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Adenocarcinoma of the lung is now the most common histologic subtype of non-small-cell lung cancer (NSCLC) worldwide. In Chinese populations, the incidence of lung adenocarcinoma is amongst the highest worldwide and its development in non-smoking females is particularly striking. Information on the associated underlying genetic changes has been, however, minimal to date. The present study represents the first systematic analysis on the overall genetic changes in lung adenocarcinoma of Chinese female non-smokers. We undertook a genome-wide investigation into the abnormalities in lung adenocarcinomas of 18 life-long non-smoking Chinese females using the technique of comparative genomic hybridization (CGH). With a view to isolating the relative roles of gender, ethnicity and tobacco consumption, we recruited control groups of 10 Caucasian female non-smokers and 22 male Chinese smokers. Although gains on 1q, 5p, 7p and 8q, and regional losses on 8p, 17p, 13q and 18q were commonly seen, there were no significant differences between the Caucasian and Chinese non-smoking women. The observation suggests that lung adenocarcinomas, regardless of ethnic origin, adopt similar pathologic pathways during the accumulation of genetic events. Besides, genomic imbalances, particularly gains per tumor, were significantly more common among the tobacco-related tumors (P=0.006). In particular, regional over-representations of 13q21-q34 (P=0.044), 17q25 (P=0.015), 19q13.1 (P=0.044) and 22q (P=0.044) may have implications for the pathologic pathways associated with the tobacco-related lung adenocarcinoma.

Thymectomy is an established therapy in the management of generalized myasthenia gravis, in addition to medical treatment. However, the optimal surgical approach to thymectomy has remained controversial. There are advocates for transternal, transcervical approaches or "maximal" thymectomy. Video-assisted thoracic surgery (VATS) presents a new approach to thymectomy and forms the basis of this article, in which we discuss patient selection, technique, and results. We believe complete thymectomy, comparable with the transternal approach, could be achieved by VATS. Our intermediate-term results compare well with other surgical techniques. By minimizing chest wall trauma, VATS not only causes less postoperative pain, shortens hospital stay, gives better cosmetic results but also leads to wider acceptance by patients (and their neurologists) for earlier surgery. However, the true role of this approach in thoracic surgery awaits long-term results.

The insertion of intraluminal stents is an effective method of relieving the distressing symptom of asphyxia in patients with obstructive lesions in the trachea and main-stem bronchi. We report our experience in the use of the studded Dumon silicone stent (Endoxane prosthesis; Axion, Aubagne, France). Between February 1994 and August 1996, 42 stents were placed in 30 patients. Of the 27 patients with a malignant stricture, 10 had carcinoma of the bronchus, 13 carcinoma of the esophagus, and 4 metastatic carcinoma involving the tracheobronchial tree. The benign lesions were made up of two tuberculous strictures and one suprastomal stenosis after tracheostomy. Stents were placed through a rigid bronchoscope with patients under general anesthesia. Postplacement assessment was performed with a 10-point, symptom-based visual analog scale. In eight less urgent cases, forced expiratory volume in 1 second and forced vital capacity were determined before and after surgery. The mean symptomatic improvement on the 10-point scale was 6.1 points, whereas the forced expiratory volume in 1 second (in the eight patients tested) improved by 75%, and the forced vital capacity improved by 54%. The median survival was 2 months for patients with carcinoma of the bronchus and 3 months for patients with carcinoma of the esophagus. Two patients with metastatic carcinoma and all of the patients with the benign lesions were alive and well after 12 months of follow-up. Insertion of the Dumon stent is a simple, safe, and effective method of countering the distressing symptoms arising from obstructive tracheobronchial lesions.

The application of video-assisted thoracic surgery (VATS) to major lung resection is controversial. We reviewed our combined experience in this technique from two centers in Asia. From January 1993 to December 1995, 78 patients (44 male and 34 female patients with ages ranging from 16 to 85 years) successfully underwent VATS major lung resections. Selection criteria for this approach include (a) lesions < 5 cm in maximal diameter; (b) for primary lung carcinomas, clinical stage I status; (c) absence of chest wall involvement; (d) absence of pleural symphysis; and (e) complete or near complete interlobar fissures. Procedures included segmentectomy (1), lobectomy (69), bilobectomy (2), and pneumonectomy (6) together with mediastinal lymph node sampling in cases of primary malignancy. We emphasized not spreading ribs and using conventional thoracic instruments for dissection together with wound protection on specimen retrieval. There was one perioperative death and five nonfatal complications that included persistent air leak over 10 days in two patients, pneumonia in one, and persistent dysesthesia related to surgery in two. We conclude that VATS major lung resection is technically feasible. Stringent patient selection is important. Specific complications exist and special training is needed. The exact role of this approach in thoracic surgery remains to be defined by prospective randomized study compared with conventional thoracotomy with long-term follow-up.

Background: Video-assisted thoracoscopic surgery (VATS) is now an established approach in the management of many thoracic conditions. However, the high cost of this new technology has deterred many Asian hospitals from widely applying this technique., Methods: This article describes our strategies to reduce cost in our practice of VATS over the last few years., Results: VATS involves (1) careful patient selection, (2) use of conventional thoracic instruments as much as possible, (3) modification of conventional instruments, (4) limited use of expensive consumables, and (5) development and application of endoscopic suturing technique., Conclusions: VATS is still in evolution. Cost containment, while desirable in the West, is a high priority in Asia if this new surgical approach is to be applicable even in developing countries. More research is greatly needed in this area.

Although video-assisted thoracoscopic surgery (VATS) is now accepted by many as the approach of choice in the management of primary spontaneous pneumothorax (PSP), the optimal procedure and timing of surgical intervention remain as areas of contention. The author reviewed his personal experience with 224 consecutive VATS procedures for PSP. Mechanical pleurodesis was performed in every case and was the only procedure in 20 patients. We had experienced with several means of eliminating subpleural bullae once identified: stapled bullectomy (151), endoloop (12), argon beam coagulation (6) and endoscopic suturing (35). There were no mortality or intraoperative complications. The median postoperative hospital stay was 3 days. So far, we have had 4 recurrences (1.8%) after a mean follow-up of 20 months (range 1 to 36 months). Complications consisted of 10 persistent air leaks, 1 wound complication, and 1 chest wall bleeding. We conclude that 1) VATS is a safe and effective approach in the treatment of PSP; 2) Stapled-bullectomy is quick and reliable but costly; 3) Endoloop and suturing are viable alternative techniques that may prove to be more cost effective; and 4) we do not recommend the use of argon beam coagulation as the primary treatment modality.

Teratoma is a rare tumour in children accounting for about 3% of all childhood malignancy. A case of immature mediastinal teratoma in a young Chinese girl is reported.

We report our combined experience on video-assisted thoracoscopic (VAT) anatomic lung resections from two major hospitals in Hong Kong over a 17-month period. From August 1993 to December 1994, 82 cases of major lung resections were attempted using the VATS approach, of which 60 were successfully completed (55 lobectomies, 2 bilobectomies, 2 pneumonectomies, and 1 segmentectomy). Of these 60 cases, there were 43 men and 17 women with a mean age of 66 years (range, 37 to 85 years). The final pathologies were 52 primary lung cancers (37 adenocarcinoma, 11 squamous cell carcinoma, 2 bronchoalveolar carcinoma, 1 adenosquamous carcinoma, and 1 undifferentiated carcinoma); 1 pulmonary metastasis (from nasopharyngeal carcinoma); and 7 benign lesions (3 tuberculosis, 1 bronchiectasis, 1 sclerosing hemangioma, 2 organizing pneumonia). There was one postoperative death (mortality rate, 1.8%). Complications include persistent air leak over 10 days (four), wound infection (two), supraventricular tachycardia (three), and recurrence of tumor over the utility thoracotomy scar (one). All the patients were followed up from 8 weeks to 19 months (mean, 10 months). The mean duration of chest drainage was 5.4 days (range, 2 to 25 days). The mean hospital stay was 7.2 days (range, 4 to 35 days). The average postoperative parenteral narcotic (meperidine hydrochloride [Pethidine]) requirement by patient-controlled analgesia was 275 mg (range, 75 to 800 mg). This compared favorably with an age- and sex-matched historic group of patients who underwent posterolateral thoracotomy and had a hospital stay of 10.4 days (statistically non-significant) and narcotic requirement of 950 mg (statistically significant by paired t test). We conclude that VAT anatomic lung resection is technically feasible. However, there are some specific complications associated with major lung resection through minimal access. Refinement of our present technique and attention to details are important to improve our results.

Video-assisted thoracoscopy (VAT) offers a new approach to the diagnosis and treatment of many thoracic conditions. From September 1992 to August 1993, a total of 163 VAT procedures were successfully performed on 108 patients (87 male, 21 female; age range from 12 to 77) which consisted of 42 bleb eliminations and 64 mechanical pleurodesis for spontaneous pneumothorax, 11 wedge resections for pulmonary nodules, three wedge biopsies for diffuse pulmonary infiltrate, four thoracic sympathectomies, resections of two mediastinal masses, three pericardial windows, 10 guided pleural biopsies for undiagnosed effusions, six guided drainage of empyema and haemothorax, 16 staging of intrathoracic tumours and two explorations for penetrating thoracic trauma. There was no procedure-related mortality. Complications included one recurrence for spontaneous pneumothorax, one re-exploration for bleeding (also by VAT approach), one wound infection, and six persistent air leaks for more than 10 days. The median duration of postoperative chest tube drainage was 2 days and the median hospital stay was 4 days. It was concluded that VAT is a safe and effective approach in thoracic surgery and with further refinement in instrumentation even more procedures will be technically feasible. The long-term results of VAT are being awaited in order to define its true merits in thoracic surgery.