzed between VATS and open, and between different VATS approaches looking at oncological outcomes (survival, recurrence, lymph node evaluation), safety (adverse events), function (pain, quality of life, pulmonary function), and cost-effectiveness. Fifteen statements addressing these areas achieved consensus. The highest level of evidence suggested that mVATS is preferable to open lobectomy with lower adverse events (36% versus 42%; 88,460 patients) and less pain (IIa recommendation). Our meta-analysis suggested that overall survival was better (IIb) with mVATS compared with open (71.5% versus 66.7% 5-years; 16,200 patients). Different VATS approaches were similar for most outcomes, although uVATS may be associated with less pain and analgesic requirements (IIb)., Conclusions: This meta-analysis supports the role of VATS lobectomy for non-small cell lung cancer. Apart from potentially less pain and analgesic requirement with uVATS, different minimally invasive surgical approaches appear to have similar outcomes.

Background: The purpose of this study was to determine whether the damaging effects of cardiopulmonary bypass, ischemia, and reperfusion would be more pronounced in patients with glucose-6-phosphate dehydrogenase deficiency undergoing cardiac surgery., Methods: Forty-two patients with glucose-6-phosphate dehydrogenase deficiency underwent open heart procedures using cardiopulmonary bypass. This group was matched with a control group of identical size for comparison of operative course and postoperative outcome. The perioperative variables were compared between the two groups using univariate and multivariate analysis., Results: The duration of ventilation after the operation was significantly longer in the glucose-6-phosphate dehydrogenase-deficient group (13.7 +/- 7.6 hours versus 7.7 +/- 2.8 hours; p < 0.0001). Minimal value of arterial oxygen tension was lower in patients with glucose-6-phosphate dehydrogenase deficiency (66 +/- 12 mm Hg versus 85 +/- 14 mm Hg; p < 0.0001), and more cases of hypoxia (arterial oxygen tension < 60 mm Hg) were found in this group (11 versus 1; p = 0.001). Compared with the control group, patients with glucose-6-phosphate dehydrogenase deficiency had significantly elevated hemolytic indices expressed by bilirubin levels (26 +/- 10 mmol/L versus 17 +/- 6.7 mmol/L; p < 0.0001) and lactic dehydrogenase levels (970 +/- 496 U/L versus 505 +/- 195 U/L; p < 0.0001). They also required significantly more blood transfusion perioperatively (1.9 +/- 1.4 packed cell units/patient versus 0.8 +/- 1.0 packed cell units/patient; p = 0.0001)., Conclusions: Patients with glucose-6-phosphate dehydrogenase deficiency who are undergoing cardiac surgery may have a more complicated course with a longer ventilation time, more hypoxia, increased hemolysis, and a need for more blood transfusion. Because this difference may be caused by subnormal free radical deactivation, strategies that minimize bypass in general and free radicals specifically may be beneficial.

Background: Fractures of the sternum may be associated with major injuries to thoracic organs, with serious consequences., Objective: To assess the hospital course of patients diagnosed with isolated sternal fracture., Methods: We reviewed 55 medical records of patients who were admitted with isolated sternal fracture to the emergency department during the period January 1990 through August 1999., Results: Fifty-one patients were involved in motor vehicle accidents, and 4 sustained the injury as the result of a fall. Lateral chest X-ray upon admission was diagnostic in the majority of these patients (n = 53). Electrocardiography (n = 52) was abnormal in four patients--old myocardial infarction (n = 1), non-specific ST-T changes (n = 3). Cardiac enzymes (creatine-kinase-MB, n = 42) were pathologically elevated in five patients. Echocardiography, performed in patients with ECG abnormalities and/or elevated myocardial enzymes (n = 7), was normal in these patients as well as in another 18 patients. There were no intensive care unit admissions or arrhythmias during the hospital stay, which ranged from 6 hours to 6 days (mean 2.3 +/- 1.3 days, median 2 days)., Conclusion: Our findings support the view that patients with isolated sternal fracture and no abnormality in ECG and cardiac enzymes during the early hours after injury are expected to have a benign course and can be discharged home from the emergency room within the first 24 hours.

Despite extensive research in the design of endovascular catheters and advanced surgical techniques, stenosis recurs in a large percentage of patients undergoing angioplasty or anastomosis. Hence, neointimal hyperplasia, caused by migration and proliferation of vascular smooth muscle cells (SMC), remains a significant limitation to the relief of obstructive-occlusive vascular disease. It has been previously demonstrated that heparin displaces active basic fibroblast growth factor (bFGF) from the lumenal surface of blood vessels. Sequestration of the displaced bFGF by injured areas of the vessel wall is inhibited in the presence of a synthetic nonsulphated heparin-mimicking polyanionic compound (RG-13577). This compound also induces a phenotype transformation of coronary SMC into a metabolically active hypertropic status that could promote repair processes after balloon angioplasty while inhibiting cell proliferation. In this paper, the result of a continuous administration of compound RG-13577 both in the rat carotid catheter injury model and in a newly developed rat model of surgical arterial vascular injury (anastomosis) is reported: it causes a profound inhibition of intimal hyperplasia in both models. A combined treatment with heparin/heparan sulphate mimetics and halofuginone, a potent inhibitor of collagen synthesis, extracellular matrix deposition and SMC proliferation, is expected to inhibit restenosis through inhibition of both signals/activities induced by soluble molecules (ie, heparin-binding growth factors) and components of the extracellular matrix (ie, type I collagen).

We report 2 cases of myeloproliferative disorders discovered incidentally at the time of routine coronary bypass surgery. Suspicion of abnormal bone marrow tissue upon performing sternotomy and subsequent sampling for frozen section made the diagnosis. The surgical plan was changed, and partial revascularization without cardiopulmonary bypass was performed.

Recurrent spontaneous pneumothorax often requires surgical intervention. Recently, less invasive thoracic surgical techniques, such as video-assisted thoracoscopy (VAT) and limited axillary thoracotomy (LAT), have been developed and used for different thoracic procedures. We describe our results with limited axillary thoracotomy, as compared with those of video-assisted thoracoscopy as reported in the literature. From October 1994 to May 1996, 14 patients with recurrent spontaneous pneumothorax, aged 16-33 years, underwent limited axillary thoracotomy, resection of blebs and apical pleurectomy, using multifire GIA 80 staplers (Auto Suture Inc.). There were no complications or recurrences during 5-17 months of follow-up. Mean operative time was 52.2 minutes and mean hospital stay 2.3 days postoperatively. Full activity was regained within 12.1 days. In comparison with over 75 cases of VAT from the literature, LAT is safe and offers the potential benefits of decreased operative time, hospital stay and cost.

Lung transplantation is becoming an acceptable mode of therapy worldwide for the end-stage lung disease. We present our initial experience with the first 10 consecutive lung transplant patients at Hadassah University Hospital. There were 5 males and 5 females with an age range 27 to 59 years. Eight patients underwent single lung transplantation, one patient had double lung transplantation and one had heart-lung transplantation. Indications were: pulmonary fibrosis in 4, emphysema in 4, cystic fibrosis in 1, and cystic bronchiectasis in 1. Two patients had primary graft failure (1 death). Nine patients had a serious infection after transplantation (1 death). Four patients developed airway complications including dehiscence of bronchial anastomosis (1 death), bronchial stenosis requiring placement of a stent in 2 patients, and pneumothorax in 1 patient. One patient required tracheostomy. One patient died of massive brain infarction secondary to pulmonary venous thrombosis and embolization. Six patients are intermediate-term survivors, with a follow-up period of 4-24 months. Four of them had at least one episode of rejection each. In all survivors pulmonary functions and quality of life improved and they do not need supplemental oxygen. We conclude that lung transplantation is a viable option for end-stage lung disease. Better selection of patients and perhaps improved immunosuppression agents will further improve outcome in lung transplantation. Shortage of donor supply is currently the limiting factor in successful lung transplantation in Israel.

The treatment of uveal melanoma is controversial. In retrospective survival studies no therapeutic method was found to be superior. A few risk factors were found to influence survival, without relation to the method of treatment. The main ones were size of tumor, anterior location, and age of patient. In the present study all cases of uveal melanoma treated between 1970-1989 were reviewed retrospectively and 135 of the 182 cases were included in the study. There was no relationship between method of treatment (irradiation vs enucleation) and survival, nor did any clinical risk factor influence survival. Thus, whenever possible, conservative treatment should be used in order to save the eye. Further investigation on a larger group of patients is needed.

Purpose: It is difficult to assess the viability of uveal melanoma after radiotherapy treatment. The purpose of the current study is to investigate PC-10 monoclonal antibody of proliferating cell nuclear antigen as a possible marker for cell proliferation and tumor viability in conventionally processed histologic preparations of uveal melanoma irradiated by brachytherapy as well as in nonirradiated melanomas., Methods: Thirteen enucleated eyes with posterior uveal melanoma that were treated by brachytherapy (cobalt 60 or ruthenium 106 radioactive plaques) were included in this study. Thirteen enucleated eyes of the same size with nonirradiated posterior uveal melanoma served as controls. The tumors were stained with PC-10 monoclonal antibody to proliferating cell nuclear antigen. All clinical and histologic data of the tumors were recorded and analyzed., Results: Five of the irradiated tumors showed positive staining with PC-10, although with a low score. Four of these tumors showed regrowth, and the fifth tumor was treated with a low-irradiation dose (5500 rad). In the nonirradiated tumor group, nine were positive for PC-10 staining, with a higher score. Significant correlation was found in this group between the PC-10 score and the mitotic figure count, but not with other prognostic factors. In three of four tumors that caused metastatic death, the PC-10 staining was positive and had a high score., Conclusions: PC-10 immunostaining is a simple, reproducible method that can be applicable to conventionally processed histologic preparations. It clearly shows that cellular proliferation activity in nonirradiated and irradiated uveal melanomas. Based on the small number of cases reported herein, it seems that the PC-10 score can correlate with prognosis, but further studies should be performed.