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Competing Interests: Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/cdt-20-721). The series “Arts and Medicine” was commissioned by the editorial office, Cardiovascular Diagnosis and Therapy without any sponsorship or funding. The author has no conflicts of interest to declare.

Competing Interests: Conflicts of Interest: The author has no conflicts of interest to declare.

Competing Interests: Conflicts of Interest: The author has no conflicts of interest to declare.

Electromagnetic navigational bronchoscopy-guided biopsy of small pulmonary nodules can be challenging. Navigational error of the system and movement of the biopsy tool during its deployment adversely affect biopsy success. Furthermore, conventional methods to confirm navigational success such as fluoroscopy and radial endobronchial ultrasound become less useful for the biopsy of small lesions. A hybrid operating theatre can provide unparalleled real-time imaging through DynaCT scan to guide and confirm successful navigation and biopsy of difficult-to-reach or small lesions. We describe our technique for DynaCT image-guided electromagnetic navigational bronchoscopic biopsy of a small pulmonary nodule in the hybrid operating theatre. The advantages, disadvantages and special considerations in adopting this approach are discussed., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Over the past decade, uniportal video-assisted thoracic surgery (VATS) has evolved dramatically into a sophisticated technique capable of performing some of the most complex thoracic procedures. The idea of operating through fewer surgical incisions and, therefore, with potentially better cosmesis, less postoperative pain and paraesthesia, has led to uniportal VATS increasing in popularity worldwide. The uniportal approach demands instrument design to be better suited for operating with multiple instruments through a single small incision. Furthermore, the drive by surgeons and industry to develop novel, smaller, more specialized procedure-specific instruments for uniportal VATS to further allow reduction in incision size is relentless. Refinement of uniportal VATS instruments, angulated and narrower endostaplers, and improvements in video-camera systems, including 3D systems, and 120° articulating lens will make uniportal VATS major lung resection easier to perform and learn. In the future, we could see the development of subcostal or e-NOTES access, endorobotic arms that open and operate within the chest cavity, and cross-discipline imaging assistance for uniportal VATS procedures., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Adolescent idiopathic scoliosis (AIS) is a common orthopedic disorder of unknown etiology and pathogenesis. Melatonin and melatonin pathway dysfunction has been widely suspected to play an important role in the pathogenesis. Many different types of animal models have been developed to induce experimental scoliosis mimicking the pathoanatomical features of idiopathic scoliosis in human. The scoliosis deformity was believed to be induced by pinealectomy and mediated through the resulting melatonin-deficiency. However, the lack of upright mechanical spinal loading and inherent rotational instability of the curvature render the similarity of these models to the human counterparts questionable. Different concerns have been raised challenging the scientific validity and limitations of each model. The objectives of this review follow the logical need to re-examine and compare the relevance and appropriateness of each of the animal models that have been used for studying the etiopathogenesis of adolescent idiopathic scoliosis in human in the past 15 to 20 years.

Objectives: Use of titanium prostheses for reconstructing chest wall defects following major chest wall resections is rapidly increasing in popularity. Previously, complications including prosthesis fracture have been reported for the system secured to the rib ends using clips following chest wall reconstruction and pectus excavatum repair. By contrast, fracture failure in titanium systems fastening the plate to the rib with locking screws through predrilled holes has not been previously reported, possibly owing to differences in the design and material of the system., Methods: We report an index case of plate fracture in the latter design following rib reconstruction and discuss the pathophysiology and relative risks behind such fractures., Results: Fracture of titanium plate occurred after chest impact during sport at 25 months following initial plate implantation. Surgical excision was performed because of persistent pain and cough., Conclusions: Fracture failure can occur in those systems fastening the plate to the rib with locking-screws, and patients, particularly those engaged in contact sports or occupations with chest impact risks, should be informed of this possibility during consent, as surgical removal is most likely required following implant fracture failur., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The defect of the melatonin signaling pathway has been proposed to be one of the key etiopathogenic factors in adolescent idiopathic scoliosis (AIS). A previous report showed that melatonin receptor, MT2, was undetectable in some AIS girls. The present study aimed to investigate whether the abnormal MT2 expression in AIS is quantitative or qualitative. Cultured osteoblasts were obtained from 41 AIS girls and nine normal controls. Semi-quantification of protein expression by Western blot and mRNA expression by TaqMan real-time PCR for both MT1 and MT2 were performed. Anthropometric parameters were also compared and correlated with the protein expression and mRNA expression of the receptors. The results showed significantly lower protein and mRNA expression of MT2 in AIS girls compared with that in normal controls (p = 0.02 and p = 0.019, respectively). No differences were found in the expression of MT1. When dichotomizing the AIS girls according to their MT2 expression, the group with low expression was found to have a significantly longer arm span (p = 0.036). The results of this study showed for the first time a quantitative change of MT2 in AIS that was also correlated with abnormal arm span as part of abnormal systemic skeletal growth.

Background: Angiogenic factors following oncological surgery is important in tumor recurrence. Vascular endothelial growth factor (VEGF), angiopoietin 1 (Ang-1), Ang-2, soluble VEGF-receptor 1 (sVEGFR1) and sVEGFR2 may influence angiogenesis. This prospective study examined the influence of open and video-assisted thoracic surgery (VATS) lung resections for early stage non-small cell lung cancer (NSCLC) on postoperative circulating angiogenic factors., Methods: Forty-three consecutive patients underwent major lung resection through either VATS (n = 23) or Open thoracotomy (n = 20) over an 8-month period. Blood samples were collected preoperatively and postoperatively on days (POD) 1 and 3 for enzyme linked immunosorbent assay determination of angiogenic factors., Results: Patient demographics were comparable. For all patients undergoing major lung resection, postoperative Ang-1 and sVEGFR2 levels were significantly decreased, while Ang-2 and sVEGFR1 levels markedly increased. No significant peri-operative changes in VEGF levels were observed. Compared with open group, VATS had significantly lower plasma levels of VEGF (VATS 170 ± 93 pg/mL; Open 486 ± 641 pg/mL; P = 0.04) and Ang-2 (VATS 2484 ± 1119 pg/mL; Open 3379 ± 1287 pg/mL; P = 0.026) on POD3., Conclusions: Major lung resection for early stage NSCLC leads to a pro-angiogenic status, with increased Ang-2 and decreased Ang-1 productions. VATS is associated with an attenuated angiogenic response with lower circulating VEGF and Ang-2 levels compared with open. Such differences in angiogenic factors may be important in lung cancer biology and recurrence following surgery.

Isolated nasopharyngeal metastasis from lung primary is a rare condition. We report a patient with stage 1B adenocarcinoma of the lung who underwent anatomical lung resection and was subsequently found to have solitary nasopharyngeal metastasis. The patient received radiotherapy to nasopharynx and remained disease-free for 10 years from the date of diagnosis of nasopharyngeal metastasis. We postulate that solitary nasopharyngeal metastasis from lung primary might be a separate entity that responded well to radiotherapy., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We describe a 75-year-old Chinese man who presented with three separate tumors in three different lobes of the lung, without evidence of mediastinal or systemic involvement. All three tumors were surgically resected by minimal invasive approach. Based on a differing epidermal growth factor receptor (EGFR) mutation status, the tumors were characterized as synchronous triple primary rather than intrapulmonary metastases. This report highlights the clinical usefulness of molecular cancer biomarkers to determine prognosis and to guide management decision in multiple lung tumors., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Minimally invasive video-assisted thoracic surgery (VATS) thymectomy has evolved significantly over the last decade. The most common indication for VATS thymectomy is the treatment of myasthenia gravis (MG). Video-assisted thoracic surgery thymectomy results in less postoperative pain, better preserved pulmonary function, and improved cosmesis, which can be particularly important to many young female MG patients. Results of VATS thymectomy, in terms of complete stable remission from MG and symptomatic improvement, as well as safety, are comparable with conventional surgical techniques. This more patient-friendly approach would lead to wider acceptance by MG patients and their neurologists for earlier thymectomies and improved outcomes., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Pulmonary infection caused by the opportunistic organisms Penicillium marneffei and Stenotrophomonas maltophilia in patients with Job's syndrome is rare and not well documented. The case of a 30-year-old man with Job's syndrome who developed recurrent pneumonia and lung abscesses caused by P. marneffei and S. maltophilia, complicated by massive hemoptysis, is described. Bronchial artery embolization was successful in controlling the hemoptysis; however, the infection proved fatal despite appropriate antimicrobial therapy. A brief review of the literature on Job's syndrome and its associated infective pulmonary manifestations is also presented.

Background: Life-threatening massive hemoptysis requires prompt action and thoracic surgical input. Although there are a number of reports regarding each therapeutic modality for medical or surgical treatment, the significance of a multidisciplinary strategy remains undetermined., Methods: From January 1995 to December 2005, 120 patients were referred to our cardiothoracic center with massive hemoptysis. We retrospectively reviewed and compared the outcomes of a recent 5-year period (2000 to 2005) with those from the previous 5 years (1995 to 1999), as we made major changes in our practice in 2000. We currently try to avoid surgery within 48 hours after onset of active hemoptysis and adopt bronchial artery embolization as a first-line therapy. Treatment decisions are made after discussions among intensive care unit physicians, thoracic surgeons, and interventional radiologists., Results: The former group had 49 patients (57.9 +/- 14.1 years old, 41 males), and the recent group, 71 (62.2 +/- 23.5 years old, 52 males). There were no significant differences for any characteristics studied between the groups. In analyses of short-term complications after surgery, the former had a higher in-hospital mortality rate than the recent group (15% versus 0%). Furthermore, postoperative complications were seen in 8 patients (30%) in the former, whereas those occurred in 3 patients (18%) in the recent group., Conclusion: Bronchial artery embolization is an effective therapeutic tool and plays a pivotal role in management of life-threatening massive hemoptysis. Surgery is indicated when bronchial artery embolization is not suitable and can be safely performed in combination with a rigid bronchoscopy or bronchial artery embolization procedure. Our results indicate that a multidisciplinary approach should be adopted for management of life-threatening massive hemoptysis.

Objective: Pulmonary endothelial function is critical in posttransplant lung performance. Hyperkalemic organ preservation solutions alter vascular endothelial function through the non-nitric oxide and non-prostacyclin pathway, but the most frequently used lung preservation solutions, Perfadex (Vitrolife Sweden, Kungsbacka, Sweden) (K(+) 6 mmol/L) and Celsior (IMTIX SangStat Company, Lyon, France) (K(+) 15 mmol/L), have not been evaluated on pulmonary endothelial protection. We compared the non-nitric oxide and non-prostacyclin-mediated endothelial function in porcine pulmonary microarteries of lung preserved by Perfadex or Celsior solution at 4 degrees C for 4 hours., Methods: The non-nitric oxide and non-prostacyclin-mediated endothelial function was determined by measuring the membrane potential in a single pulmonary smooth muscle cell (group II, n = 6) and bradykinin-induced relaxation (group I, n = 8) in pulmonary microarteries preserved in Krebs (a, control), Perfadex (b), or Celsior (c), with inhibitors of nitric oxide and prostacyclin., Results: Membrane potential hyperpolarization decreased in IIc (4.5 +/- 0.2 mV, P < .05) but was preserved (P > .05) in IIa (6.6 +/- 0.1 mV) and IIb (6.3 +/- 0.3 mV). Resting membrane potential was depolarized in IIc (-42.8 +/- 1.3 mV) compared with IIa (-58.7 +/- 0.6 mV) and IIb (-56.7 +/- 0.9 mV) (P < .05). Hyperpolarization-associated relaxation (37.3% +/- 7.2% vs 59.7% +/- 7.7%) and sensitivity (EC(50)) (-7.29 +/- 0.13 vs -7.75 +/- 0.06 log M) to bradykinin significantly (P < .05) decreased in Ic but not in Ia and Ib., Conclusion: This in vitro study simulating clinical conditions demonstrates that Perfadex preserves endothelium-dependent smooth muscle relaxation and hyperpolarization better than Celsior solution in regard to the electrophysiologic and mechanical properties observed at cellular and vascular levels. This study provides a new method at the level of basic science to evaluate the solutions for heart/lung preservation.

Post-pneumonectomy syndrome is a well-recognised but uncommon late complication of pneumonectomy. Usually occurring after right-sided surgery, the mediastinal contents are rotated and displaced into the right hemithorax, producing airways or oesophageal compression. We report a case in which the radiological features and symptoms of post-pneumonectomy syndrome appeared to be precipitated by the development of a complex tuberculous tracheobronchial stenosis that resolved after the insertion of a bespoke Dumon stent.

Background: Video-assisted thoracoscopic surgery (VATS) major lung resection for lung cancer has been an important part of thoracic surgical training program in our institution. In this study, we compared the results of VATS major lung resection performed by surgical trainees with those performed by experienced thoracic surgeons with specialist interest in VATS., Methods: From January 2002 to October 2006, the clinical data of 111 consecutive patients scheduled for VATS major lung resection were prospectively entered into the computerized clinical management system of the local health authority; these include patient demographics, comorbidity, operating time, postoperative complications, and outcome. We retrospectively compared the data of patients who were operated on by trainees with those who were operated on by experienced VATS surgeons., Results: One hundred and eleven patients with clinical stage I and II lung cancer underwent VATS major lung resection. Fifty-one (46%) of the procedures were performed by consultant surgeons and 60 VATS lung resections (54%) were performed by supervised trainees. Patients' demography and risk factors were comparable between the two groups. Trainees spent more time in performing the operation as compared with experienced VATS surgeons (mean operating time 162 minutes, p = 0.01). There was no significant difference in intraoperative or postoperative complications and outcomes between the two groups., Conclusions: Video-assisted thoracic surgery major lung resection for early stage nonsmall-cell lung cancer can be taught to residents who work under the supervision of experienced VATS surgeons. Video-assisted thoracic surgery major lung resection for lung cancer should be an integral part of thoracic surgical training program.

Background: A complex inflammatory response associated with the use of cardiopulmonary bypass may ultimately lead to organ dysfunction. We investigate the effect of continuing ventilation during cardiopulmonary bypass on inflammatory reactions and cardiopulmonary function., Methods: Fifty patients undergoing cardiopulmonary bypass were prospectively randomized to continuous ventilation and nonventilation groups. Plasma interleukin-8, interleukin-10, matrix metalloproteinase-9, tissue inhibitor metalloproteinase-1, and thromboxane B2 levels were measured preoperatively, at 1, 4, and 6 hours after aortic declamping. Levels of these mediators were also determined in bronchoalveolar lavage preoperatively and four hours after declamping. Seven parameters of cardiopulmonary function, including dynamic compliance and systemic vascular resistance, were recorded during the same time points., Results: Plasma interleukin-10 levels were higher at 6 hours and tissue inhibitor metalloproteinase-1 levels were higher at 1 hour after aortic declamping in the continuous ventilation compared with the nonventilation group (p = 0.04 and 0.002, respectively), while bronchoalveolar lavage levels of tissue inhibitor metalloproteinase-1 were also higher in the continuous ventilation group 4 hours after declamping (p = 0.02). Plasma interleukin-8 levels were higher at 4 hours after declamping in the nonventilation group (p = 0.04). Postoperative dynamic compliance was better preserved in continuous ventilation patients than nonventilation patients at 6 hours after declamping (p = 0.0008)., Conclusions: Continued ventilation during cardiopulmonary bypass results in lesser inflammatory and proteolytic responses, and may better preserve pulmonary function than cardiopulmonary bypass without ventilation.

Background: The action of antagonists for endothelin type A (ET(A)) and type B (ET(B)) on the vasoconstriction mediated by various vasoconstrictors in the human bypass grafts have not been well-defined. We studied the role of antagonists for both ET(A) and ET(B) receptors in vasoconstriction mediated by endothelin-1 and other vasoconstrictors in the human internal mammary artery (IMA)., Methods: Isolated IMA rings (n = 192, taken from 49 patients) were studied in organ bath for the interaction between endothelin-1, angiotensin II, U46619, and potassium chloride and the antagonist for ET(A) (BQ-123) or ET(B) (BQ-788)., Results: Significant relaxations were observed by BQ-123 (agonist: endothelin-1, 84.9 +/- 7.9%; angiotensin II, 45.5 +/- 5.1%; and U46619, 30.7 +/- 5.7%) or BQ-788 (agonist: endothelin-1, 66.5 +/- 11.3%; angiotensin II, 38.9 +/- 4.2%; and U46619, 30.8 +/- 4.0%), but not to potassium chloride-induced precontraction. Incubation of IMA with BQ-123 or BQ-123 + BQ-788 significantly shifted the concentration-contraction curve to endothelin-1 rightward (p < 0.05 vs control) with effective concentration causing 50% of maximal response (EC50) (-7.59 +/- 0.04 or -7.81 +/- 0.05 vs -8.47 +/- 0.05 log M in the control, p < 0.001), whereas BQ-788 alone did not affect the contraction curve (p = 1.0 vs control). In contrast, none of the endothelin-1 inhibitors and the combination demonstrated significant depression effects on angiotensin II, U46619, or potassium chloride-induced contraction., Conclusions: The present study demonstrates the role of ET(A) and ET(B) antagonists in the endothelin-1-mediated contraction in the human IMA and indicates the dominant role of ET(A) receptors. Although these effects are specific to endothelin-1, cross-action between endothelin-1 and angiotensin II exists. These findings provide useful knowledge for the future development of the clinical antispastic protocol in coronary bypass surgery.

Objective: Despite its proven value in reducing thrombotic complications in patients undergoing coronary artery bypass graft surgery, aspirin does not reduce the incidence of late vein graft failure. It was suggested, therefore, that co-administration of nitric oxide with aspirin may compensate for these limitations. A drug class that fulfills this pharmacologic criterion is nitric oxide-donating aspirin (NCX 4016)., Methods: The effect of administration of the aspirin-nitric oxide adduct, NCX 4016, compared with those of aspirin alone and the nitric oxide donor, morpholinosydnonimine, alone (once daily for 1 month) on thickening of saphenous vein-carotid artery interposition grafts was investigated., Results: NCX 4016, at 10 mg, 30 mg, and 60 mg x kg(-1) x d(-1), inhibited neointimal thickness and area in porcine vein grafts. Aspirin alone (60 mg x kg(-1) x d(-1)) and morpholinosydnonimine alone (1 mg x kg(-1) x d(-1)), also inhibited neointimal thickness and neointimal area, although they were less potent than NCX 4016. At 30 mg x kg(-1) x d(-1), aspirin had no effect. Compared with untreated controls, NCX 4016 had little effect on medial thickness or area at 10 mg/kg or 30 mg x kg(-1) x d(-1) but had a significant effect at 60 mg x kg(-1) x d(-1). Aspirin alone and morpholinosydnonimine alone also inhibited medial thickness and area. NCX 4016 at 60 mg x kg(-1) x d(-1) and aspirin at 60 mg x kg(-1) x d(-1) increased luminal area., Conclusions: The range of properties displayed by NCX 4016 (inhibition of neointima formation, gastroprotection, antithrombotic and antiatherogenic effects) renders them potentially useful in treating both early and late vein graft failure and indicates that a clinical study on this novel drug class in patients undergoing coronary bypass grafting is warranted.

Background: Sequential administration of platinum-based doublet therapy and then a taxane may reduce the risk of drug resistance and, therefore, improve treatment outcome. This study was designed to evaluate the efficacy and tolerability of sequential administration of irinotecan and cisplatin and then docetaxel in patients with advanced non-small cell lung cancer (NSCLC)., Methods: Eligible patients received irinotecan in 60-mg/m2 infusions for 30 to 60 minutes on days 1, 8, and 15, and cisplatin in 75-mg/m2 infusions for 60 minutes on day 1 every 28 days for four cycles (IC). Regardless of the response, patients received up to four cycles of sequential docetaxel in 75-mg/m2 infusions for 60 minutes., Results: Forty-six patients with histologically confirmed chemotherapy-naïve stage IIIB or IV NSCLC were enrolled, of whom 42 were evaluable. The response rate at completion of chemotherapy with IC was 45.2% (95% confidence interval [CI]: 30.2%-60.3%). Five patients had improvement of disease status during sequential docetaxel, and seven patients had disease progression. Progression-free survival was 8.0 months (95% CI: 5.4-9.9 months), and the overall median survival was 14.6 months (95% CI: 9.8-17.9 months). The 1-, 2-, and 3-year survival rates were 54.3%, 22.6%, and 12.1%, respectively. The incidence of severe (> or =CTC V2 grade 3) neutropenia during IC was 23.9% compared with 95.7% for sequential docetaxel (p < 0.0001)., Conclusion: Sequential administration of IC and then docetaxel is feasible and is associated with a prolonged progression-free survival, but the current data do not confirm an improvement in treatment outcome by the sequential approach.

Background and Purpose: Statins (3-hydroxy-3-methyl-glutaryl coenzyme A (HMG CoA) reductase inhibitors) have been demonstrated to reduce cardiovascular mortality. It is unclear how the expression level of HMG CoA reductase in cardiovascular tissues compares with that in cells derived from the liver. We hypothesized that this enzyme exists in different cardiovascular tissues, and simvastatin modulates the vascular iberiotoxin-sensitive Ca2+-activated K(+) (BK(Ca)) channels., Experimental Approaches: Expression of HMG CoA reductase in different cardiovascular preparations was measured. Effects of simvastatin on BK(Ca) channel gatings of porcine coronary artery smooth muscle cells were evaluated., Key Results: Western immunoblots revealed the biochemical existence of HMG CoA reductase in human cardiovascular tissues and porcine coronary artery. In porcine coronary artery smooth muscle cells, extracellular simvastatin (1, 3 and 10 microM) (hydrophobic), but not simvastatin Na+ (hydrophilic), inhibited the BK(Ca) channels with a minimal recovery upon washout. Isopimaric acid (10 microM)-mediated enhancement of the BK(Ca) amplitude was reversed by external simvastatin. Simvastatin Na+ (10 microM, applied internally), markedly attenuated isopimaric acid (10 microM)-induced enhancement of the BK(Ca) amplitude. Reduced glutathione (5 mM; in the pipette solution) abolished simvastatin -elicited inhibition. Mevalonolactone (500 microM) and geranylgeranyl pyrophosphate (20 microM) only prevented simvastatin (1 and 3 microM)-induced responses. simvastatin (10 microM ) caused a rottlerin (1 microM)-sensitive (cycloheximide (10 microM)-insensitive) increase of PKC-delta protein expression., Conclusions and Implications: Our results demonstrated the biochemical presence of HMG CoA reductase in different cardiovascular tissues, and that simvastatin inhibited the BK(Ca) channels of the arterial smooth muscle cells through multiple intracellular pathways.

Objective: In patients who have undergone coronary artery bypass grafting, blood copper levels are elevated for 6 weeks after surgery. Copper is an established risk factor for cardiovascular disease and atherogenesis and promotes oxidative stress, lipid oxidation, cell proliferation, and matrix formation, all components of vein graft disease. This project therefore examined the effect of the copper chelator penicillamine on saphenous vein graft thickening in a pig model., Methods: Saphenous vein-carotid artery interposition grafts were carried out in Landrace pigs. Penicillamine (10 mg/kg once daily, n = 8) was administered orally incorporated into small amounts of mashed potato for 1 month (n = 8 controls). Vein grafts were then excised and fixed at 100 mm Hg, histologic sections were prepared, and morphometry and measurement of proliferating cell nuclear antigen count were carried out. In vitro studies on the effect of copper or penicillamine on human vascular smooth muscle cell replication was carried out with bromodeoxyuridine incorporation., Results: Administration of penicillamine had a potent inhibitory effect on both neointimal and medial thickness and proliferating cell nuclear antigen count but elicited a marked increase in luminal area and reduced serum copper concentrations. In vitro, copper augmented vascular smooth muscle cell proliferation, an effect blocked by penicillamine. Penicillamine alone also inhibited in vitro vascular smooth muscle cell replication., Conclusion: The administration of penicillamine reduces vein graft thickening and promotes positive remodeling through negation of copper-induced cell proliferation. Copper chelators may therefore be therapeutically useful in preventing late vein graft failure in patients undergoing reconstructive arterial surgery.

Objective: Studies in other surgical specialties have suggested that pre-emptive wound infiltration using a local anesthetic may reduce post-operative pain. We report the first randomized trial to assess the use of pre-emptive local anesthesia in video-assisted thoracic surgery (VATS)., Method: Thirty-one consecutive patients undergoing bilateral needlescopic VATS sympathectomy for palmar hyperhidrosis were studied prospectively. Each patient acted as their own control. For each patient, one side was randomized to receive 10ml 0.5% bupivicaine injected to the port sites before incision, and the contralateral control side to receive 10ml saline. Pain severity on a visual analog scale (VAS) was recorded for each chest side at 4h, 1 day and 7 days following surgery. All patients were blinded to the results of randomization throughout the study., Results: Follow up was complete for all patients. At 7 days after surgery, wound pain was significantly reduced by pre-emptive local anesthesia, with 10 (62.5%) of the 16 patients having residual pain reporting less pain on the pre-treated side (p=0.039). There was a trend for reduced pain on the pre-treated side at the other time points. Pain reduction by pre-emptive local anesthesia was not correlated with any demographic or clinical variable. Chest wall paresthesia distinct from localized wound pain was noted by six patients (19.4%), but was not reduced by pre-emptive local anesthesia. Overall, the post-operative discomforts felt by the patients after needlescopic VATS were mild, and did not cause significant functional disturbances., Conclusion: Pre-emptive wound infiltration with a local anesthetic may reduce post-operative wound pain in needlescopic VATS procedures.

Objective: Major surgery is immunosuppressive and could have an impact on postoperative tumor immunosurveillance and recurrence in cancer patients. Low circulating levels of insulin growth factor binding protein (IGFBP)-3 have been linked to advance prostate and the development of colonic cancers. This prospective study examined the early postoperative circulating levels of IGFBP-3, matrix metalloproteinase (MMP)-9, and tissue inhibitor of metalloproteinase (TIMP)-1 in early stage non-small cell lung cancer (NSCLC) patients undergoing major lung resection by VATS versus thoracotomy., Methods: Forty-two consecutive patients with resectable primary NSCLC were assigned to VATS or thoracotomy approach over a 7-month-period. Blood samples were collected preoperatively and postoperatively on days (POD) 1 and 3 for enzyme linked immunosorbent assay determination of IGFBP-3, MMP-9 and TIMP-1 levels in the serum., Results: There were no demographic differences between the two groups. VATS lung resection was associated with lower levels of MMP-9 and TIMP-1 on POD1 (median 628 vs 1311ng/ml, p=0.009; and 131 vs 211ng/ml, p=0.004, respectively) but higher levels of IGFBP-3 on POD3 (1366 vs 1144ng/ml, p=0.02), when compared with the thoracotomy approach. There was no perioperative mortality., Conclusions: VATS major lung resection for NSCLC is associated with higher circulating levels of IGFBP-3, and lower levels of MMP-9 and TIMP-1, compared to the thoracotomy approach. The clinical relevance of these postoperative changes on tumor biology following lung resection for cancer warrants further investigation.

In contrast to many industrialized countries, the growth of thoracic surgery in China was much more difficult over the first 5 decades under the ever-changing political and harsh socioeconomic conditions. As a matter of fact, the struggle to establish this specialty in a developing country with more than one fifth of the world population was certainly one of the most crucial challenges in the last century. The unique story of a pioneering Chinese thoracic surgeon--Dr Jia-Si Huang (1906-1984) was a glorious example of heroic leadership and self sacrifice. His fundamental role in developing cardiothoracic surgery in China was clearly reflected not only by some first-in-China operations he personally performed, but also by his continued contributions in educating younger generations of Chinese surgeons.

Background: The aim of this study is to evaluate the early outcome of patients with poor lung function who underwent video-assisted thoracic surgery (VATS) pulmonary resection for primary non-small cell lung carcinoma., Methods: We reviewed retrospectively the records of patients with lung cancer undergoing VATS lung resection over a period of 5 years. Twenty-five patients with preoperative poor lung function defined as forced expiratory volume in 1 second less than 0.8 L or the percentage predicted value for forced expiratory volume in 1 second less than 50% were identified. Thirteen patients underwent VATS lobectomies and 12 VATS wedge resections. Data were analyzed with respect to demographics, risk factors, and early postoperative outcome and survival., Results: There were 8 cases of morbidities (29%) and no surgical mortality. Five of these 8 patients had respiratory-related complications after surgery. A deterioration in pulmonary performance as indicated by the Eastern Cooperative Oncology Group (ECOG) score was seen in 7 patients (28%), with only 1 patient having an ECOG score greater than 2. No patient required home oxygen supplementation beyond the third month postoperatively. After a median follow-up period of 15.1 months (range, 1 to 24), 5 patients died. Only 1 patient (4%) died of a respiratory complication (pneumonia 6 weeks after surgery). The other 4 deaths were due to recurrent or metastatic disease. The actuarial survival rates at 1 and 2 years were 80% and 69%, respectively., Conclusions: Video-assisted thoracic surgery pulmonary resection for cancer in patients with poor lung function can achieve acceptable functional and oncologic outcome.

Background: The role of electroacupuncture in postthoracotomy pain control is uncertain. We conducted a pilot study to evaluate the role of electroacupuncture in the management of early postthoracotomy wound pain., Methods: A total of 27 patients with operable non-small cell lung carcinoma who received thoracotomy were recruited and randomized to receive either electroacupuncture or sham acupuncture in addition to routine oral analgesics and patient-controlled intravenous analgesia for postoperative pain control. All patients received acupuncture twice daily with visual analog pain score recorded for the first 7 postoperative days. Specific chest acupoints (LI 4, GB 34, GB 36, and TE 8) were targeted. Patient-controlled analgesia was used for the first 3 postoperative days in all patients, and the cumulative dosage used was recorded., Results: Two patients were excluded after randomization because of complications unrelated to acupuncture. Interventions and data collection were completed for the remaining 25 patients (13 in the electroacupuncture group; 12 in the sham acupuncture group). There was a trend for lower visual analog scale pain scores in the electro-acupuncture group between postoperative days 2 and 6, although this did not reach statistical significance. The cumulative dose of patient-controlled analgesia morphine used on postoperative day 2 was significantly lower in the electroacupuncture group (7.5 +/- 5 mg versus 15.6 +/- 12 mg; p < 0.05). Such delay of onset of pain control may be related to the frequency of electroacupuncture used., Conclusions: Electroacupuncture may reduce narcotic analgesic usage in the early postoperative period. A prospective randomized controlled trial using different electroacupuncture frequency is warranted to verify this benefit.

Objective: The pain following thoracic surgery and trauma is often refractory to conventional analgesic strategies. However, it shares key characteristics with neuropathic pain which gabapentin, an anticonvulsant, has been proven to effectively treat. To our knowledge, this is the first prospective study assessing the use of gabapentin in cardiothoracic surgery patients., Methods: Gabapentin was prescribed to 60 consecutive out-patients with refractory pain persisting at four weeks or more after thoracic surgery or trauma. Follow-up of 45 patients (75%) was performed for a median of 21 months (range: 12-28), and clinical data collected prospectively. The mean age of these patients was 51.6 years (range 22-83). Of these 45 patients, 22 had received video-assisted thoracic surgery (VATS), 8 had received thoracotomy, 3 had received median sternotomy, and 12 were treated for blunt chest trauma., Results: The mean duration of pre-treatment refractory pain was 5.76 months (range 1-62). The mean duration of gabapentin use was 21.9 weeks (range 1-68). No deaths or major complications were encountered. Minor side effects-mostly somnolence and dizziness-occurred in 18 patients (40.0%), causing 3 patients (6.7%) to discontinue gabapentin. Overall, 33 patients (73.3%) noted reduction of pain. Chest wall paresthesia distinguishable from wound pain was relieved in 24 (75.0%) of 32 affected patients. Severe initial pain was significantly correlated with pain relief using gabapentin (p=0.009). No other demographical or clinical variable correlated with benefit or side effects. Satisfaction with gabapentin use was expressed by 40 patients (88.9%). Side effects were not a source of dissatisfaction in any patient., Conclusions: Gabapentin appears safe and well tolerated when used for persistent post-operative and post-traumatic pain in thoracic surgery patients, although minor side effects do occur. Gabapentin may relieve refractory chest wall pain in some of these patients, particularly those with more severe pain. Further studies are warranted to define the role of gabapentin in cardiothoracic surgical practice.

Objective: Neointimal and medial thickening play a critical role in late vein graft failure following CABG. Previous ex vivo experiment suggested that perivenous application of fibrin glue may reduce the damage in the circular smooth muscle cell layer of the media of the vein graft shortly after exposing to arterial pressure. However, the in vivo as well as the longer term impact of this intervention remain unknown., Methods: Bilateral saphenous vein-carotid artery interposition grafting was performed in eight large white pigs (35-45 kg). In each pig, one of the grafts was randomly selected to receive perivenous fibrin glue support while the contralateral graft served as control. At 1 and 4 months following surgery (n=4 pigs in each group), all 16 patent vein grafts were removed and pressure-fixed. Multiple histological sections from each graft were prepared. Proliferating cell nuclear antigen (PCNA) was detected by immunocytochemistry. Vein graft morphology was assessed using computer-aided planimetry., Results: Although perivenous application of fibrin glue had little effects either on medial thickness 1 month after implantation or on PCNA index, it significantly increased medial thickness (control: 0.37+/-0.02 mm; treated: 0.55+/-0.02 mm, p<0.001) and total wall thickness (control: 0.75+/-0.04 mm; treated: 0.92+/-0.04 mm, p=0.008) at 4 months (mean+/-SEM; n=4 in each group)., Conclusions: Our data indicated that perivenous application of fibrin glue enhances graft thickening and as such does not constitute a strategy for preventing late vein graft failure after CABG.

The present report describes a case of severe airway obstruction caused by endobronchial tuberculosis in an 11-year-old girl who was successfully treated by bronchoscopic balloon dilation. This case illustrates the insidious presentation and the increasingly important role of bronchoscopic intervention in the management of endobronchial tuberculosis. In addition, a brief literature review of the condition in the pediatric age group is included.

Background: The cardiac venous system possesses up to 30% of total coronary vascular resistance and the effect of hypoxia-reoxygenation (H-R) and St Thomas (ST) cardioplegic solution on the vein is unknown. We investigated the effects of H-R, with or without ST, on endothelium-derived hyperpolarizing factor (EDHF)-mediated relaxation in porcine cardiac microveins under clinically relevant temperatures., Methods: The microveins (diameter 200 to 450 microM) mounted in a myograph were subjected to hypoxia (Po2 < 5 mm Hg) for 30 minutes in Krebs solution (n = 8) or for 60 minutes in Krebs (n = 8) or in ST at 37 degrees C (n = 8) or 4 degrees C (n = 8), followed by 30-minute reoxygenation. The microvein was precontracted with thromboxane A2 mimetic U46619 (-7 log M) and the EDHF-mediated relaxation was induced by bradykinin (-10 to -6 log M) in the presence of indomethacin, NG-nitro-L-arginine, and oxyhemoglobin before and after H-R., Results: The maximal EDHF-mediated relaxation was significantly reduced after 30-minute hypoxia (38.7 +/- 2.0% vs 61.1 +/- 2.3%, n = 8, p < 0.001) or 60-minute hypoxia in either Krebs or ST at 37 degrees C (Krebs: 27.8 +/- 1.2% vs 56.6 +/- 2.5%, n = 8, p < 0.001; ST: 23.8 +/- 4.1% vs 57.1 +/- 1.5%, n = 8, p < 0.001). The relaxation was significantly less after prolonged H-R in Krebs (p < 0.001). Incubation in Krebs or ST at 4 degrees C also reduced the EDHF-mediated relaxation (Krebs: 25.3 +/- 3.3%, n = 8, p < 0.001; ST: 29.1 +/- 4.4%, n = 8, p < 0.001) and there were no significant differences between Krebs and ST regarding the relaxation at either 37 degrees C or 4 degrees C (p > 0.05)., Conclusions: We conclude that (1) H-R impairs EDHF-mediated relaxation in the coronary microveins with more severe injury during prolonged H-R and (2) ST does not provide protection to the EDHF-mediated relaxation impaired by H-R at either 37 degrees C or 4 degrees C.

Over the past decade, video assisted thoracic surgery (VATS) has changed the way spontaneous pneumothorax (SP) is managed. Benefits of VATS include less postoperative pain, shorter hospital stay, and attenuated postoperative inflammatory response are evident compared with open thoracic procedures. Furthermore, the increasing acceptance by patients and referring physicians is testament to its success. Recent studies and the authors decade of experience in management of SP by VATS show that it is quick, safe, and effective, with recurrence rates generally comparable to open procedures, with some exceptions. However, selecting the correct procedure and patient, as well as knowing the limitations of the surgeons and techniques are paramount for success. Even to this day, there are considerable variations in the treatment of SP and large scale controlled studies are needed to better define timing of surgery and the role of the different procedures in the treatment and prevention of SP.