A Rare Case of Laparoscopic Repair of Simultaneously Occurring Morgagni and Paraesophageal Hernias.

Simultaneously occurring Morgagni hernia and paraesophageal hernia is an extremely rare clinical condition with only six case reports in the English-language literature and only two laparoscopic repair reports. We report a 73-year-old woman with both Morgagni hernia and paraesophageal hernia who underwent successful laparoscopic repair of the hernia defects using transabdominal wall suturing. The laparoscopic operation can provide excellent exposure and repair the hernia defect easily with minimal invasiveness and fewer complications. This case report reported the concurring Morgagni and paraesophageal hernias and validated the feasibility of laparoscopic repair both hernias simultaneously.

[Preliminary comparison research of thoracoscopy and thoracotomy lobectomy for clinical N0 and post-operatively pathological N2 non-small cell lung cancer].

OBJECTIVE: To evaluate the safty, thoroughness and efficacy of the video-assisted thoracoscopic surgery compared with open thoracotomy, in treatment of patients with the preoperative staging of lymph node negative and postoperative pathological mediastinal lymph node positive (cN0-pN2) locally advanced non-small cell lung cancer(NSCLC). METHODS: We performed a retrospective review of 616 patients who underwent either VATS lobectomy or open thoracotomy from July 2000 to December 2009. Of which 386 patients were diagnosed with preoperative staging of lymph node negative(cN0) non-small cell lung cancer. Of the 386 patients 76 were diagnosed with postoperative pathological mediastinal lymph node positive (pN2). Twenty-nine patients were operated by video-assisted thoracoscopic surgery (VATS group), 47 patients were operated by open thoracotomy(T group).The patients' preoperative and intraoperative conditions, postoperative survival and recurrence, etc. were compared. RESULTS: The two groups were similar in age, gender distribution, pulmonary function, preoperative complications and the preoperative clinical stage. VATS group was slightly lower than T group in operation time, and blood loss. The station number of mediastinal lymph nodes dissection was (3.3±1.1) vs. (3.3±1.3), P=0.959; the number of lymph nodes dissected (12.7±8.9) vs. (10.5±7.2),P=0.260; positive lymph nodes / lymph nodes dissection 28.7% vs. 32.5%, P=0.592; the postoperative proportion of single-station N2 55.2% vs. 66.0%(P=0.189) in VATS group and T group, respectively. One, three-year disease-free survival rates after operation in VATS and T group were 82.6% vs.69.2%(P=0.088) and 49.3% vs. 51.3% respectively(P=0.996); one, three-year overall survival rates were 84.9% vs. 71.2%(P=0.149) and 64.0% vs. 42.7% (P=0.121). Both groups had the similar pattern of recurrence, most of which were distant metastases. CONCLUSION: With respect to the safety,thoroughness and recent effect, VATS is not inferior to open thoracotomy in the treatment of cN0-pN2 non-small cell lung cancer.

[Establishment of a mathematical prediction model to evaluate the probability of malignancy or benign in patients with solitary pulmonary nodules].

OBJECTIVE: To evaluate the clinical factors affecting the definite pathological diagnosis of solitary pulmonary nodules (SPN) with multivariate Logistic regression analysis, and to build the clinical prediction model to estimate the probability of malignancy. METHODS: A retrospective cohort study in our institution included 371 patients (197 males and 174 females) with definite pathological diagnosis of solitary pulmonary nodules from Jan 2000 to Sep 2009 (group A). Clinical data included age, gender, course of disease, symptoms, history and quantity of smoking history, history of tumor, family history of tumor, site, diameter, calcification, speculation, border, lobulation, traction of pleural, vascular convergence sign, and cavity. The independent predictors of malignancy were estimated with multivariate analysis, then the clinical prediction model was built. Other 62 SPN patients (group B) with definite pathological diagnosis in our institute from Oct 2009 to Mar 2010, were used to validate value of this clinical prediction model. RESULTS: 53.1% of the nodules were malignant, and 46.9% were benign in goup A. Logistic regression analysis showed that seven clinical characteristics [age of patient (OR: 1.073), diameter (OR: 1.966), border (OR: 0.245), calcification (OR: 0.199), spiculation (OR: 2.088) and the family history of tumor (OR: 3.550)] were independent predictors of malignancy in patients with SPN (P<0.05). The cut-off value was 0.463. The sensitivity in group B was 92.5%, specificity 81.8%, positive predictive value 90.2%, and negative predictive value 85.7%. The area under the ROC curve for our model was 0.888±0.054. CONCLUSION: Age of patient, diameter, border, calcification, spiculation and the family history of tumor are independent predictors of malignancy in patients with SPN. Our prediction model is accurate and sufficient to estimate the malignancy of patients with SPN.

Comparison of the autofluorescence bronchoscope and the white light bronchoscope in airway examination.

BACKGROUND AND OBJECTIVE: The sensitivity and accuracy of white light bronchoscopy (WLB) in airway examination are low. Autofluorescence bronchoscope (AFB) can determine early lesions in bronchial mucosa more sensitively, but it has seldom performed in China. To assess the clinical value of the AFB in airway examination, we compared the sensitivity and specificity of the AFB and WLB in detecting cancer of the airway mucosa. METHODS: Between September 2009 and May 2010, bronchoscope examinations using both the AFB and WLB were performed on 136 patients, 95 men and 41 women with a median age of 61.5 years (ranged from 25 to 84 years). There were 46 lesions located in the central airway, 84 in the peripheral lung parenchyma, and 6 in the mediastinal region. All patients received local and general anesthesia and were subsequently examined with the WLB and AFB in tandem. All procedures were completed safely. Abnormal visual findings were recorded, and biopsies of the affected regions were collected for pathologic examination. RESULTS: Of 241 regions sampled for biopsy, 76 sites contained malignant lesions, whereas 165 sites contained benign lesions. The AFB detected 72 of the 76 malignant lesions, but the WLB detected only 50. The sensitivities of the AFB and WLB were 94.7% and 65.8%, respectively, and the specificities were 57.0% and 83.6%, respectively. The negative predictive values of the AFB and WLB were 95.9% and 84.1%, respectively. CONCLUSIONS: The AFB is more sensitive than the WLB in detecting cancerous lesions in the mucosa, and is an effective airway examination.

[Tumor growth inhibition of paclitaxel-octreotide conjugates on human non small cell lung cancer: experiment with mice].

OBJECTIVE: To evaluate the antitumor effects of the conjugates synthesized by coupling cytotoxic paclitaxel (PTX) to somatostatin analog octreotide (OCT) on human non small cell lung cancer (NSCLC). METHODS: Two cytotoxic somatostatin analog, PTX-OCT and 2PTX-OCT, were developed in which PTX was linked to octreotide. Forty-five BALB/c nu/nu nude mice were injected with human NSCLC cells of the line A549 into the right armpit. The nude mice that were xenografted were randomly divided into 8 groups. (1) control group (n = 6), (2) PTX-OCT group (n = 5), injected intravenously with PTC-OCT 150 nmol/kg on days 1, 7, and 21, (3) 2PTX-OCT group (n = 6), injected intravenously with PTC-OCT 150 nmol/kg, (4) OP group (n = 6), injected with mixture of PTX and OCT 150 nmol/kg, (5) OCT group (n = 5) injected with OCT 150 nmol/kg (6) PTX group (n = 6), injected with PTX 150 nmol/kg, (7) 2PTX group, injected with PTX 300 nmol/kg, and (8) 2(PTX-OCT) injected with PTX-OCT 300 nmol/kg, The tumor volume and body weight (BW) were observed regularly. The tumor volume doubling time was calculated. White blood cells were counted by collecting peripheral blood sample. By the end of experiment the mice were killed with the tumors taken out. The expression of mRNA of subtypes1-5 of human somatostatin receptor (SSTR1-SSTR5) were investigated using RT-PCR. Histological apoptosis was detected by DNA ladder. Immunohistochemistry was used to examine the SSTR2 and SSTR5 expression and tumor microvessel density (MVD). RESULTS: The tumor volumes of 2PTX-OCT and 2(2PTX-OCT) groups were significantly smaller than those of other groups (all P < 0.01). The tumor doubling times of the 2PTX-OCT and 2 (2PTX-OCT) groups were significantly longer than those of the other groups too (all P < 0.01). The MVD levels of the 2PTX-OCT and 2 (2PTX-OCT) groups were significant lower than those of the other groups (all P < 0.01). The toxicity of the PTX group was more obvious. The WBC count levels of the PTX and 2PTX groups were significantly lower than those of the other groups (all P < 0.05). mRNA expression could be found for SSTR1, 2, 4, and 5 in the A549 xenografts. Immunohistochemistry showed that SSTR2 was mainly found in the tumor cell membrane, and SSTR5 was found in the tumor cell membrane and cytoplasm. More histological apoptosis bands were shown by DNA ladder method in the 2PTX-OCT and 2 (PTX-OCT) groups. CONCLUSION: The targeting conjugate 2PTX-OCT inhibits the proliferation of tumor cells, reduces microvessel, and decreases the toxicity in comparison with the cytotoxic radical PTX.

[Clinical analysis of thoracoscopic lobectomy: a report of 40 cases].

OBJECTIVE: To review the technology of completely thoracoscopic lobectomy procedures. METHODS: From September 2006 to July 2007, 40 patients (23 male and 17 female) underwent completely thoracoscopic lobectomy. The median age was 59.5-years-old, with a range from 24 to 79-years-old. The lobectomy was completed through 3 incision in the 5th, 8th and 7th intercostal space. The procedures were similar with conventional open lobectomy. RESULTS: All procedure were carried out safely, including lung cancer (n = 34), lymphoma(n = 1), pulmonary cyst (n = 1), middle lobe syndrome (n = 1) , bronchiectasis (n = 2) and renal carcinoma metastasis to lung (n = 1). There were no operative mortality or serious complications. There was one patient opposed to open thoracotomy because of the mediastinal lymph nodes metastasis. The average surgical duration was 206 min (range from 60 to 300 min). The average blood loss was 221 ml (range from 100 to 400 ml) with no blood transfusion required. The average length of stay was 8.9 d. No recurrence and metastasis was observed in a follow-up range from 1 to 10 months except one patient with adenocarcinoma occurred metastasis of tumor 3 months postoperation. CONCLUSION: The completely thoracoscopic lobectomy is a safe and feasible surgical procedure compared with conventional open lobectomy for selected patients.

[Value of mediastinoscopy in the diagnosis of stage I thoracic sarcoidosis].

OBJECTIVE: To determine the current role of mediastinoscopy in the diagnosis and differential diagnosis of stage I thoracic sarcoidosis. METHODS: The clinical data of 60 patients with a presumptive diagnosis of stage I thoracic sarcoidosis underwent mediastinoscopy from November 1999 to June 2007 were analyzed retrospectively. All the patients had hilum of lung and/or mediastinal lymphadenopathy with normal lung parenchyma on thoracic CT scan. Typical stage I sarcoidosis was defined as presence of bilateral hilum of lung lymphadenopathy with/without mediastinal lymphadenopathy. RESULTS: All the patients had definitive pathologic diagnosis. Among the 33 patients with typical presentation of stage I sarcoidosis, 32 patients were confirmed by pathology. One patient was reactive lymph node. Among the 27 patients with atypical patterns on CT, 17 patients were confirmed by pathology. No postoperative complication and mortality occurred. CONCLUSION: For the patient with a presumptive diagnosis of typical stage I thoracic sarcoidosis after clinical and radiological evaluation, confirmation of the diagnosis by mediastinoscopy and lymph node biopsy is unwarranted.

T3/T4 thoracic sympathictomy and compensatory sweating in treatment of palmar hyperhidrosis.

BACKGROUND: Compensatory sweating (CS) is one of the most common postoperative complications after thoracic sympathectomy, sympathicotomy or endoscopic sympathetic block (ESB) for palmar hyperhidrosis. This study was conducted to examine the relevance between CS and the sympathetic segment being transected in the surgical treatment of palmar hyperhidrosis, and thus to detect the potential mechanism of the occurrence of CS. METHODS: Between October 2004 and June 2006, 163 patients with primary hyperhidrosis were randomly divided into two groups, T(3) sympathicotomy (78 patients) and T(4) sympathicotomy (85), who were operated upon under general anesthesia via single lumen intubation and intercostal video-mediastinoscopy (VM). RESULTS: No morbidity or mortality occurred. Palmar hyperhidrosis was cured in all patients. Follow-up (mean (13.8 +/- 6.2) months) showed no recurrence of palmar hyperhidrosis. The difference of rates of mild CS in groups T(3) and T(4) was of no statistical significance. The rate of moderate CS was significantly lower in group T(4) than in group T(3). No severe CS occurred. CONCLUSION: The rates of occurrence and severity of CS are lowered with the lower sympathetic chain being transected.

[A comparison of T3 sympathectomy versus T4 sympathectomy in the treatment of primary palmer hyperhidrosis].

OBJECTIVE: To evaluate the effect and side effect of T(3) versus T(4) sympathectomy in the surgical management of primary palmar hyperhidrosis through prospective multi-center randomized controlled trial. METHODS: From Sep 2004 to Feb 2006, 106 consecutive patients (49 males and 54 females) with primary palmar hyperhidrosis were enrolled in the study and randomly assigned into T(3) or T(4) level sympathectomy groups. 66 patients received T(3) sympathetic chain transection and 37 patients received T(4) sympathetic chain transection. The two groups were comparable in all other parameters. RESULTS: All procedures were carried out successfully without severe morbidity or mortality. After a mean follow-up period of 8.6 months, both groups remained satisfactory in palmar sweating control. The T(4) group had more moisture hands compared with the T(3) branch (54.1% vs 15.2%, P < 0.01), but this didn't compromise the patients' satisfactory. The patients in T(4) group showed significantly less dry hand problems than the patients in the T(3) group (5.4% vs. 25.8%, P < 0.05), and so did compensatory sweating (21.6% vs. 45.6%, P < 0.05). CONCLUSION: The procedure of T(3) or T(4) sympathectomy, both transecting the sympathetic chain in one single position in relatively lower segment, are comparatively effective in the treatment of primary palmar hyperhidrosis, but T(4) sympathectomy shows less side effect.

[The value of mediastinoscopy in the diagnosis of thoracic sarcoidosis].

OBJECTIVE: To evaluate the role of mediastinoscopy in the diagnosis of thoracic sarcoidosis. METHODS: This study was retrospective. Mediastinoscopy was performed in a total of 30 patients who had enlarged mediastinal lymph nodes on chest CT and were clinically suspected of having sarcoidosis from November 1999 to June 2004. Biopsy tissues from peritracheal, retrosternal, subcarinal, or bilateral hilar regions were obtained for pathological study. RESULTS: All the patients had a definitive pathologic diagnosis, consisting of 24 cases of stage I and 6 stage II thoracic sarcoidosis. The diagnostic consistency between preoperation and postoperation was 40% (12/30), and the misdiagnosis rate preoperation was 60% (18/30). In this series, the initial diagnosis had been malignancy in 17 cases (57%), of whom 3 had received chemotherapy at local hospitals. The overall incidences of postoperative complication and mortality were 0. CONCLUSION: Our experience showed that mediastinoscopy is a valuable procedure which helps confirm the diagnosis of mediastinal disease. Given its safety and efficacy, it should be considered in the diagnosis and differential diagnosis of thoracic sarcoidosis of stage I or II.

[Craniofacial hyperhidrosis treated by video-assisted thoracoscopic sympathectomy].

OBJECTIVE: To investigate the feasibility, safety and prospect application value of video-assisted thoracoscopic sympathectomy utilized in the treatment of craniofacial hyperhidrosis. METHODS: Eighteen patients with craniofacial hyperhidrosis underwent sympathectomy from January 2003 to December 2004, including 10 cases combined with palmar hyperhidrosis. There were 17 males and 1 females with a mean age of 36.5 years (ranges, 25-42). Sympathetic chain was transected just below the stellate ganglion in pure craniofacial hyperhidrosis. Additional T(3) sympathectomy was performed in those patients combined with palmar hyperhidrosis. RESULTS: There were no surgical complication or surgical mortality cases. Seventeen patients achieved improvement of craniofacial hyperhidrosis without recurrent symptoms, but one had partial remission due to thoracic adhesion and false location of the ganglions. The effective rate was 97% (35/36). No recurrent symptoms occurred after a mean of 8.3 months of follow-up. No relapse occurred. Fifteen patients (83%) developed compensatory sweating of the trunk and lower limbs. Six patients (33%) presented palmar dry (severe hypohidrosis) and they all can tolerate the condition. All patients were satisfied with the outcomes of their operations. CONCLUSION: The initial results show that thoracoscopic sympathectomy is a safe and effective method for the treatment of craniofacial hyperhidrosis.

[Hardship of development of mini-invasive surgery: the hard history of sympathectomy].

The authors review the history of sympathectomy in the past more than fifty years and divide the whole course into four stages: thoracotomy, attempting toward mini-invasion, conventional thoracoscopy and video-assisted thoracoscopy (VATS). Emphasis is laid on the difficult course of how this procedure has developed step by step from its original embarrassed 'large incision, small surgery' status to the modern mini-invasion surgery. The fact has proved that it is the modern natural science particularly the development and utilization of modern instruments that has notably promoted, and will continuously promote, the whole surgery toward mini-invasion.

[Video-assisted thoracoscopic left sympathectomy for the treatment of congenital long QT syndrome].

OBJECTIVE: To assess the feasibility, safety and effectiveness of video-assisted thoracoscopic sympathectomy (VATS) for the treatment of congenital long QT syndrome. METHODS: Under general anaesthesia, pleural cavity was entered via two or three small incisions in the left intercostal space. The left thoracic sympathetic chain was identified and resected from T2 approximately T5. The lower one at the third of the left stellate ganglion was also resected. RESULTS: VATS resulted in a significant shortening in corrected QT intervals in three patients. The average QT interval of the four patients was 537.5 ms before VATS and 512.5 ms after VATS. The heart rate of the patients remained unchanged. There were no major peri-operative complications apart from mild ptosis of the left upper eyelid in one patient who recovered in the following days. The syndrome recurred in one patient in syncopal events in four months after VATS. CONCLUSION: VATS is a safe as well as an effective technique for the treatment of congenital long QT syndromes.