Video-thoracoscopic enucleation of esophageal leiomyoma.

BACKGROUND: Leiomyoma is the most common benign tumor of the esophagus. Surgical enucleation is indicated in case of symptoms or an unclear diagnosis, and open thoracotomy has long been the standard approach for this procedure. However, enucleation through video assisted thoracoscopic surgery (VATS) has been developed as a preferred approach for most lesions in recent years. METHOD: Herein we report our twelve patients (seven men and five women, with median age of 42 years) from 2001 to 2009, who underwent enucleation through VATS for esophageal leiomyomas, with a size from 1 to 8 cm in diameter (median: 5), and at different locations, from the thoracic outlet to near the diaphragmatic level of the thoracic esophagus. Intraoperative fiberoptic esophagoscopy was performed in two patients for localization by illumination. A right-sided approach was performed in eight cases (upper two thirds of esophagus) and the left-sided in another four cases (lower third of esophagus). RESULT: The median operative time was 95 minutes (70 to 230 minutes). Four of them required small utility incisions (4-6 cm) for better exploration and manipulation. There were no major complications, such as death or empyema due to leaks from mucosal tears, and the presenting symptoms were improved during the follow-up period, from 12 to 98 months. CONCLUSION: VATS can be considered as an initial approach for most patients with esophageal leiomyomas, even large in size, irregular in shape, or at unfavorable location. It is a safe, minimally invasive, and effective treatment. However, conversion to open thoracotomy should be required for the sake of clinical or technical concern.

Video-assisted thoracoscopic surgery in the treatment of patients with bullous emphysema.

PURPOSE: Surgical operation for bullous emphysema is indicated for patients with symptoms related to the compression of giant bullae (usually >30% of hemithorax) or other related complications, such as infection, rupture, or bleeding. Video-assisted thoracoscopic surgery (VATS) has been widely applied in the diagnosis and treatment of patients with intrathoracic diseases, including bullous emphysema. MATERIALS AND METHODS: We retrospectively reviewed nine patients with symptomatic or complicated bullous emphysema, who were treated by bullectomy using VATS in the past two years. Eight males and one female were included, with ages ranging from 39 to 82 (median 62) years. Eight (89%) were heavy smokers. Pulmonary function tests were performed preoperatively in only three patients because of their compromised condition on admission. RESULTS: Bullae resection and pleurodesis was performed using VATS in the eight patients. The operating time ranged from 35 to 75 (median 50) minutes. Two patients had minor postoperative complications (one prolonged air leak for more than seven days and one wound infection), which recovered with conservative treatment. The chest tube was successfully removed 5-14 days postoperatively. Either symptomatic relief or improved pulmonary function was noted in these patients postoperatively. One patient complained of intermittent dyspnea during follow-up, but the imaging study was essentially normal. CONCLUSION: Bullectomy for patients with bullous emphysema can be performed safely and effectively using VATS. Additional pleurodesis or suturing reinforcement can prevent the complication of air leak.

Review: Diagnosis and treatment of primary spontaneous pneumothorax.

Primary spontaneous pneumothorax (PSP) commonly occurs in tall, thin, adolescent men. Though the pathogenesis of PSP has been gradually uncovered, there is still a lack of consensus in the diagnostic approach and treatment strategies for this disorder. Herein, the literature is reviewed concerning mechanisms and personal clinical experience with PSP. The chest computed tomography (CT) has been more commonly used than before to help understand the pathogenesis of PSP and plan further management strategies. The development of video-assisted thoracoscopic surgery (VATS) has changed the profiles of management strategies of PSP due to its minimal invasiveness and high effectiveness for patients with these diseases.

Metastasis of gastric carcinoma to the thyroid and lung: a case report and review of literature.

Cancer metastasis to the thyroid is extremely rare. The more commonly reported primary sites for metastasis to the thyroid are the kidney, breast, lung, colon, esophagus, and uterus. Thyroid metastasis from the stomach has only been reported in three cases. Herein, we report a 71-year-old man presenting with bilateral thyroid multinodular lesions. Bilateral near-total thyroidectomy was performed due to airway compression with related symptoms. Wedge resection of a suspicious pulmonary nodule, detected on CT, was performed for diagnosis. Polypoid lesions in the stomach were examined by trans-scopic biopsy. Poorly differentiated adenocarcinomas with the same histological profiles were noted at these three sites. The immunohistochemical staining for thyroglobulin of these specimens was negative. We conclude that a new thyroid mass appearing in a patient with present or prior malignancies should raise the concern of metastatic disease.

Second primary lung carcinoma in patients with first primary breast carcinoma: two case reports and review of the literature.

INTRODUCTION: Patients undergoing complete treatments of breast carcinoma can be found with pulmonary nodules during the follow up period. Either metastasis from breast carcinoma or second primary bronchogenic carcinoma should be considered as a possible diagnosis. CASE PRESENTATIONS: Two female patients with ages of 66 and 64, underwent modified radical mastectomy for breast carcinoma 5 and 2 years ago, were found with single pulmonary nodule, 1.0 cm and 0.8 cm from the left lower and right upper lobe. There was no other site of metastasis being noted after systemic survey. Wedge resections through video assisted thoracic surgery were performed and one of them underwent lobectomy and mediastinal lymph node dissection after the primary lung carcinoma being proved pathologically (thyroid transcription factor 1 and cytokeratin 7 positive). The dissected lymph node in this patient is negative for malignancy. They underwent low dose chemotherapy postoperatively because of increased risk of tumor occurrence for these patients. Patients with smoking or irradiation history usually favor the diagnosis of second primary lung carcinoma. However, these two treated breast carcinoma cases, which didn't have smoking or irradiation history, developed second primary lung carcinomas. It is relatively rare reported before. CONCLUSIONS: Pulmonary nodules in patients with prior breast carcinomas were usually regarded as metastatic lesions. However, the possibility of second primary still cannot be excluded, especially to the solitary type. Video assisted thoracic surgery can provide early and accurate diagnosis as well as effective treatment.

Video-assisted thoracoscopic surgery (VATS) for the treatment of hepatic hydrothorax: report of twelve cases.

BACKGROUND: Hepatic hydrothorax is defined as a significant pleural effusion in patients with liver cirrhosis and without underlying cardiopulmonary diseases. Treatment of hepatic hydrothorax remains a challenge at present. METHODS: Herein we share our experiences in the treatment of 12 patients with hepatic hydrothorax by video-assisted thoracoscopic surgery (VATS). Repair of the diaphragmatic defects, or pleurodesis by focal pleurectomy, talc spray, mechanical abrasion, electro-cauterization or injection was administered intraoperatively, and tetracycline intrapleural injection was used postoperatively for patients with prolonged (>7 d) high-output (>300 ml/d) pleural effusion. RESULTS: Out of the 12 patients, 8 (67%) had uneventful postoperative course and did not require tube for drainage more than 3 months after discharge. In 4 (33%) patients the pleural effusion still recurred after discharge due to end-stage cirrhosis with massive ascites. CONCLUSION: We conclude that the repair of the diaphragmatic defect and pleurodesis through VATS could be an alternative of transjugular intrahepatic portal systemic shunt (TIPS) or a bridge to liver transplantation for patients with refractory hepatic hydrothorax. Pleurodesis with electrocauterization can be an alternative therapy if talc is unavailable.

Value of video-assisted thoracoscopic surgery in the diagnosis and treatment of pulmonary tuberculoma: 53 cases analysis and review of literature.

Tuberculoma of the lung is one of manifestations in tuberculosis and usually presents as a solitary pulmonary nodule (SPN). It is difficult to differentiate tuberculoma from SPN by other benign or malignant diseases. At present, the crucial role of video-assisted thoracoscopic surgery (VATS) in diagnosis and treatment of pulmonary diseases has been well acknowledged. Here, we reported 53 patients undergoing VATS resection for tuberculomas in our series. No postoperative mortality was found and only two patients experienced prolonged air-leakage (>7 d) and two had minor wound infections that were recovered after anti-tuberculosis or antibiotic treatment. Anti-tuberculosis chemotherapy from 6 to 12 months was routinely used postoperatively. We conclude that VATS is a satisfactory tool for the diagnosis and treatment of tuberculoma and can also establish a reliable diagnosis for all patients with SPNs.

Chest wall abscess due to Prevotella bivia.

Prevotella bivia is associated with pelvic inflammatory disease. A 77-year-old man developed a rapidly growing chest wall abscess due to P. bivia within days. He underwent surgical resection of the infected area; his postoperative course was uneventful. This is the first case of chest wall abscess due to P. bivia infection. Its correct diagnosis cannot be underestimated because fulminant infections can occur in aged or immunocompromised patients if treated incorrectly. Prompt, appropriate surgical management, and antibiotic therapy affect treatment outcome.

Double primary bronchogenic carcinoma of the lung and papillary thyroid carcinoma: a case report.

INTRODUCTION: Double primary bronchogenic carcinoma and papillary carcinoma of the thyroid are extremely rare. We describe the case of a patient who underwent surgical resection for these two cancers. CASE PRESENTATION: A 56-year-old man presented to our hospital complaining of a cough with blood-tinged sputum. A slowly growing mass in the left lobe of the lung had been noted for about 1 year. He underwent video-assisted thoracic surgery of the left lower lobe and mediastinal lymph node dissection through an 8 cm utility incision. Pathology revealed a well-differentiated adenocarcinoma and the dissected lymph nodes were negative for malignancy. He also complained of a mass in his neck, which had grown slowly for over 5 years. A computed tomography scan of the neck revealed a left thyroid mass compressing the trachea towards the right side. There was no cervical lymphadenopathy. A left thyroid lobectomy was performed and pathology revealed a papillary carcinoma. Thus, he underwent a second operation to remove the right lobe of the thyroid. He underwent subsequent adjuvant chemotherapy. CONCLUSION: In a review of the literature, it appears that there has only been one previously reported case of these two cancers, which was in Japan. The relationship between these two cancers is still unclear, and more case reports are required to determine this relationship.

Physician and nurse job climates in hospital-based emergency departments in Taiwan: management and implications.

This study evaluates how emergency physicians and nurses perceive their job climates in their hospital-based emergency departments (ED). In total, 208 emergency physicians and 234 emergency nurses were surveyed, applying a validated survey instrument covering the job facets of medical and nursing autonomy, professional accomplishments and outcomes, leadership, communication, management, hospital policies and regulations, and external health policy environments germane to emergency medicine. The findings reveal that the average satisfaction score for professional growth and accomplishments was ranked highest by emergency physicians, and job communication within EDs was ranked highest by emergency nurses. Several emergency medical professional characteristics, including age, education, medical authority, employment duration, full-time or part-time statuses, perceived workloads, and hospital accreditation levels, were all related to job satisfaction in this surveyed population. New insights generated from this study could provide increased guidance to hospital and ED unit managers toward enhancing wellness and limiting dissatisfaction and disharmony relative to long-term career survival and the well-being of ED specialists.

Complicated parapneumonic effusion and empyema: pleural decortication and video-assisted thoracic surgery.

Complicated parapneumonic effusion or empyema, in which the fluid becomes more exudative, develops in 10% to 20% of patients with parapneumonic effusions. Early diagnosis and effective treatment strategies are required. New treatment strategies such as fibrinolytic therapy and decortication or debridement through video-assisted thoracoscopic surgery, have changed the choice of treatment for different stages of empyema or complicated pleural effusion. This review discusses the definition, clinical presentations, diagnosis, and treatment of these conditions, focusing on the value and comparison of video-assisted thoracoscopic surgery decortication and fibrinolytic therapies.

Video-assisted thoracoscopic surgery (VATS) for bilateral primary spontaneous pneumothorax.

OBJECTIVE: To review our experience of the treatment of bilateral primary spontaneous pneumothorax (PSP) by video-assisted thoracoscopic surgery (VATS). MATERIALS AND METHODS: Retrospective chart review was followed by an on-clinic or telephone interview. Patients were cared for by one thoracic surgeon in four medical centers or community hospitals in Northern and Central Taiwan. Thirteen patients with bilateral PSP underwent bilateral VATS simultaneously or sequentially from July 1994 to December 2005. RESULTS: Twelve males and one female, with age ranging from 15 to 36 years (mean 23.1 years), were treated with VATS for bilateral PSP, under the indications of bilateral pneumothoracis simultaneously (n=4) or sequentially (n=9). The interval between the first and second contra-lateral VATS procedure for non-simultaneous PSP patients ranged from 7 d to 6 years. Eleven of 13 patients (84.6%) had prominent pulmonary bullae/blebs, and underwent bullae resection with mechanical or chemical pleurodesis. The mean operative time was (45.6+/-18.3) min (range 25 approximately 96 min) and (120.6+/-28.7) min (range 84 approximately 166 min) respectively for the non-simultaneous (second VATS for the recurrence of contralateral side after first VATS) and simultaneous (bilateral VATS in one operation) procedures. There was no postoperative mortality. However, prolonged air leakage (>7 d) occurred in one patient (7.7%) who recovered after conservative treatment. The mean duration of chest tube drainage was 3.1 d and the median follow up period was 3.4 years. CONCLUSIONS: VATS is a safe and effective procedure in the treatment of bilateral PSP. Bilateral VATS is only recommended for patients with simultaneously bilateral PSP, because the incidence of recurrence, even with visible bullae, was not so high in my group and in some previous literature. Bilateral VATS in a supine position should only be used in selective cases, because of possible pleural adhesion or hidden bullae on the posterior side.

Primary leiomyosarcoma of the nipple-areola complex: report of a case and review of literature.

Primary leiomyosarcoma of the nipple-areola complex is extremely rare. Less than ten such cases have been reported in English literature so far. Herein we describe a 52-year-old female presenting with a 1.5 cmx1.1 cmx0.7 cm nodular lesion over her left nipple, and leiomyosarcoma was proved by pathological examination of the excised specimen. Positron emitted tomogram (PET) revealed no abnormal signal other than the primary site. Microscopically, this poorly circumscribed tumor was composed of interlacing bundles of smooth muscle cells with bizarre and pleomorphic nuclei, as well as prominent nucleoli. Its mitotic count was up to 7 mitoses per 10 high power fields (HPF). Immunohistochemical study of tumor cells revealed positive stain for alpha-smooth muscle actin and vimentin; and negative for cytokeratin, CD34 and S-100. Left simple mastectomy was undertaken and no residual mass lesion was noted on the resected specimen. Related literatures about the diagnosis and treatment for breast leiomyosarcoma will be presented here.

Breast metastasis from small cell lung carcinoma.

Breast metastases from extramammary neoplasms are very rare. We presented a 66 year-old female with metastasis of small cell lung carcinoma to the breast. She presented with consolidation over the left upper lobe of her lung undetermined after endobronchial or video-assisted thoracoscopic surgery (VATS) biopsy, and this was treated effectively after antibiotic therapy at initial stage. The left breast lumps were noted 4 months later, and she underwent a modified radical mastectomy under the impression of primary breast carcinoma. However, the subsequent chest imaging revealed re-growing mass over the left mediastinum and hilum, and cells with the same morphological and staining features were found from specimens of transbronchial brushing and biopsy. An accurate diagnosis to distinguish a primary breast carcinoma from metastatic one is very important because the therapeutic planning and the outcome between them are different.

A study on the personal traits and knowledge base of Taiwanese medical students following problem-based learning instructions.

INTRODUCTION: Problem-based learning (PBL), a pedagogic concept using a student-centred approach and problem-solving through small group discussions, has been adopted in varying degrees for years at all 11 medical institutes in Taiwan. Much evidence has shown that a number of factors can seriously affect student performance in PBL courses, such as the design of PBL scenarios, the tutors' character and students' attitudes and efforts. MATERIALS AND METHODS: The aim of this study was to examine how the personal characters or knowledge base of Taiwanese medical students influence their performance in a hybrid-PBL curriculum. A total of 309 (234 male, 75 female) high-school entry undergraduate medical students participated in this survey. Self-assessed personal traits were presented in a 44-item questionnaire with a Big Five factor structure. Knowledge base was assessed by students' score point average (SPA) based on their previous 4-year education in medical school. Peer-assessed performance of students in the PBL curriculum was carried out using a well-developed, reliable and validated evaluation form. RESULTS: Each student's peer-evaluated PBL performance can be divided into 5 principal components, which included control-lead, assist-coordinate, written organisation and compromise- comply (Eigen value >1). The consistency and reliability of the Big Five questionnaire on personal traits was analysed and discordant items were deleted (Cronbach's alpha = 0.72 to 0.86 after deletion). The relationship between the personal traits, knowledge base and PBL performance, as analysed by simple regression, showed that "extraversion" and "openness to experience" were positively related to the "assist-coordinate" characteristic in PBL performance, and "conscientiousness" was positively related to the "control-lead" characteristic in PBL performance. The SPA was positively related to the "assist-coordinate" or "control-lead" characteristic in PBL performance. The "agreeableness" was negatively correlated with the "control-lead" characteristic in PBL performance. After stepwise regression between the Big Five and each component of PBL performance, only the correlation between conscientiousness and control/lead, and between extraversion and assist/coordinate remained significant. CONCLUSION: Knowledge and personality characteristics appear to be associated with student performance in a hybrid-PBL curriculum. The implications of this study on the future development and application of this assessment tool in medical schools are presented.

Pulmonary actinomycosis: a case undergoing resection through video-assisted thoracic surgery (VATS).

Actinomycosis is an uncommon disease, which is usually manifested as cervicofacial infection and related to poor oral hygiene or compromised immune function. Pulmonary actinomycosis is rare, but its diagnosis is changing due to its variable presentation and the similarity in appearance to other intrapulmonary diseases. Here we report an 80-year-old man with a solitary pulmonary nodule over the left upper lobe. Pulmonary neoplasm was highly suspected in this patient and thus resection of the mass was undertaken through video-assisted thoracic surgery (VATS). Histopathological examination demonstrated this patient had an Actinomyeces infection. While the application of VATS in patients with pulmonary actinomycosis has rarely been reported in literature, we conclude that VATS is valuable for the diagnosis and treatment of patients with undetermined pulmonary nodule(s).

Extramedullary plasmacytoma (EMP): Report of a case manifested as a mediastinal mass and multiple pulmonary nodules and review of literature.

BACKGROUND: Extramedullary plasmacytoma (EMP) is a rare plasma cell neoplasm of soft tissue without bone marrow involvement or other systemic characteristics of multiple myeloma CASE PRESENTATION: A 42 year-old woman presented with intermittent dry cough of 10 months duration. Her breathing sound was slightly coarse without rales or rhonchi on auscultation. CT scan revealed a right anterior mediastinal shadow with multiple pulmonary nodular lesions. A video-assisted thoracoscopic surgery (VATS) was performed. Histopathology showed it to be a myeloma. CONCLUSION: This is the first presentation of EMP with a mediastinal mass with multiple pulmonary nodules.

Primary tuberculous infection of breast: experiences of surgical resection for aged patients and review of literature.

Primary mammary tuberculosis is a rare entity that usually occurs in female of reproductive age. Herein three such patients including two males with ages over 80 years, who underwent surgical resection, are reported. Fine needle biopsy failed to achieve specific diagnosis before surgical operation. All of their conditions got satisfactory improvement and anti-tuberculosis chemotherapy was administered postoperatively. Previous literature related to the epidemiology, diagnosis and treatment for mammary tuberculosis will be also reviewed. Mammary tuberculosis is usually related to breast feeding women and is extremely rare in aged man. The possible mechanisms resulting in this disease in our three patients, including direct extension, reactivation, or transmitted by staffs or peers of the nursing home, would also be discussed.

Effects of thermal preconditioning on the ischemia-reperfusion-induced acute lung injury in minipigs.

Lung ischemia-reperfusion (I/R) injury plays an important role in many clinical issues. A series of mechanisms after I/R has been uncovered after numerous related studies. Organ preconditioning (PC) is a process whereby a brief antecedent event, such as transient ischemia, oxidative stress, temperature change, or drug administration, bestows on an organ an early or delayed tolerance to further insults by the same or different stressors. In this study, we want to uncover the optimal thermal PC patterns that cause maximal early or delayed protective effect on the subsequent pulmonary I/R with the use of miniature pig model. Twenty-eight 15- to 20-kg weight Lanyu miniature pigs are used and divided into four groups (seven sham operation control [NC], seven PC only [PC], seven I/R [I/R], and seven PC followed by I/R [PC + I/R]). The PC was performed with the animals being anesthetized and, using an alternative hyperthermic (40 degrees C) and normothermic moist air to ventilate their lungs for 15 min, respectively, for 2 cycles, followed by I/R, which consists of 90 min of blocking the perfusion and ventilation of the left lung followed by 240 min of reperfusion. Control animals had a thoracotomy with hilar dissection only. Indicators of lung injury included hemodynamic parameters, blood gas analysis, histopathological (lung pathology, wet/dry weight ratio, myeloperoxidase assay), and molecular biological profiles (interleukin-1beta [IL-1beta], IL-6, tumor necrosis factor-alpha by enzyme-linked immunosorbent assay analysis). Lung tissue heat shock protein 70 (HSP-70) expression was also detected by Western blotting. This model of lung I/R induced significant lung injury with pulmonary hypertension, increased pulmonary vascular resistance, and pulmonary venous hypoxemia at the ischemia side, increased pulmonary tissue injury score and neutrophil infiltration, increased wet/dry ratio, myeloperoxidase assay, tumor necrosis factor-alpha, IL-1beta, and IL-6 assay. This type of thermal PC would not injure the lung parenchyma or tracheal epithelium. Moreover, it could attenuate the I/R-related lung injury, with some of these parameters improved significantly. Increased expression of HSP-70 was also found in the group of PC plus I/R than the I/R only. Less prominent and transient increase in expression of HSP-70 was found in the PC group. We concluded that the intratracheal thermal PC can effectively attenuate I/R-induced lung injury through various mechanisms, including the decrease of various proinflammatory cytokines. The mechanism of its protective effect might be related to the increased expression of HSP-70.