Early thrombus detection in the extracorporeal membrane oxygenation circuit by noninvasive real-time ultrasonic sensors.

Thrombus formation in extracorporeal membrane oxygenation (ECMO) remains a major concern as it can lead to fatal outcomes. To the best of our knowledge, there is no standard non-invasive method for quantitatively measuring thrombi. This study's purpose was to verify thrombus detection in an ECMO circuit using novel, non-invasive ultrasonic sensors in real-time, utilizing the fact that the ultrasonic velocity in a thrombus is known to be higher than that in the blood. Ultrasonic sensors with a customized chamber, an ultrasonic pulse-receiver, and a digital storage oscilloscope (DSO) were used to set up the measuring unit. The customized chamber was connected to an ECMO circuit primed with porcine blood. Thrombi formed from static porcine blood were placed in the circuit and ultrasonic signals were extracted from the oscilloscope at various ECMO flow rates of 1-4 L/min. The ultrasonic signal changes were successfully detected at each flow rate on the DSO. The ultrasonic pulse signal shifted leftward when a thrombus passed between the two ultrasonic sensors and was easily detected on the DSO screen. This novel real-time non-invasive thrombus detection method may enable the early detection of floating thrombi in the ECMO system and early management of ECMO thrombi.

Delayed Sternal Closure Using a Vacuum-Assisted Closure System in Adult Cardiac Surgery.

Background: Delayed sternal closure (DSC) is a useful option for patients with intractable bleeding and hemodynamic instability due to prolonged cardiopulmonary bypass and a preoperative bleeding tendency. Vacuum-assisted closure (VAC) has been widely used for sternal wound problems, but only rarely for DSC, and its efficacy for mediastinal drainage immediately after cardiac surgery has not been well established. Therefore, we evaluated the usefulness of DSC using VAC in adult cardiac surgery. Methods: We analyzed 33 patients who underwent DSC using VAC from January 2017 to July 2022. After packing sterile gauze around the heart surface and great vessels, VAC was applied directly without sternal self-retaining retractors and mediastinal drain tubes. Results: Twenty-one patients (63.6%) underwent emergency surgery for conditions including type A acute aortic dissection (n=13), and 8 patients (24.2%) received postoperative extracorporeal membrane oxygenation support. Intractable bleeding (n=25) was the most common reason for an open sternum. The median duration of open sternum was 2 days (interquartile range [25th-75th pertentiles], 2-3.25 days) and 9 patients underwent VAC application more than once. The overall in-hospital mortality rate was 27.3%. Superficial wound problems occurred in 10 patients (30.3%), and there were no deep sternal wound infections. Conclusion: For patients with an open sternum, VAC alone, which is effective for mediastinal drainage and cardiac decompression, had an acceptable superficial wound infection rate and no deep sternal wound infections. In adult cardiac surgery, DSC using VAC may be useful in patients with intractable bleeding or unstable hemodynamics with myocardial edema.

Outcome of massive pulmonary embolism treated only with extracorporeal membrane oxygenation and anticoagulation without thrombolytic therapy or surgical embolectomy.

INTRODUCTION: Although thrombolytic therapy is the standard treatment for massive pulmonary thromboembolism (PTE), it is often ineffective in patients with circulatory collapse. Surgical embolectomy is another treatment option, but whether it is absolutely necessary is controversial. We sought to evaluate the outcomes of patients with massive PTE treated with intensive critical care including extracorporeal membrane oxygenation (ECMO) without thrombolytic therapy or surgical embolectomy. METHODS: We analyzed 39 patients who were treated for massive PTE from January 2011 to June 2019. Massive PTE was treated with anticoagulation and hemodynamic support at an intensive care unit. ECMO was applied in patients with circulatory collapse. The computed tomography (CT) obstruction index and the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) were measured using serial CT angiography to confirm changes in pulmonary emboli and RV strain. RESULTS: Twenty-one patients were in cardiogenic shock, and 15 of them needed cardiopulmonary resuscitation (CPR). Fifteen patients were treated with ECMO and nine of them were weaned successfully. The overall in-hospital mortality was 23% (9/39). On the follow-up CT scan after 6 months, residual PTE was observed in 10 patients and their median CT obstruction index was 6.25 % (range 2.5-35). The initial mean RV/LV ratio was 1.8 ± 0.47 and the value measured at follow-up CT decreased to less than 1 (0.9 ± 0.1). CONCLUSIONS: Intensive critical care with heparin alone and timely ECMO support without thrombolytic therapy could be an effective treatment option in patients with acute massive PTE.

Relationship between Systemic Inflammatory Markers, GLUT1 Expression, and Maximum 18F-Fluorodeoxyglucose Uptake in Non-Small Cell Lung Carcinoma and Their Prognostic Significance.

BACKGROUND: Factors involved in inflammation and cancer interact in various ways with each other, and biomarkers of systemic inflammation may have a prognostic value in cancer. Glucose transporter 1 (GLUT1) plays a pivotal role in glucose transport and metabolism and it is aberrantly expressed in various cancer types. We evaluated the differential expression of GLUT1, along with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in non-small-cell lung cancer (NSCLC), and then analyzed their prognostic significance. METHODS: A total of 163 patients with resectable NSCLC were included in this study. Tumor sections were immunohistochemically stained for GLUT1 and GLUT3. Maximum standardized uptake value (SUVmax) was measured by preoperative FDG-PET, and neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and lymphocyte-monocyte ratio (LMR) were derived from pretreatment blood count. RESULTS: GLUT1 and GLUT3 was positively expressed in 74.8% and 6.1% of the NSCLC tissues, respectively. GLUT1 expression was significantly correlated with squamous cell carcinoma histology, poor differentiation, high pathologic stage, old age, male, smoking, and high SUVmax (>7) (all p < 0.05). The squamous cell carcinoma and smoker group also showed significantly higher SUVmax (both p < 0.001). Systemic inflammation markers, including NLR, PLR, and LMR, were positively correlated with high SUVmax (all p < 0.05). High GLUT1 expression, high SUVmax, high NLR, and low LMR, were significantly associated with poor overall survival in patients with NSCLC. However, in the multivariate survival analysis, LMR was an independent prognostic factor overall (HR 1.86, 95% CI 1.05-3.3) and for the stage I/II cohort (HR 2.3, 95% CI 1.24-4.3) (all p < 0.05). CONCLUSIONS: Systemic inflammatory markers-NLR, PLR, and LMR are strongly correlated with the SUVmax and are indicators of aggressive tumor behavior. Specifically, LMR is a promising prognostic biomarker in NSCLC patients.

Optimal Airway Management in the Treatment of Descending Necrotizing Mediastinitis Secondary to Deep Neck Infection.

PURPOSE: To review our experiences of descending necrotizing mediastinitis (DNM) secondary to deep neck infection (DNI) and determine appropriate airway management for decreasing mortality and morbidity of patients with DNM. METHODS: Medical records of 20 patients (8 women and 12 men) who had been managed for DNM secondary to DNI between March 2006 and December 2019 were analyzed. Diagnosis and extent of infection were confirmed by computed tomography of the neck and chest. The upper airway was closely monitored with a fiberoptic laryngoscope. Complications were evaluated according to various types of airway management in our serial cases. RESULTS: Five (25%) out of 20 patients died as a result of septic shock and multiorgan failure. None of these patients died of accidental airway obstruction or airway management mishaps. Keeping short-term orotracheal intubation was safe and adequate after the initial surgery. Early tracheotomy was performed for 4 patients and it was significantly associated with mortality (P = .032). Three patients who underwent late tracheotomy had no mortality. Patients with tracheotomy had longer duration of overall hospital stay than those without tracheotomy. CONCLUSIONS: Well-controlled airway management might decrease mortality, hospitalization, and airway complications in patients with DNM secondary to DNI. Keeping orotracheal intubation rather than upfront tracheotomy should be first considered when managing airway along with examination of the upper airway with a fiberoptic laryngoscope.

Characteristics of female lung cancer in Korea: analysis of Korean National Lung Cancer Registry.

BACKGROUNDS: The present study evaluated Korean women with lung cancer and compared the clinical characteristics of ever-smoker and never-smoker groups using the National Lung Cancer Registry. METHODS: In affiliation with the Korean Central Cancer Registry, the Korean Association for Lung Cancer constructed a registry into which 10% of the lung cancer cases in Korea were registered. Female lung cancer patients with valid smoking history were evaluated. RESULTS: Among 735 female lung cancer patients, 643 (87.5%) were never-smokers and 92 (12.5%) were smokers. The median survival was significantly longer in the never-smoker group (28 vs. 14 months; P<0.001). Among 683 patients with non-small cell lung cancer (NSCLC), the never-smoker group showed significantly longer median survival (29 vs. 14 months; P=0.002) and a higher proportion of stage I cancer (40.3% vs. 25.7%; P<0.001). Survival analysis of the NSCLC patients showed that smoking status, receiving only supportive care, EGFR mutation status, lung cancer stage, and forced vital capacity (FVC) (%) were significantly associated with mortality in the multivariate analysis (P=0.025, HR 2.39, 95% CI: 1.12-5.11; P=0.017, HR 3.14, 95% CI: 1.22-8.06; P=0.033, HR 0.63, 95% CI: 0.41-0.96; P<0.001, HR 11.88, 95% CI: 5.79-24.38; P=0.002, HR 0.98, 95% CI: 0.96-0.99, respectively). CONCLUSIONS: In Korean women with NSCLC, smoking status, not receiving active anticancer treatment, EGFR mutation status, lung cancer stage, and pulmonary function were significantly associated with mortality.

Erratum: Clinical Characteristics and Prognostic Factors of Lung Cancer in Korea: A Pilot Study of Data from the Korean Nationwide Lung Cancer Registry.

This corrects the article on p. 118 in vol. 82, PMID: 29926550.

Prognostic Factors in Stage IIB Non-Small Cell Lung Cancer according to the 8th Edition of TNM Staging System.

BACKGROUND: The purposes of this study were to evaluate the appropriateness of the stage migration of stage IIA non-small cell lung cancer (NSCLC) in the seventh edition of the tumor, node, and metastasis classification for lung cancer to stage IIB lung cancer in the eighth edition, and to identify prognostic factors in patients with eighth-edition stage IIB disease. METHODS: Patients with eighth-edition stage IIB disease were subclassified into those with seventh-edition stage IIA disease and those with seventh-edition stage IIB disease, and their recurrence-free survival and disease-specific survival rates were compared. Risk factors for recurrence after curative resection were identified in all included patients. RESULTS: Of 122 patients with eighth-edition stage IIB NSCLC, 101 (82.8%) had seventh-edition stage IIA disease and 21 (17.2%) had seventh-edition stage IIB disease. Nonsignificant differences were observed in the 5-year recurrence-free survival rate and the 5-year disease-specific survival rate between the patients with seventh-edition stage IIA disease and those with seventh-edition stage IIB disease. Visceral pleural invasion was a significant risk factor for recurrence in patients with eighth-edition stage IIB NSCLC. CONCLUSION: The stage migration from seventh-edition stage IIA NSCLC to eighth-edition stage IIB NSCLC was appropriate in terms of oncological outcomes. Visceral pleural invasion was the only prognostic factor in patients with eighth-edition stage IIB NSCLC.

Early detection of complications: anastomotic leakage.

Anastomotic leakage (AL) is one of the most critical and detrimental complications in esophageal surgery. Early diagnosis and timely therapeutic action are necessary if patients are to avoid AL-related problems. However, there is no gold standard or consensus for early diagnosis. In this review, we focus on summarizing the definition and types of AL and modalities for early diagnosis of AL after esophagectomy.

Long-Term Survival after Wide Resection of Malignant Fibrous Histiocytoma of the Chest Wall.

Primary malignant fibrous histiocytoma (MFH) of the chest wall is extremely rare and is characterized by aggressive features, including a high incidence of local recurrence and distant metastasis. Surgical resection of the chest wall is the primary modality of management. However, surgical treatment is not generally recommended in patients with evidence of distant metastasis. Here, we present a case of chest wall MFH along with a schwannoma mimicking distant metastasis in the right upper arm. The patient was treated by radical en bloc resection and survived for more than 9 years without recurrence.

Report of the Korean Association of Lung Cancer Registry (KALC-R), 2014.

PURPOSE: The aim of this study was to investigate epidemiology, clinical characteristics and sex differences of patients with lung cancer using nationwide registry in Korea. MATERIALS AND METHODS: The Korean Association for Lung Cancer developed a registry in cooperation with the Korean Central Cancer Registry, and surveyed about 10% of lung cancer cases. For this first survey of cases diagnosed in 2014, cases were selected through a systematic sampling method. RESULTS: Total 2,621 lung cancer patients were surveyed, and the median patient age was 70 years. During the study period, adenocarcinoma was the most frequent histologic type, the proportion of female patients was 28.4%, and women had a better prognosis (median survival, not reached vs. 13 months; p<0.001) than did men for non-small cell lung cancer. The proportion of never-smokers was 36.4%, and never-smoking was more prevalent in women than in men (87.5 vs. 16.0%, p<0.001). Epidermal growth factor receptor (EGFR) mutations were found in 36.8% of stage IV adenocarcinoma patients, and higher in female compared to male patients (51.2 vs. 26.6%, p<0.001). In addition, patients with EGFR mutation showed better survival (median survival, 18 vs. 8 months; p<0.001) than patients without EGFR mutation in these patients. CONCLUSION: This is the first survey to gather unbiased nationwide lung cancer statistics in Korea. More than one-third of lung cancer patients had no smoking history. Female had a high proportion of non-smoker, more adenocarcinoma with EGFR mutation and generally better prognosis than male.

Clinical Characteristics and Prognostic Factors of Lung Cancer in Korea: A Pilot Study of Data from the Korean Nationwide Lung Cancer Registry.

BACKGROUND: Lung cancer is a leading cause of morbidity and mortality worldwide, and the incidence continues to rise. Although many prognostic factors have been identified, the clinical characteristics and outcomes in Korean lung cancer patients are not well defined. METHODS: Of the 23,254 new lung cancer cases registered at the Korea Central Cancer Registry in 2013, total 489 patients from 19 hospitals were abstracted by the Korean Central Cancer Registry. The clinical data retrospectively analyzed, patients were followed up until December 2015. RESULTS: The median age was 69 years (interquartile range, 60-74 years); 65.4% were male and 62.1% were ever-smokers. Cough was the most common initial symptom (33.5%); 13.1% of patients were asymptomatic. While squamous cell carcinoma was the most common subtype in male patients (37.2%), adenocarcinoma was the most frequent histological type in all patients (48.7%) and females (76.3%). The majority of patients received treatment (76.5%), which included surgery, radiation therapy, and chemotherapy. Older age (hazard ratio [HR], 1.037), lower body mass index (HR, 0.904), ever-smoker (HR, 2.003), small cell lung cancer (HR, 1.627), and distant metastasis (HR, 3.990) were independent predictors of mortality. Patients without symptoms (HR, 0.387) and without treatment (HR, 0.364) were associated with a favorable outcome in multivariate Cox analysis. CONCLUSION: Lung cancer in Korea occurs predominantly in elderly patients, with adenocarcinoma being the most frequent subtype. The prognosis was poorer in ever-smokers and older, malnourished, and untreated patients with advanced lung cancer.

Validity of upfront surgery for patients with unsuspected lymph node metastasis in esophageal cancer: a propensity scoring matching study.

BACKGROUND: Although neoadjuvant therapy followed by esophagectomy is well-established as being superior to upfront esophagectomy when locoregional lymph node (LN) metastasis is present in esophageal cancer, upfront esophagectomy without neoadjuvant therapy may be performed in patients with LN metastasis due to unreliable preoperative evaluations. However, outcomes in this setting remain unclear. The purpose of the present study was to clarify whether upfront esophagectomy without neoadjuvant therapy in patients with unsuspected lymph node metastasis in esophageal cancer is appropriate. METHODS: We included 215 squamous cell esophageal cancer patients who met the study criteria. Inclusion criteria included complete (R0) and curative surgery cases, intra-thoracic esophageal cancer, preoperative biopsy-proven squamous cell carcinoma, and cases without LN metastasis (WL, cN0 and pN0) or with unsuspected LN metastasis (UL, cN0 and pN1). Exclusion criteria were palliation or salvage cases, other uncured previous or current primary cancers, complete remission cases, and operative mortalities (defined as patients who died during hospitalization or within one month after surgery). We compared 5-year disease- free survival (DFS) between WL and UL. In addition, we investigated the influence of neoadjuvant therapy in UL. To overcome heterogeneity in baseline characteristics between the groups, a propensity matched-analysis based on propensity scores was then carried out to create a cohort of WL with clinical characteristics similar to those in UL. RESULTS: The incidence of UL among preoperative N0 patients was 25.6% and the incidence of UL cases who did not receive neoadjuvant therapy was 47.2%. All subjects were stratified into either WL (160 patients) or UL (55 patients). Twenty nine of 55 patients in UL received neoadjuvant therapy before esophagectomy and all patients with LN metastasis received adjuvant therapy after esophagectomy. There was no significant difference in DFS between WL and UL (p = 0.242). Furthermore, there were no significant differences in DFS between cases that received and did not receive neoadjuvant therapy (p = 0.769). CONCLUSIONS: Upfront surgery without neoadjuvant therapy in UL is appropriate for patients who can tolerate adjuvant therapy.

A national survey of lung cancer specialists' views on low-dose CT screening for lung cancer in Korea.

Lung cancer specialists play an important role in designing and implementing lung cancer screening. We aimed to describe their 1) attitudes toward low-dose lung computed tomography (LDCT) screening, 2) current practices and experiences of LDCT screening and 3) attitudes and opinions towards national lung cancer screening program (NLCSP). We conducted a national web-based survey of pulmonologists, thoracic surgeons, medical oncologists, and radiological oncologists who are members of Korean Association for Lung Cancer (N = 183). Almost all respondents agreed that LDCT screening increases early detection (100%), improves survival (95.1%), and gives a good smoking cessation counseling opportunity (88.6%). Most were concerned about its high false positive results (79.8%) and the subsequent negative effects. Less than half were concerned about radiation hazard (37.2%). Overall, most (89.1%) believed that the benefits outweigh the risks and harms. Most (79.2%) stated that they proactively recommend LDCT screening to those who are eligible for the current guidelines, but the screening propensity varied considerably. The majority (77.6%) agreed with the idea of NLCSP and its beneficial effect, but had concerns about the quality control of CT devices (74.9%), quality assurance of radiologic interpretation (63.3%), poor access to LDCT (56.3%), and difficulties in selecting eligible population using self-report history (66.7%). Most (79.2%) thought that program need to be funded by a specialized fund rather than by the National Health Insurance. The opinions on the level of copayment for screening varied. Our findings would be an important source for health policy decision when considering for NLCSP in Korea.

Recurrence of pectus excavatum following the Nuss procedure.

BACKGROUND: The recurrence of pectus excavatum (PE), in other words, chest wall depression after the completion of repair, is one of the most important issues in PE. However, little about the recurrence of PE is known. The present study aimed (I) to evaluate the characteristics of chest wall depression during treatment and (II) to present the definition of recurrence of PE, investigate the risk factors for recurrence, and predict the recurrence at one year after bar removal (BR). METHODS: Consecutive 99 patients who had undergone BR for PE in a single hospital from March 2012 to June 2017 were included in the present study. Severity of PE is presented as a radiographical Haller index (RHI) in the present study. RHI is calculated by the ratio of the transverse diameter to the anteroposterior (AP) diameter at the point of the deepest chest wall depression. Patients with a ≥3.5 RHI value, which simultaneously increased to more than the value of RHI before BR, were considered as demonstrating recurrence in the present study. Follow-up data after BR were collected at subsequent time points (i.e., immediate before and after, one month, sixth months, and one year after BR). All postoperative chest wall changes were analyzed to find out the difference according to the age at the time of the Nuss procedure (NP) [<10 years old (early group; EG) vs. ≥10 years old (late group, LG)]. RESULTS: The mean age of patients was 8.91 (±5.23) years at the age of the NP and the mean duration of bar placement was 28.4 (±5.04) months. Seventy-eight males and 21 females were included. The pectus type was 79 symmetric and 20 asymmetric cases. The mean observation period after BR was 16.47 (±3.74) months. There was a significant correlation between the Haller index using chest CT and simple radiography data (P<0.001). Irrespective of the age groups, there were a significant decrease in RHI values after the NP (both P<0.001). In addition, there were no differences in RHI values between the EG and the LG cohort before the NP and immediately after the NP (P=0.775, P=0.356, respectively). RHI values was significantly decreased in the EG (P=0.040) and increased without a significance in the LG (P=0.330) during bar placement. The chest wall depression progressed for the first six months after BR. However, the chest wall depression did not progress one year after BR. Recurrence occurred in nine cases at one year after BR (four cases in the EG and five cases in LG). The recurrence rate was higher in the LG than in the EG without a significance (P=0.479). Multivariate analysis of the recurrence revealed that only RHI after the NP was identified as an independent risk factor of the recurrence. ROC study also showed that RHI value after the NP had a significant predictable cutoff value for the recurrence [cutoff value of RHI: 2.91, sensitivity: 88.9%, specificity: 90.0%, P<0.001, area: 0.899, 95% confidence interval (CI): 0.806-0.993]. CONCLUSIONS: The present study shows the characteristics of chest wall depression and the risk factor of the recurrence of PE after BR. The effect of the NP is different according to the patient age at the time of the procedure. Early correction of PE can provide better corrective results because of the existence of a more pliable chest wall, which can be easily and sufficiently elevated by the NP. Sufficient elevation of the depressed chest wall should be ensured during the NP to prevent the recurrence of PE.

Results of repeated video-assisted thoracic surgery for recurrent pneumothorax after primary spontaneous pneumothorax.

OBJECTIVES: This study aimed to identify the causes of recurrent pneumothorax and to evaluate the results of repeated video-assisted thoracic surgery (VATS) for recurrent pneumothorax after VATS wedge resection for primary spontaneous pneumothorax (PSP). METHODS: A retrospective review was conducted on 188 patients with recurrent PSP, of a population of 1414 patients who underwent VATS wedge resection for PSP. Reoperations were performed when an air leak persisted longer than 3 days after closed thoracostomy, when a visible bulla of greater than 1 cm on high-resolution computed tomography (HRCT) was observed and when rerecurrence took place after other treatments. The HRCT findings before and after recurrence were compared to evaluate the type of the new bulla. Patients were divided into 2 groups according to the additional procedure performed during the first operation; in Group I, a coverage procedure was performed, and in Group II, mechanical pleurodesis was performed after VATS wedge resection. RESULTS: During a median follow-up period of 27.7 months, 76 patients underwent repeated VATS for ipsilateral recurrent PSP after VATS. The indications for repeated VATS were the presence of a bulla on HRCT in 41 patients and a persistent air leak in 35 patients. Group I comprised 36 patients and Group II comprised 40 patients. The HRCT findings showed no bulla in 3 (4%) patients, were suspicious for a bulla in 11 (15%) patients, showed a bulla at the staple line in 26 (34%) patients and showed a new bulla in a location other than on the staple line in 36 (47%) patients. The frequency of new bullae was not different between the 2 groups, but Group I showed a lesser tendency for bullae to occur at the staple line than Group II. Dense fibrosis around the staple line was also found intraoperatively. CONCLUSIONS: Repeated VATS was a feasible method to treat recurrent PSP after VATS for PSP.

A laceration of left internal mammary artery caused by an amateur golfer's swing.

We report the rare case of a patient presenting with a spontaneous laceration of left internal mammary artery (LIMA) after playing golf. The patient had no specific history except for cardiac surgery, and there were no results that caused bleeding on preoperative examination. A computed tomography (CT) scan of the chest demonstrated an anterior mediastinal hematoma and a left hemothorax with active extravasation close to LIMA. Through thoracotomy, hematoma evacuation and clipping for lacerated artery were performed. The patient was discharged in stable condition on the sixteenth postoperative day. This is the first reported case of a spontaneous laceration of internal mammary artery (IMA) after playing golf.

Lung cancer specialist physicians' attitudes towards e-cigarettes: A nationwide survey.

OBJECTIVES: Despite a sharp increase in e-cigarette use, there is debate about whether e-cigarettes are a viable alternative for harm reduction, and the forms that regulation should take. Healthcare providers can be effective in offering guidance to patients and their families and shaping regulatory policy. We described lung cancer specialists' attitudes toward e-cigarettes and its regulation. METHODS: We undertook a nationwide survey of pulmonologists, thoracic surgeons, medical and radiological oncologists who are members of Korean Association for Lung Cancer. Survey items included beliefs and attitudes toward e-cigarettes, attitudes toward e-cigarette regulation and preparedness on discussing e-cigarettes with their patients. RESULTS: Most respondents believed that e-cigarettes are not safer than conventional tobacco cigarettes (75.7%) or smokeless tobacco (83.2%), and feared that discussing e-cigarettes with the patients would encourage use (65.4%). They did not consider it a smoking cessation treatment (78.3%), and thus would not recommend it to smokers who do not want to quit (82.2%) or who failed to quit with conventional smoking cessation treatment (74.1%). Most respondents supported all examples of e-cigarette regulations, including the safety and quality check (97.8%), warning label (97.8%), advertisement ban (95.1%), restriction of flavoring (78.4%), minimum purchasing age (99.5%), and restriction of indoor use (94.6%). Most learned about e-cigarettes from media and advertisements, or conversation with patients rather than through professional scientific resources, and reported discomfort when discussing e-cigarette with patients. CONCLUSION: Lung cancer specialist physicians in Korea doubt the safety of e-cigarette and use of e-cigarette as smoking cessation treatment, and supported strict regulation. However, only 20% reported that they obtained information on e-cigarettes from the scientific literature and many lacked adequate knowledge based on scientific evidence, suggesting the need for better preparedness. Nevertheless, the views of professionals revealed from our study could help to develop clinical guidelines and regulatory guidance.

Thoracoscopic Bilateral Bullectomy for Simultaneously Developed Bilateral Primary Spontaneous Pneumothorax: Ipsilateral Transmediastinal versus Bilateral Sequential Approach.

Background Simultaneously developed bilateral primary spontaneous pneumothorax (BPSP) is an indication for thoracic surgery of both sides. Recently, we have reported a new technique for BPSP, which is ipsilateral apicoposterior transmediastinal (TM) bullectomy of both sides using video-assisted thoracoscopic surgery (VATS), and we compared this TM VATS with bilateral sequential (BS) VATS for BPSP. Materials and Methods From June 2003 to May 2014, 11 and 14 patients were performed VATS TM and BS bullectomy for BPSP, respectively. We reviewed the medical records and compared the clinical data between the two groups. For TM group, we first performed the right VATS bullectomy and approached through the apicoposterior mediastinal region for contralateral VATS. In the other group, conventional BS VATS bullectomy was performed in the lateral decubitus position change. Results The mean follow-up was 62.0 ± 32.6 months. No mortality and major complications were observed. The operative time (68.18 ± 24.93 vs. 96.07 ± 37.73, p = 0.046), duration of left pleural drainage (1.00 ± 0.45 vs. 3.21 ± 1.37, p = 0.000), and length of hospital stay (3.82 ± 1.54 vs. 4.93 ± 1.07, p = 0.044) were significantly shorter in the TM group than in the BS group. No significant differences were seen in duration of general anesthesia, total number of wedge resections and endostaplers used in both lungs, duration of right drainage, and postoperative recurrence. Conclusion The TM VATS approach may be a safe and feasible modality for BPSP. It may decrease the operative time, patients inconvenience such as bilateral multiple wounds and longstanding placement of chest tubes, and decrease the hospital stay compared with the BS VATS approach.