National Utilization of Glaucoma Laser and Surgical Management in Medicare Beneficiaries: Disparities and Accessibility.

PRCIS: In this population-based, cross-sectional study of Medicare beneficiaries, there were lower odds of national glaucoma surgery among ages older than 85, female sex, Hispanic ethnicity, and diabetic comorbidity. Glaucoma surgery rates were independent of ophthalmologist distribution. PURPOSE: With an increasing prevalence of glaucoma in the United States, it is crucial to elucidate surgical procedure accessibility to deliver quality care. The objective of this study was to estimate national access to surgical glaucoma care by (1) comparing diagnostic and surgical management Medicare insurance claims followed by (2) correlating Medicare treatment claims with regional ophthalmologist availability. PATIENTS AND METHODS: This cross-sectional study included Medicare claims from the 2017 Vision and Eye Health Surveillance System and workforce data from the 2017 Area Health Resource Files, both public domain databases. A total of 25,443,400 beneficiaries fully enrolled in Medicare Part B Fee-for-Service with glaucoma diagnosis claims were included. Rates of US MD ophthalmologists were determined by Area Health Resource Files distribution densities. Surgical glaucoma management rates included Medicare service utilization claims for drain, laser, and incisional glaucoma surgery. RESULTS: While Black, non-Hispanic Americans had the highest prevalence of glaucoma, Hispanic beneficiaries had the highest odds of surgery. Older age (85+ vs. 65-84 y; Odds Ratio [OR]=0.864; 95% Confidence Interval [CI], 0.854-0.874), female sex (OR=0.923; 95% CI, 0.914-0.932), and having diabetes (OR=0.944; 95% CI, 0.936-0.953) was associated with lower odds of having a surgical glaucoma intervention. Glaucoma surgery rates were not associated with ophthalmologist density by state. CONCLUSIONS: Glaucoma surgery utilization differences by age, sex, race/ethnicity, and systemic comorbidities warrant further investigation. Glaucoma surgery rates are independent of ophthalmologist distribution by state.

Esophagopericardial fistula, septic shock and intracranial hemorrhage with hydrocephalus after lung transplantation.

A 57-year old woman underwent lung transplantation for non-specific interstitial pneumonia. Primary graft dysfunction was diagnosed requiring continued use of extracorporeal membrane oxygenation (ECMO). Within three days she developed recurring hemothoraces requiring two surgical evacuations. After ECMO removal a series of complications occurred within four months: femoral thrombosis, persisting tachycardic atrial fibrillation, pneumopericardium with an esophagopericardial fistula and purulent pericarditis, septic shock, multiorgan failure and intracerebral hemorrhage with ventricular involvement requiring external ventricular drainage. Interdisciplinary management coordinated by the intensive care specialist, transplant surgeon and pulmonologist with various interventions by the respective specialists followed by intensive physical rehabilitation allowed for discharge home on day 235 post transplant. Subsequently quality of life was considered good by the patient and family.

[Lung Volume Reduction Surgery - State of the Art 2016]. / Emphysemchirurgie - State of the Art 2016.

In a number of large case series in the mid-1990s, lung volume reduction surgery (LVRS) was shown to reduce dyspnoea and improve pulmonary function and quality of life in patients with advanced pulmonary emphysema. The large randomised National Emphysema Treatment Trial (NETT) confirmed this in the early 2000s and also demonstrated that selected patients live longer after surgery. Patient selection is crucial to the success of the procedure and should be performed at a specialised experienced centre with a multidisciplinary team approach on emphysema treatment. The upper-lobe predominant heterogeneous type of emphysema is the best indication, but there are other types of emphysema morphology that are also eligible for surgery, if ideally chosen. Nowadays there is also growing evidence for positive effects after different types of bronchoscopic lung volume reduction (BLVR) with increasing quality. These methods add to the range of multimodal emphysema treatment.

Decrease of Airway Allergies After Lung Transplantation Is Associated With Reduced Basophils and Eosinophils.

BACKGROUND: Allergies are hypersensitive reactions of the immune system on antigen exposure similar to immune reactions after transplantation (Tx). Their activity can change after Tx. The lung as a transplantable organ is challenged two-fold, by antigens from the blood and the air environment. Herein we analyzed if airway allergies change after lung Tx. METHODS: We systematically reviewed patients' airway allergies before and after lung Tx between 1992 and 2014. The course of lymphocytes, thrombocytes, and leukocytes, among them neutrophils, eosinophils, and basophils, was analyzed in patients in whom airway allergies have changed and in whom they did not change. RESULTS: From 362 lung transplanted patients, 44 patients had suffered from allergies before Tx (12.2%). In 20 of these patients (45.5%), airway allergies disappeared completely within 1 year after lung Tx and were persistently absent thereafter. In these patients, basophils and eosinophils decreased significantly (P < .0012); in contrast, cells did not decrease in patients whose allergies did not disappear. Leukocytes overall, and in particular, neutrophils, decreased significantly in patients whose allergy disappeared (P < .014, P < .012, respectively). CONCLUSIONS: Airway allergies disappeared in almost half of cases after lung Tx. Along with this reduction, basophils and eosinophils decreased as potentially responsible cells for this phenomenon. These findings may stimulate intensified research on basophils and eosinophils as major drivers of airway allergies.

Exposure to moxifloxacin and cytomegalovirus replication is associated with skin squamous cell carcinoma development in lung transplant recipients.

BACKGROUND: Lung transplant recipients (LTR) are at increased risk for squamous cell carcinoma of the skin (SCC), but risk factors (RF) are incompletely understood. OBJECTIVE: To assess associations between exposure to certain medications and viral infections, and subsequent SCC development. METHODS: Retrospective study examining incidence and potential RF for SCC in LTR transplanted from 1992 to 2010 followed up at one centre. Cumulative incidence and Cox proportional hazards regression models were used to evaluate RF in the first year post-transplant for SCC formation during the follow-up. RESULTS: In 205 analysed LTR, 46 patients were diagnosed with SCC during a median follow-up of 4.9 years. The cumulative incidences of first SCC were 16.7% and 34.1%, for 5 and 10 years post-transplantation respectively. Multivariable analysis identified CMV replication (HR 7.69, 95% CI 2.93-20.2, P < 0.001) and moxifloxacin exposure (HR 2.35, 95% CI 1.15-4.81, P = 0.020) during the first year post-transplantation as independent RF for SCC development during follow-up. CONCLUSION: In our cohort, moxifloxacin use and CMV replication during the first year post-transplantation were associated with increased risk for SCC. These two factors could be indicators of over-immunosuppression. Their role in SCC development requires investigations in larger cohorts and prospective studies.

Psychomotor vigilance and visual field test performance.

INTRODUCTION: Visual field test is an invaluable tool to evaluate the detection and progression of glaucoma. On the other hand, as a subjective test, reliable results depend on patients' optimum performance including vigilance during the test. The purpose of this study was to understand patient's attitude and preferences about the visual field test taking, and in addition to assess the relationship between the reliability indices of visual field testing (VFT) and the Walter Reed Psychomotor Vigilance Test (PVT). MATERIAL AND METHODS: In this cross-sectional, non-interventional study, VFT reliability indices were recorded for all 140 patients. In the 46 patients who completed the PVT, average reaction time and minimum reaction times were recorded. All 140 patients completed a survey about their VFT experience. RESULTS: Based on the survey results, most subjects found VFT to be difficult. Subjects who rated their VFT performance excellent/good had similar VFT reliability rates compared to the ones with fair/poor self-assessments. The average reaction time (RT) was 0.6 seconds (0.3-1.9 seconds). Higher average RT was associated with increased age and less formal education (p < 0.001 and 0.03, respectively). There was a marginally significant correlation between average RT and the VFT "reliability" status (p = 0.045). CONCLUSIONS: While VFT is the least favorable part of the work-up for glaucoma patients, their self-assessment about VFT performance did not correlate with current VF reliability indicators. Although reliability of the VFT was not strongly affected by slower reaction times when tested by the PVT, the effect of psychomotor reaction time on other aspects of test outcomes is unknown and warrants further investigation.

Intensive pulmonary care after liver surgery: a retrospective survey from a single center.

BACKGROUND: Prevention from postoperative pulmonary complications (PPCs) has been an important topic. The aims of this study were to determine the risk factors for PPC after liver surgery and to analyze the efficacy of postoperative pulmonary care on PPC prevention. MATERIALS AND METHODS: We retrospectively analyzed variables of 81 patients who underwent hepatectomy and 4 transplantations between January 2007 and March 2012. RESULTS: Nineteen patients suffered PPCs (22.4%). Bivariate analysis identified four risk factors: preoperative anemia (odds ratio [OR] = 5.69), the American Society of Anesthesiologists (ASA) score of 3 or 4 (OR = 5.36), blood transfusion (OR = 2.81), and prolonged operative time (OR = 1.01). Upon multivariate analysis, only prolonged operative time was an independent risk factor for PPC (OR = 1.01). Pulmonary function test (PFT) was performed for 22 of 41 patients with an ASA score ≥ 2 (53.7%); there was no significant relationship between abnormal PFTs (n = 13) and the development of PPCs (P = .12). CONCLUSIONS: The elimination of risk factors may reduce the incidence of PPCs. Postoperative intensive pulmonary care should be given to all patients after liver surgery but particularly to patients with high ASA scores and those with abnormal PFTs irrespective of age.

Auricular cartilage repair using cryogel scaffolds loaded with BMP-7-expressing primary chondrocytes.

The loss of cartilage tissue due to trauma, tumour surgery or congenital defects, such as microtia and anotia, is one of the major concerns in head and neck surgery. Recently tissue-engineering approaches, including gene delivery, have been proposed for the regeneration of cartilage tissue. In this study, primary chondrocytes were genetically modified with plasmid-encoding bone morphogenetic protein-7 (BMP-7) via the commercially available non-viral Turbofect vector, with the aim of bringing ex vivo transfected chondrocytes to resynthesize BMP-7 in vitro as they would in vivo. Genetically modified cells were implanted into gelatin-oxidized dextran scaffolds and cartilage tissue formation was investigated in 15 × 15 mm auricular cartilage defects in vivo in 48 New Zealand (NZ) white rabbits for 4 months. The results were evaluated via histology and early gene expression. Early gene expression results indicated a strong effect of exogenous BMP-7 on matrix synthesis and chondrocyte growth. In addition, histological analysis results exhibited significantly better cartilage healing with BMP-7-modified (transfected) cells than in the non-modified (non-transfected) group and as well as the control.

Optic disc and visual test findings in patients with migraine.

This study was conducted to determine whether the optic disc appearance and the visual field parameters of patients with migraine vary from those of age-matched controls. Twenty-two patients with migraine and 20 control participants were enrolled in the study. The automated visual field tests by Humphrey Field Analyzer® and optic disc images by Topcon® fundus camera were obtained from each participant. Horizontal and vertical cup-to-disc ratios were calculated by a manual, planimetric technique performed by two independent observers. The visual field indices including mean deviation (MD) and pattern standard deviations (PSD) were documented. No difference was found in the average cup-to-disc ratio between patients with migraine and control participants. However, MD and PSD of the groups were different. The average MD in the migraine group was -0.86+1.21, and in the control group was 0.10+1.03 (p=0.009). The average PSD in the migraine group was 2.11+0.68 and in the control group was 1.68+0.44 (p=0.024). In conclusion, this study demonstrated that patients with migraine had decreased sensitivity in their visual fields compared to the control participants.

A model of chronic lung allograft rejection in the rat.

Bronchiolitis obliterans, the pathological hallmark of chronic pulmonary rejection, severely impacts long-term survival following lung transplantation. However, experimental reproduction of this pathophysiological phenomenon has not been achieved with contemporary in vivo models. Here, a model of chronic rejection is described, with sensitised recipients receiving unilateral orthotopic rat lung transplants. Lewis rats, sensitised with skin from brown Norway rats 7 days before receiving left lung transplants from donors that were Lewis x brown Norway F(1) hybrids, were analysed during day 21-84. The development of chronic rejection was modulated by a treatment with rapamycin and cyclosporin, and characterised histologically, immunohistochemically and by reverse transcriptase PCR. Characteristic histopathological changes leading to chronic rejection were induced over time by an initial treatment with cyclosporin in the presence of continuous rapamycin application. At day 84, fibrotic lesions replaced the respiratory epithelium within small bronchioles, with strong expression of smooth muscle alpha-actin and upregulation of mRNA for T-helper cell type-1 cytokines, smooth muscle alpha-actin, transforming growth factor-beta and CC chemokine ligand 5, but decreased forkhead box protein P3 gene expression. A reproducible and clinically relevant experimental set-up for progressive chronic rejection in rat pulmonary allografts is described. This model will permit better understanding of the pathological changes of small airways during the development of bronchiolitis obliterans, and may serve as an in vivo set-up for testing the efficacy of novel therapeutic interventions.

Thoracic outlet syndrome with right subclavian artery dilatation in a child - transaxillary resection of the pediatric cervical rib.

Cervical rib is a well-documented congenital anomaly, and thoracic outlet syndrome (TOS) with vascular compression is extremely rare in childhood. The subclavian artery, subclavian vein, brachial plexus, or a combination of these can be affected in this syndrome. We present a case of TOS in an eight-year-old boy and describe the rare finding of subclavian artery compression with post-stenotic dilatation and severe brachial plexus compression symptoms. The patient underwent right transaxillary resection of the first thoracic and cervical rib. The presentation is unique and may be elusive.

Ischemia/reperfusion injury: The role of CD26/dipeptidyl-peptidase-IV-inhibition in lung transplantation.

UNLABELLED: CD26/Dipeptidyl peptidase (DPP) IV is an integral membrane protein of lymphocytes that modulates the activities of chemokines, interleukins, and neuropeptides. We investigated the effect of enzymatic DPP IV inhibition on ischemia/reperfusion injury after extended ischemia prior to transplantation. MATERIALS AND METHODS: We used a syngeneic rat (Lewis) orthotopic left lung transplantation model. In the control group (group I), donor lungs were flushed and preserved in Perfadex for 18 hours at 4 degrees C, then transplanted and reperfused for 2 hours. Group II donor lungs were perfused with and stored in Perfadex +25mol/L AB192 (bis(4-acetamidophenyl) 1-(S)-prolylpyrrolidine-2(R,S)-phosphonate), a small molecular weight DPP IV inhibitor. After 2-hour reperfusion, we measured blood gas, peak airway pressure, and thiobarbituric acid reactive substances. RESULTS: Grafts from group II versus group I showed a significantly increased oxygenation capacity (II: 298.4 +/- 87.6 mm Hg vs 120.9 +/- 48.0, P < .01), lower peak airway pressure (11.8 +/- 0.9 mm Hg vs 16.0 +/- 1.4, P < .01), and less lipid peroxidation (9.3 +/- 2.0 micromol/L vs 13.8 +/- 1.8, P < .01). CONCLUSION: Inhibition of intragraft DPP IV enzymatic activity significantly reduced ischemia/reperfusion-associated pulmonary injury, allowing for successful transplantation after 18 hours of ischemia.

Normal gas exchange after 30-h ischemia and treatment with phosphodiesterase inhibitor PDI747.

OBJECTIVE: Phosphodiesterases (PDEs) negatively regulate the concentrations of cAMP and/or cGMP, which act as downstream second messengers to the prostaglandins. PDE type-4 (PDE4) is selective for cAMP and is found in high concentrations in endothelial, epithelial, and different blood cells. The aim of this study was to evaluate if PDI747, a novel selective inhibitor of PDE4, can restore pretransplant cAMP levels and thereby posttransplant organ function after prolonged cold ischemia. METHODS: Left lung transplantation was performed in pigs (25-31 kg). Donor lungs were flushed with low potassium dextran glucose (LPDG) solution only (control, n=5)or, in addition with 1 micromol of PDI747 (PDI747, n=5) and stored for 30 h at 1 degrees C. PDI747 animals further received a bolus of PDI747 (0.3 mg/kg) 15 min prior to reperfusion and a continuous infusion (0.3 mg/kg per hour) during the 5 h after reperfusion. After occlusion of the right pulmonary arteries and the right main bronchus, hemodynamic and gas exchange parameters and extravascular lung water (EVLW) levels of the transplanted lung were assessed. RESULTS: Two control animals died of severe lung edema leading to heart failure (control, n=3). One animal in the treatment group was excluded due to a patent ductus arteriosus (PDI747, n=4). Gas exchange at the end of the experiment was restored to normal levels in the PDI747 group (Pa, O(2) 47.6+/-11.2 kPa, Pa,CO(2) 6.4+/-1.8 kPa) but not in the control group (Pa, O(2) 7.7+/-2.9 kPa, Pa, CO(2) 11.9+/-3.0 kPa, P(PaO2)<0.0001, P(Pa, CO2)=0.06). Extravascular lung water (EVLW) was normal in the PDI747 group (8.5+/-1.1 ml/kg) and clearly elevated in the control group (16.2+/-5.6 ml/kg, P=0.007). Airway pressure in the PDI747 group was significantly lower than in the control group (7.8+/-0.5 cm H(2)O vs. 11.3+/-0.6 cm H(2)O, respectively, P<0.0001). The free radical mediated tissue injury measured by lipid peroxidation (TBARS) was significantly reduced (P=0.001) in the PDI747 group. CONCLUSIONS: With the inhibition of PDE4 with PDI747 we achieved normal gas exchange, no posttransplant lung edema, normal airway pressures, and a reduced free radical injury after 30 h of cold ischemia.

Trimetazidine protects the energy status after ischemia and reduces reperfusion injury in a rat single lung transplant model.

BACKGROUND: Ischemia-reperfusion injury involves free radical generation and polymorphonuclear neutrophil chemotaxis. Trimetazidine is an anti-ischemic drug that restores the ability of the ischemic cells to produce energy and reduces the generation of oxygen-derived free radicals. We evaluated the effect of trimetazidine against ischemia-reperfusion injury after lung transplantation. METHODS: Rat single lung transplantation was performed in 3 experimental groups (n = 5): (1) the immediate transplantation group was defined as animals undergoing transplantation immediately after harvest without treatment; (2) the ischemic control group was defined as animals undergoing transplantation after 18 hours of cold (4 degrees C) ischemia without treatment; and (3) the trimetazidine-treated group was defined as animals undergoing transplantation after 18 hours of cold (4 degrees C) ischemia and donor and recipient treatment with 5 mg/kg intravenous trimetazidine 10 minutes before harvest and reperfusion, respectively. All donor lungs were flushed with low-potassium dextran-glucose solution. After 2 hours of reperfusion, oxygenation was measured, and lung tissue was frozen and assessed for adenosine triphosphate content, myeloperoxidase activity, and thiobarbituric acid-reactive substances. Peak airway pressure was recorded throughout the reperfusion period. RESULTS: The trimetazidine group showed significantly higher levels of adenosine triphosphate content (1.73 +/- 0.8 pmol vs 0.72 +/- 0.2 pmol [ischemic control], P =.008), better oxygenation (238.82 +/- 113.9 mm Hg vs 89.39 +/- 14.7 mm Hg [ischemic control], P =.008), and reduced lipid peroxidation (1.28 +/- 0.1 nmol/g vs 2.09 +/- 0.4 nmol/g [ischemic control], P =.008). Adenosine triphosphate levels of the trimetazidine group were comparable with those of the immediate transplantation group (1.73 +/- 0.8 pmol vs 1.89 +/- 0.5 pmol, respectively; P =.31). Peak airway pressure and myeloperoxidase activity were comparable among groups. CONCLUSION: Donor and recipient treatment with trimetazidine provided a significant protection of the energy status, better oxygenation, and reduced lipid peroxidation in this experimental model. Our data suggest that trimetazidine may be an important adjunct to prolong ischemic time safely and to decrease lung ischemia-reperfusion injury.

Accelerated treatment for early and late postpneumonectomy empyema.

BACKGROUND: Postpneumonectomy empyema is a rare but serious complication of pneumonectomy. Despite use of various therapeutic approaches and techniques during the last five decades, successful therapy remains difficult and is often associated with high morbidity and prolonged hospitalization. METHODS: We evaluated a concept for accelerated treatment, which consists of radical debridement of the pleural cavity and packing with wet dressings of povidoneiodine. This was repeated in the operating theater every second day, until the chest cavity was macroscopically clean. If present, bronchial stump insufficiency was closed and secured by omentopexy. Finally, the pleural space was obliterated with antibiotic solution. RESULTS: Twenty patients, 13 with early postpneumonectomy empyema (10 to 89 days; mean, 37 days) and 7 with late postpneumonectomy empyema (124 to 7,200 days; mean, 1,126 days) were treated. Fifteen patients presented with bronchopleural fistula (11 right, 4 left), which developed after chemotherapy (n = 6) or after radiotherapy (n = 3) (unknown cause in 4 patients). Six patients were referred after previously unsuccessful surgical attempts. Pleural cultures were positive in 17 cases for one or several bacteria including fungoides (n = 2). The average number of interventions was 3.5 (3 to 5). The chest was definitively closed in all patients within 8 days. Mean hospitalization time was 17 days (7 to 35 days). During the same hospitalization, 2 patients needed reoperation because of an undetected bronchopleural fistula. Postpneumonectomy empyema was successfully treated in all patients. There was no in-hospital or 3-month postoperative mortality. CONCLUSIONS: Repeated surgical debridement combined with closure of bronchopleural fistula and antimicrobial therapy enables successful treatment of early and late postpneumonectomy empyema within a short period and is a well-tolerated concept.

Recipient treatment with trimetazidine improves graft function and protects energy status after lung transplantation.

BACKGROUND: Ischemia-reperfusion injury remains an important obstacle to successful lung transplantation. Trimetazidine is an anti-ischemic drug that restores the ability of ischemic cells to produce energy and reduces the generation of oxygen-derived free radicals. The aim of this study was to assess the protective effect of trimetazidine after prolonged ischemia in lung transplantation. METHODS: Rat single-lung transplantation was performed in 4 experimental groups (n = 5 each). In all groups, transplantation was performed after 18 hours of cold (4 degrees C) ischemia. All donor lungs were flushed with low-potassium dextran-glucose (LPDG) solution that also contained 500 microg/liter prostaglandin estradiol (E(1)). Groups studied included: Group I: flush solution was administered containing 10(-6) mol/liter trimetazidine (TMZ), neither donor nor recipient treatment given; Group II: donors were treated with 5 mg/kg intravenous TMZ 10 minutes prior to harvest, but the flush solution did not contain TMZ; Group III: recipients treated with 5 mg/kg intravenous TMZ 10 minutes before reperfusion, and flush solution contained 10(-6) mol/liter trimetazidine; Group IV: ischemic control group. After 2 hours of reperfusion, oxygenation was measured and lung tissue was frozen and assessed for adenosine triphosphate (ATP) content, myeloperoxidase (MPO) activity and thiobarbituric acid-reactive substances (TBARS). Peak airway pressure (PawP) was recorded throughout the reperfusion period. RESULTS: Group III showed significantly higher levels of ATP content (11.1 +/- 5.01 pmol vs Group I, 3.36 +/- 1.8 pmol, p = 0.008; vs Group II, 4.7 +/- 1.9 pmol, p = 0.03; vs Group IV, 0.7 +/- 0.2 pmol, p = 0.008), better oxygenation (442.5 +/- 26.5 mm Hg, vs Group I, 161.06 +/- 54.5 mm Hg; vs Group II, 266.02 +/- 76.9 mm Hg; vs Group IV, 89.4 +/- 14.7 mm Hg, p = 0.008) and reduced lipid peroxidation (TBARS) (0.15 +/- 0.03 nmol/g; vs Group I, 1.04 +/- 0.76 nmol/g; vs Group II, 0.69 +/- 0.4 nmol/g; vs Group IV, 2.29 +/- 0.4 nmol/g, p = 0.008). PawP and MPO activity were comparable in the 4 study groups. CONCLUSION: Recipient treatment with TMZ provided significant protection of energy status, better oxygenation and reduced lipid peroxidation. Our data suggest that TMZ may be an important adjunct in the prevention of post-transplant lung ischemia-reperfusion injury.

Thoracoscopic lobectomy for benign disease--a single centre study on 64 cases.

OBJECTIVE: Chronic lung infection is the main indication for lobectomy in benign pulmonary disease and may be technically demanding due to inflammatory changes such as adhesions, lymph node enlargement and neovascularization. The role of the thoracoscopic operation in these indications is yet ill-defined. METHODS: We retrospectively analyzed the results of patients who underwent thoracoscopic lobectomy (TL) between 1992 and June 1999 and compared this study group with patients who underwent open lobectomy (OL), all for benign disease. Data were not normally distributed, therefore, the median and range is given and nonparametric statistical analysis was applied. RESULTS: A total of 117 lobectomies for benign disease (64 TL) were analyzed. Indications included bronchiectasis (36 TL; 18 OL), chronic infections (13 TL; eight OL), tuberculosis (five TL; 15 OL), emphysema (five TL; one OL), AV-malformations (two TL; one OL), severe haemoptysis (four OL), and others (three TL; six OL). Twelve conversions to thoracotomy were necessary due to severe adhesions. One patient in the open lobectomy group died within 30 days postoperative. Drainage time was 5.0 (1-32) days in TL and 6.0 (3-21) days in OL, hospital stay was 8.5 (4-41) days and 10.0 (5-52) days, respectively. Blood loss was 0 (0-2000) ml in TL and 300 (0-6000) ml in OL. Operation time for thoracoscopic lobectomies significantly decreased from 2.5 (1-6) h for cases between 1992 and 1997 (n=49) to 1.5 (0.5-2.5) h for recent cases (n=15) (P<0.01). In addition, a trend towards less blood loss was noted (100 (0-2000) ml vs. 0 (0-400) ml; P=0.06). Drainage time and hospital stay did not differ significantly. CONCLUSIONS: Thoracoscopic lobectomy in chronic inflammatory disease can be performed safely in selected patients, especially with bronchiectasis. Conversion rate to thoracotomy is low. Operation time with this approach declined significantly over time.

Myoepithelioma of the lung.

A 54-year-old woman with myoepithelioma, a very rare tumor of the lung, is reported. The patient presented with exertional dyspnea, cough and intermittent pleuritic chest pain. Her chest X-ray revealed a peripheral 2 cm mass in the left lower lung zone. Bronchoscopy was normal. She underwent thoracotomy in which a wedge-resection was performed. Histological examination of the specimen demonstrated myoepithelioma of the lung.

Congenital broncho-esophageal fistula in the adult.

The case of a 62-year-old woman with a type II congenital broncho-esophageal fistula is presented. She had had recurrent pulmonary infections that were more prominent in the last 15 years. A barium swallow examination showed a communication between the esophagus and the right lower lobe. High resolution computed tomographic scan of the chest revealed right middle and lower lobe bronchiectasis. Bronchoscopy was unremarkable. At thoracotomy bronchoesophageal fistula was divided and the esophageal end was repaired in two layered fashion and reinforced by pediculed parietal pleural flap. Right middle and lower lobectomies were performed. Demonstration of the broncho-esophageal fistula and assessment of the status of the pulmonary parenchyma are important steps prior to surgery.