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Lung decortication for the treatment of chronic pleural empyema remains a technically challenging procedure that is associated with bleeding and air leak. The recent advent of pure argon plasma has provided thoracic surgeons with an electrically neutral energy source for dissection and coagulation of pulmonary tissue with minimal depth of necrosis. In this article, we describe the technique of lung decortication with argon plasma energy (PlasmaJet, Plasma Surgical, Roswell, GA, USA) for the treatment of chronic pleural empyema. With appropriate application, the PlasmaJet can facilitate the removal of fibrous cortex with satisfactory hemostasis and aerostasis. Argon plasma energy can potentially be a useful adjunct in lung decortication. Controlled trials are needed to determine its role in the surgical management of advanced pleural empyema.

Background Congenital long-QT syndrome represents the most common cardiac channelopathy and manifests as potentially lethal ventricular arrhythmias. Prevention strategies include beta-blockade pharmacotherapy, implantable cardioverter-defibrillators, and left cardiac sympathetic denervation, which can increase the threshold for ventricular fibrillation. Herein, we report our experience with video-assisted thoracoscopic left cardiac sympathetic denervation. Methods We performed a retrospective review of the electronic medical records of all patients with congenital long-QT syndrome who underwent video-assisted thoracoscopic left cardiac sympathetic denervation at our institution. Results From September 2009 to May 2016, 6 patients with a mean age of 30.5 years (range 20–47 years) underwent video-assisted thoracoscopic left cardiac sympathetic denervation for medically refractory long-QT syndrome. All patients had an uneventful recovery and were discharged 1–3 days after the operation. At a median follow-up of 14 months (range 12–60 months), 4 patients had no cardiac events while 2 experienced 1 episode of arrhythmic syncope and 1 episode of appropriate implantable cardioverter-defibrillator shock. Following surgery, the mean annual cardiac events in the study cohort decreased from 2.13 to 0.33 ( p = 0.004) and the mean corrected QT interval reduced from 560 ms to 491 ms ( p = 0.006). Conclusions Video-assisted thoracoscopic left cardiac sympathetic denervation is a safe and effective therapy in patients with congenital long-QT syndrome who continue to suffer from recurrent life-threatening arrhythmias or frequent implantable cardioverter-defibrillator discharges despite maximum tolerated doses of beta blockers.

Although Nuss procedure is performed with satisfactory results, there has been a controversy in the literature regarding the effect of a Nuss procedure on the spine. This review article aims to perform an updated overview of the literature about the effect of pectus excavatum correction at the spine and the management of patients with both pectus excavatum and scoliosis. Although acquired scoliosis has been rarely reported after a Nuss procedure, studies show that the Nuss procedure can have a beneficial effect in mild coexisting scoliosis especially when it is performed during the adolescence. The management of cases presented with both pectus excavatum and scoliosis depends on the severity of pre-operative scoliosis and demands detailed evaluation of the spine pre and postoperatively. In the rare condition of post-operative scoliosis following a Nuss procedure, the removal of the metallic bar and conservative measures may have satisfactory results on the spine.

Highlights • Carcinoma of unknown primary clinical manifestations usually associated with head and neck region. • Painless cervical Lymphadenopathy is the most common symptom of the disease. • Laboratory tests usually do not identify the primary disease. • Limited data exists about management and the role of surgery in carcinoma of unknown primary if a single neck mass exists without evidence of lymph node implication., Introduction Carcinoma of unknown primary is a well-recognized clinical syndrome which accounts for the 3–5% of all the malignancies. Patients with carcinoma of unknown primary usually present with late stage disease without having identified the primary source of the tumour despite an extensive diagnostic work-up. Presentation of case A 60 years old male presented to the clinic complaining of a neck mass to the left lateral neck. Patient’s history was unremarkable without evidence of any malignant disease. Clinical and radiological examination revealed a cystic mass extending from the lower one third of the neck to the left clavicle causing periostal reaction. Mass biopsy and PET-CT was unspecific for the primary origin of the mass. However in the context of tumour immunohistochemistry, HPV status, neck location and basaloid cell differentiation, the tumour mass was considered as carcinoma of unknown primary with possible oropharyngeal primary location. The patient underwent surgical resection of the mass, left clavicle and the first rib. One year after the operation the patient is disease free. Discussion Although CUP usually presents with cervical lyphadenopathy, in our case there was no evidence of lymph node tissue infiltration in the neck region. Surgical resection of the mass showed that the location was extending within the cervical soft tissues and upper thorax. Taking into consideration the absence of lymphadenopathy this is an uncommon location of carcinoma of unknown primary in the neck. Conclusion This is an uncommon location of CUP with possible implications in survival and management.

Aims Post-operative systemic inflammatory reaction is part of the stress response caused by major thoracic surgery. Different anaesthetic agents used affect different immunological phenomena. This systematic review evaluates the impact of anaesthetic agents on the immunological profile and the associated clinical significance. Methods A systematic review of MEDLINE, EMBASE and Cohrane databases to explore how different anaesthetic agents affect post-operative inflammatory response. Results A total of nine studies were included in our analysis. Peri-operative use of dexmedetomidine, propofol, sevoflurane, isoflurane, ropivacaine, sufentanil, naloxone and clonidine were compared, based on their effect on the systemic release of inflammatory markers. Variance on the levels of the circulating inflammatory molecules such as interleukins, interferon-γ, tumor necrosis factor a and on the cellular response including natural killer, CD4 and CD8 T cells, were observed among different anaesthetic agents. Conclusions Inflammation improves immunity and regenerative cell recruitment, however excessive responses can lead to delayed wound healing, organ dysfunction and increased morbidity and mortality. There is still uncertainty regarding the role of immune changes on clinical outcomes of patients undergoing thoracic surgery, and more research is needed to explore other immunological effects related to anaesthetic agents.

Lung carcinoma management secondary to chronic lymphocytic leukemia could be quite challenging. We report a case of a 60-year-old male with several co-morbidities, who presented with shortness of breath and persistent cough. A chest imaging showed a right pleural effusion and complete white-out of the right chest cavity. A computed tomography scan revealed consolidation of the right upper lobe with a 6-cm lesion in hilum with complete occlusion of right lobe bronchus. The patient underwent a video-assisted thoracoscopic surgery, drainage of pleural effusion and pleural and lung biopsy. Talc pleurodesis as well as a flexible bronchoscopy of the endobronchial lesion was performed. Histopathological examination showed a small B-cell lymphoma of the right pleura and an invasive non-small cell carcinoma of the right lung. Dual neoplasms are challenging in terms of diagnosing, and they usually require a multidisciplinary team for the right treatment strategy, including surgery and chemotherapy.

Pectus Excavatum (PE) or "funnel chest," the most common deformity of the anterior chest wall characterized by sternal depression, can be repaired via either operative or non-invasive techniques. Vacuum Bell (VB) device is the most widespread of the latter one which can be applied either intraoperatively or as monotherapy. The present narrative review examines the efficacy of that innovative method. A thorough search of the literature resulted in 13 English-written articles concerning VB therapy from its first description to February 2019. The studies included patients with mild to moderate PE, mainly evaluated via Haller-Index and/or sternum depth prior to and following treatment. Concerning depth-improvement, 37-90% showed amelioration while 10-40% of them an excellent correction to normal. In 42%, Haller-Index also improved with a median decrease of 0.3 after VB application. A correlation was attempted to be found between the efficacy of VB and factors such as the frequency and duration of VB application, patient age, gender, PE severity and type, and differential pressure of the suction cup. Complications may be frequent yet mild and temporary. Intraoperatively, VB widows Minimally Invasive Repair of Pectus Excavatum (MIRPE) operation a safer procedure with greater results. VB as conservative treatment is an effective and well-tolerated alternative therapeutic option for selected patients with PE who meet specific criteria. It also constitutes a device of significant efficacy, appropriate for intraoperative use during MIRPE procedure.

Ameloblastoma is a rare odontogenic neoplasm of the jaw. It usually behaves as a benign, slow growing tumour of the oral cavity with a high recurrence rate, especially when it is inadequately resected. A small proportion of ameloblastomas metastasize to distant organs, with lungs representing the most common site of metastatic spread. In this report, we present the case of a middle-aged man with two pulmonary nodules and a history of mandibular ameloblastoma excised 10 years prior to this radiological finding. Following resection and histopathological analysis of the lung lesion, a diagnosis of metastatic ameloblastoma was confirmed. No local recurrence of the primary tumour was identified. At 1-year follow-up, the patient had no evidence of local or metastatic disease.

Desmoid tumours are rare, locally aggressive neoplasms exhibiting high tendency for recurrence, even after complete resection. Only 1 in 5 of them originates from the chest wall, usually measuring less than 10 cm at diagnosis. Herein, we report the case of a woman presenting with symptoms of gradual lung compression by a giant desmoid tumour occupying the entire hemithorax. She underwent complete surgical resection of the tumour and chest wall reconstruction. She had disease recurrence 15 months later and currently remains under regular follow-up. The management of intrathoracic desmoid tumours is challenging because they are usually not diagnosed until they become large enough to cause compression symptoms. While medical management is the primary modality of treatment, surgery could be considered in selected cases where significant symptoms arise, and the functional status is impaired secondary to the tumour. Adjuvant radiotherapy to minimise the risk of local recurrence should also be considered.

Background Two million non-emergency surgeries are being cancelled globally every week due to the COVID-19 pandemic, which will have a major impact on patients and healthcare systems. Methods During the peak of the pandemic in the United Kingdom, we set up a multicentre cancer network amongst 14 National Health Service institutions, performing urological, thoracic, gynaecological and general surgical urgent and cancer operations at a central COVID-19 cold site. This is a cohort study of 500 consecutive patients undergoing surgery in this network. The primary outcome was 30-day mortality from COVID-19. Secondary outcomes included all-cause mortality and post-operative complications at 30-days. Results 500 patients underwent surgery with median age 62.5 (IQR 51–71). 65% were male, 60% had a known diagnosis of cancer and 61% of surgeries were considered complex or major. No patient died from COVID-19 at 30-days. 30-day all-cause mortality was 3/500 (1%). 10 (2%) patients were diagnosed with COVID-19, 4 (1%) with confirmed laboratory diagnosis and 6 (1%) with probable COVID-19. 33/500 (7%) of patients developed Clavien-Dindo grade 3 or higher complications, with 1/33 (3%) occurring in a patient with COVID-19. Conclusion It is safe to continue cancer and urgent surgery during the COVID-19 pandemic with appropriate service reconfiguration., Highlights • Priority surgeries are being cancelled every week due to the COVID-19 pandemic. • A multicentre surgical referral network was set up as part of an NHS England approach to continuing safe surgery • The referral network consisted of 14 NHS trusts and surgery was performed at a single COVID-19 ‘cold site’. • After 500 surgeries performed, there was a 0% 30-day mortality from COVID-19. • It is safe to continue cancer and priority surgery during the COVID-19 pandemic with appropriate service reconfiguration.

Cystic fibrohistiocytic tumour of the lung is a very rare pathological entity that occurs either as a primary pulmonary neoplasm or as a metastasis from skin lesions called cellular fibrous histiocytomas. Herein, we present the case of a 19-year old man with a history of recurrent pneumothoraces who was managed surgically and was eventually diagnosed with cystic fibrohistiocytic tumour of the lung. Clinicians should include this disease in the differential diagnosis of pulmonary cystic lesions and be aware of its association with cellular fibrous histiocytoma. Reporting of more cases is warranted to further elucidate the natural course of the disease and optimise its management.

Robotic procedures in the anterior mediastinum can be challenging in the existence of pectus excavatum deformity due to the limited intrathoracic working space caused by sternal depression. We propose that the temporary application of a vacuum bell device during the procedure can correct the deformity and thus, facilitate robotic approach similarly to the standard procedure.

Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.

Indications and surgical techniques for pulmonary metastasectomy (PME) are controversially discussed issues. Laser-assisted surgery (LAS) is a recent innovation that has been advocated especially in patients with multiple pulmonary metastases (PM). However, there are hardly any studies comparing surgical outcomes after laser-assisted and conventional resection. The aim of the current study was to evaluate the value of LAS in a larger study population.A retrospective analysis was completed on 178 consecutive patients undergoing 236 PMEs at a single center between 2010 and 2015. The main endpoint was survival. Statistical analysis was performed using the Kaplan-Meier method and survival rates were compared with the log rank test. Follow-up was done with special attention to the development of recurrent PM. Local relapse was defined as a recurrent metastasis in direct relation to the previously resected area according to CT scan comparisons.LAS was performed on 256 metastases in 99 patients, non-laser-assisted surgery (NLAS) on 127 metastases in 79 patients. 5-year-survival rates were 69.3% in all patients, 65.7% after LAS and 73.6% after NLAS. There was no statistically significant survival difference after LAS or NLAS (p = 0.41). The rate of local relapse was 0.8% after LAS vs 3.1% after NLAS (p = 0.073).Despite a larger number of negative predictors for survival in LAS patients, overall survival (OS) was similar in the compared groups. There was also a trend for a lower risk of local relapses after LAS. Therefore, LAS should be considered a promising method for PME.

Wstęp: Choroba Castlemana jest rzadką, łagodną chorobą limfoproliferacyjną o nieznanej etiologii. Schorzenie występuje w dwóch postaciach klinicznych o różnym rokowaniu, sposobie leczenia i objawach: postaci zlokalizowanej (UCD) oraz wieloogniskowej, charakteryzującej się powiększeniem węzłów chłonnych oraz objawami ogólnymi. Celem pracy był przegląd piśmiennictwa, a także analiza dowodów na skuteczność resekcji chirurgicznej w zlokalizowanej postaci choroby. Materiał i metody: Przeprowadzono przegląd systematyczny piśmiennictwa angielskojęzycznego oraz baz danych (Medline, Pubmed, Cochrane i źródeł dodatkowych) w poszukiwaniu artykułów dotyczących leczenia zlokalizowanej postaci choroby Castlemana. Każdy artykuł oceniony był przez dwóch autorów przy użyciu ustrukturyzowanego narzędzia oceny, a następnie skategoryzowany zgodnie z siłą dowodu. Wyniki: Zgodnie z kryteriami włączenia, do badania zakwalifikowano 14 badań. Nie znaleziono prospektywnych, randomizowanych badań z grupą kontrolną. W jednej metaanalizie, obejmującej 278 chorych na UCD, stwierdzono, że resekcja chirurgiczna jest bezpieczna i powinna być traktowana jako „złoty standard” w leczeniu. Wnioski zawarte w siedmiu badaniach retrospektywnych potwierdzały ten punkt widzenia. Radioterapia (RT) była stosowana w sześciu badaniach, z różnym efektem. Wnioski: W leczeniu choroby Castlemana zlokalizowanej w klatce piersiowej resekcja chirurgiczna wydaje się metodą o najwyższej skuteczności. Ponadto, pozytywną odpowiedź kliniczną można w niektórych przypadkach osiągnąć przy zastosowaniu radioterapii.

Introduction: Castleman’s disease is a rare benign lymphoproliferative disorder of unknown etiology. The disease occurs in two clinical forms with different prognoses, treatments and symptoms: a unicentric form (UCD), which is solitary, localized, and a multicentric form characterized by generalized lymphadenopathy and systemic symptoms. This article aims to review the current literature to consolidate the evidence surrounding the curative potential of surgical treatment to the unicentric type. Material and methods: A systematic review of English-language literature was performed and databases (Medline, Pubmed, the Cochrane Database and grey literature) were searched to identify articles pertaining to the treatment of unicentric form of Castleman’s disease. Each article was critiqued by two authors using a structured appraisal tool, and stratified according to the level of evidence. Results: After application of inclusion criteria, 14 studies were included. There were no prospective randomized control studies identified. One meta-analysis including 278 patients with UCD reported that resective surgery is safe and should be considered the gold standard for treatment. Seven retrospective studies enhance this standpoint. Radiotherapy (RT) has been used in six studies with controversial results. Conclusions: We conclude that surgical resection appears to be the most effective treatment for Unicentric Castleman’s Disease of the thoracic cavity. Radiotherapy can also achieve clinical response and cure in selected patients.

Long QT syndrome (LQTS) is an uncommon and potentially fatal cardiac channelopathy. Treatment options can be medical with β-blockers or surgical with implantable cardioverter defibrillator (ICD) implantations and left cardiac sympathetic denervation (LCSD). Purpose of this paper is through a literature review to identify the management algorithm and the role of sympathectomy in LQTS.

Pulmonary alveolar microlithiasis (PAM) is an uncommon genetic disorder associated with alveolar cell injury. This injury is caused in most cases by inactivating mutations in SLC34A2 gene, which is responsible for the production of a sodium-dependent phosphate co-transporter. The dysfunction or deficiency of this transporter leads to the aggregation of local phosphate intra-alveolarly and formation of microliths. Most of the patients are asymptomatic at the time of the diagnosis but as the disease progress it leads to fatal respiratory or cardiac failure. We describe a case of a 63-year-old man referred to our department for a surgical lung biopsy. He has been symptomatic for one year with progressive shortness of breath and deteriorating exercise tolerance. The imaging was suggestive of extensive interstitial bilateral lung disease. Histological findings after the lung biopsy by video-assisted thoracic surgery (VATS) established the diagnosis of pulmonary alveolar microlithiasis. His sister suffered from the same disease and passed away at the age of 54. It is remarkably rare for PAM to have such a late onset with a previous normal X-ray and only a few cases have been reported worldwide.

This case study looks at Long term complications of thoracotomy- chest wall paraesthesia and neuralgic chest pain , and provides questions with model answers.

This case study looks at A patient with T2N1M0 squamous cell carcinoma, and provides questions with model answers.

Multicentric Castleman disease (MCD) causes an extensive range of systematic symptoms and can be life-threatening if not treated promptly and appropriately. The pathophysiology of the disease remains unclear; however, interleukin 6 (IL-6) pathway and human herpesvirus 8 infection appear to play an important role. As a result, the treatment of MCD remains complex and often insufficient, although a plethora of therapeutic approaches have been used. Between these, biological agents in the form of monoclonal antibodies against specific pathogenic processes of the disease have improved survival rates significantly. In the present study, we review the clinical results of rituximab, which targets B lymphocytes, siltuximab and tocilizumab, which target the IL-6 pathway, bortezomib, which is a selective proteasome inhibitor, and anakinra, which is an interleukin 1 receptor antagonist. The introduction of these biological agents in the treatment of MCD appears to be promising in the first studies performed. However, more clinical trials are required to assess the efficacy and safety of each agent and to form therapeutic strategies that will be widely accepted.

The vast majority of lung cancer (80%) are non-small cell lung cancer (NSCLC) presenting in huge proportion of patients in a metastatic stage at the time of diagnosis with an overall survival (OS) of only 6 months. Standard treatment at this stage involves systemic platinum based chemotherapy improving the OS for only few months. For the vast majority of patients disease progression occurs and cure cannot achieved. An exception to this general rule is represented by patients with a limited number of metastasis (approximately 7% of patients with metastatic NSCLC): in 1995 Hellman and Weichselbaum introduced the term "oligometastatic" for a selected group of patients with metastatic disease. Several retrospective studies have been published and documented an improved outcome in patients managed surgically. The purpose of this narrative review is to gather all relevant information and present the various clinicopathological and generic aspects of diagnosis, management strategies and prognostic factors in patients with oligometastatic NSCLC. The key for long term survival includes radical treatment of the primary NSCLC, single organ site with either synchronous or metachronous presentation, a disease free interval to be as long as possible and the absence of intrathoracic lymph node spread (N0). A more accurate staging with combination of FDG-PET and CT scan can have on impact on the survival rates due to an increased accuracy in mediastinal staging and in the diagnosis of distant metastasis. No randomized data but only retrospective series are available to date to address this topic: in the future, additional prospective studies will be necessary to provide robust evidence to support the surgical resection as treatment of oligometastatic NSCLC.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Is systematic lymph node dissection (SLND) mandatory or is sampling adequate in stage I non-small-cell lung cancer (NSCLC)? Two hundred and eleven papers were identified, of which 12 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and the results of these papers are tabulated. There are 7 retrospective cohort reviews, 3 meta-analyses and 2 randomized controlled clinical trials (RCTs) to answer the clinical question. Four of the 7 retrospective studies demonstrated that the total number of resected lymph nodes and the number of lymph node stations sampled affected the accuracy of staging in patients with early-stage NSCLC and had an impact on overall survival and disease-free survival. Two RCTs, 1 meta-analysis and 1 cohort study revealed no significant benefit in overall survival and disease-free survival in patients undergoing SLND. One meta-analysis, which contained only 1 RCT, revealed significantly better 3- and 5-year survival with SLND. One further meta-analysis revealed improved survival with SLND in cohort studies but no significant difference in the 4 RCTs included. Two further studies identified specific subgroups of patients in whom LN sampling could be justified and SLND avoided. We conclude that there is no significant difference in the recurrence rate when performing either SLND or LN sampling in patients with stage I NSCLC. While retrospective cohort studies implied survival benefit with SLND, this was not borne out in RCTs and meta-analyses. However, there may be a potential survival benefit for patients who are upstaged by SLND identifying mediastinal nodal involvement.

Objective Thrombin has been reported to play a pivotal role in the initiation of angiogenesis by indirectly regulating and organizing a network of angiogenic molecules. On the basis of these reports, we investigated the angiogenic action of thrombin in a rabbit model of acute myocardial infarction. Methods A rabbit model of acute myocardial infarction was established by ligation of the left anterior descending coronary branch. Subjects were then divided into 2 groups and treated with intramyocardial administration of thrombin (2500 IU; n = 13) or an equal volume of normal saline (n = 13). Four weeks later, animals were euthanized and histopathologic analysis, immunohistochemical staining for endothelial markers CD31 and vascular endothelial growth factor-A, and electron microscopy examination were performed on excised hearts. Electrocardiography, cardiac enzymes, and assessment of cardiac function by measuring left ventricular end-diastolic pressure and ejection fraction were recorded before and after myocardial infarction, and both left ventricular end-diastolic pressure and ejection fraction were further measured on the day of euthanasia (n = 5-8 in each case). Results Increased levels of troponin, ST elevation, and histopathologically confirmed myocardial infarction were observed in all animals. A significant increase of microvessel density at the infarct border zone, as evaluated by CD31 immunohistochemistry, was observed in the thrombin-treated group compared with the control group (30.3 ± 12.8 vs 12.6 ± 4.8, P = .0065). A significantly higher number of vascular endothelial growth factor-A–positive vessels at the infarct border zone was observed in the thrombin-treated animals compared with the control group (21.8 ± 8.9 vs 5.6 ± 4.4; P = .0009). The thrombin-treated animals showed a statistically significant reduction in left ventricular end-diastolic pressure values (6.9 ± 1.8 mm Hg vs 12.7 ± 2.2 mm Hg, P = .0002) and significant improvement in left ventricular ejection fraction (59.8% ± 3.1% vs 42.2% ± 6.14%, P = .002) on the day of euthanasia compared with the post-infarct day, reflecting significantly improved cardiac function compared with control subjects that showed no significant change. Conclusions Intramyocardial administration of thrombin seems to promote angiogenesis and improve cardiac function of the ischemic myocardium, which may provide a new therapeutic approach in patients with myocardial ischemia.

Coronary artery stenosis is a potentially life-threatening complication after heart valve surgery. The details are presented of a patient with unobstructed coronary arteries, who underwent routine aortic valve replacement and developed dissection of the right coronary artery (RCA) on the third postoperative day, and occlusion of the left anterior descending (LAD) artery one month after surgery. This complication required prompt clinical recognition and diagnosis by repeat coronary angiography, and a rapid intervention with coronary artery bypass grafting or with angioplasty and stenting.

Aim To highlight an interesting case report of a rare cause of surgically treated hypoglycemia.

Optimal management and the role of surgery in multimodality treatment for N2 disease nonsmall cell lung cancer (NSCLC) are controversial. In this review, we focus on the possible role of pneumonectomy as a justified procedure in patients with persistent N2 disease following induction therapy. We have conducted an OVID PubMedbased search including manuscripts published in English for relevant studies. The interpretation of these trials highlights the lack of clarity and consistency in our management and leaves areas of controversy. There are no Level 1 data to support either performing or not performing pneumonectomy in this setting. The majority of the literature reviewed stresses the high risk of mortality and morbidity following pneumonectomy as a part of a trimodality approach to Stage IIIA/N2 NSCLC disease. However, selected highvolume institutions do follow this strategy with the level of risk seemingly justifying it for a highly selected group of patients, and this approach to Stage III/N2 NSCLC can be offered safely with acceptable mortality. Patient selection, response rate to induction therapy, and R0 resection are crucial for survival in experienced centers.

Myocardial ischemia is one of the most extensively studied topics in modern cardiovascular research. Early investigators first reported experimental myocardial ischemia (EMI) in 1862. The open-chest (surgical) approach is a well-developed model of EMI that enables researchers to directly access and observe the heart. With this approach, EMI is generally induced by surgical ligation of a coronary artery. A drawback of the open-chest model is the need for major surgery, which can result in local and systemic side effects. Alternative closed-chest models of EMI have been developed; most of these models involve endovascular catheterization with coronary artery embolization or thrombosis. Closed-chest techniques eliminate the need for invasive surgery, and the resultant model is more physiologically similar to clinical myocardial ischemia than is EMI produced by artery ligation. The authors present a review of open- and closed-chest models of EMI and discuss the advantages and disadvantages of each approach.