Contemporary issues in the surgical management of pleural mesothelioma.

The surgical management of pleural mesothelioma (PM) can be divided into diagnostic, staging, palliation, and cytoreductive surgery. In the cytoreductive surgical setting, the combination of different treatment modalities has led to better outcomes than surgery alone. The scarcity of high-quality studies has led to heterogeneity in management of PM across the mesothelioma treatment centers. Here, we review the literature regarding the most important open questions and ongoing clinical trials.

Fusion and patient-reported outcomes after navigated decortication and direct arthrodesis in minimally invasive sacroiliac joint fusion using cylindrical threaded implants: a case series and literature review.

OBJECTIVE: Sacroiliac joint (SIJ) dysfunction is a significant cause of back pain. Despite recent advances in minimally invasive (MIS) SIJ fusion, the fusion rate remains controversial. This study sought to demonstrate that a navigated decortication and direct arthrodesis technique in MIS SIJ fusion would result in satisfactory fusion rates and patient-reported outcomes (PROs). METHODS: The authors retrospectively reviewed consecutive patients who underwent MIS SIJ fusion from 2018 to 2021. SIJ fusion was performed using cylindrical threaded implants and SIJ decortication employing the O-arm surgical imaging system and StealthStation. The primary outcome was fusion, evaluated using CT at 6, 9, and 12 months postoperatively. Secondary outcomes included revision surgery, time to revision surgery, visual analog scale (VAS) score for back pain, and the Oswestry Disability Index (ODI), measured preoperatively and 6 and 12 months postoperatively. Patient demographics and perioperative data were also collected. PROs over time were analyzed using ANOVA followed by a post hoc analysis. RESULTS: One hundred eighteen patients were included in this study. The mean (± SD) patient age was 58.56 ± 13.12 years, and most patients were female (68.6% vs 31.4% male). There were 19 smokers (16.1%) with an average BMI of 29.92 ± 6.73. One hundred twelve patients (94.9%) underwent successful fusion on CT. The ODI improved significantly from baseline to 6 months (Δ7.73, 95% CI 2.43-13.03, p = 0.002) and from baseline to 12 months (Δ7.54, 95% CI 1.65-13.43, p = 0.008). Similarly, VAS back pain scores improved significantly from baseline to 6 months (Δ2.31, 95% CI 1.07-3.56, p < 0.001) and from baseline to 12 months (Δ1.63, 95% CI 0.25-3.00, p = 0.015). CONCLUSIONS: MIS SIJ fusion with navigated decortication and direct arthrodesis was associated with a high fusion rate and significant improvement in disability and pain scores. Further prospective studies examining this technique are warranted.

Long-term effect of chemotherapy after ovarian decortication on the ovarian function in women surviving cancer.

PURPOSE: Ovarian decortication may affect ovarian function. We investigated the status of ovarian reserve after ovarian decortication plus chemotherapy at a stage of presumed stabilized recovery in women surviving cancer. METHODS: We searched our database for cancer survivors subjected to ovarian decortication and chemotherapy at least 3 years previously. Ovarian function was explored for levels of anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), and estradiol (E2), and menstrual pattern. RESULTS: Forty women (mean age 29.6 (SD, 6.1) years) were assessed at a mean of 4.7 (1.5) years after surgery. The predecortication levels of AMH and FSH changed at post-treatment from 2.2 (1.4) to 0.5 (1.3) ng/mL for AMH (p < 0.001) and from 4.7 (2.1) to 16.7 (21. 6) IU/L for FSH (p < 0.001). Amenorrhea consistent with primary ovarian insufficiency (POI) was diagnosed in 11 women, and normal ovarian reserve (AMH ≥ 1.0 ng/mL) was found in 4 of the 21 women who recovered regular cycles. Logistic regression confirmed AMH as an independent predictor of diminished ovarian reserve (OR = 0.24, 95% CI: 0.04-0.63, p = 0.025) and POI (OR = 0.11, 95% CI: 0.01-0.52, p = 0.027), and age was predictive of POI (OR = 1.36, 95% CI: 1.08-1.96, p = 0.035) and of irregular menstrual cycle (OR = 1.20, 95% CI: 1.03-1.46, p = 0.034). CONCLUSION: Ovarian decortication plus chemotherapy had a deleterious effect when assessed at a stage of stabilized ovarian recovery, but whether ovarian decortication had a specific impact cannot be revealed from our data.

Pleural decortication and hyperthermic intrathoracic chemotherapy for pseudomyxoma.

Aim: Pleural dissemination of pseudomyxoma peritonei (PMP) is an extremely rare diagnosis, for which no standard therapy is available.Methods: We describe the successful treatment of a 67-year-old male diagnosed with left-sided intrapleural dissemination of PMP (low-grade appendiceal mucinous neoplasm), 2 years after treatment of abdominal PMP with cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy. Treatment consisted of extended pleural decortication (ePD) and oxaliplatin-based hyperthermic intrathoracic chemotherapy (HITHOC). The patient is doing well without complications or signs of recurrence, 26 months after thoracic surgery.Conclusion: ePD in combination with HITHOC is a valuable treatment for thoracic PMP.

Surgical strategy for malignant pleural mesothelioma: the superiority of pleurectomy/decortication.

PURPOSE: Both extrapleural pneumonectomy (EPP) and pleurectomy/decortication (P/D) are used for the surgical treatment of malignant pleural mesothelioma (MPM). This study aimed to compare the operative and clinical outcomes and survival between EPP and P/D. METHODS: We performed a retrospective analysis of the surgical and clinical data of 40 patients who underwent either EPP (n = 18) or P/D (n = 22) for MPM at our institution between January 2000 and December 2018. RESULTS: In comparison to EPP, P/D was associated with a higher intraoperative bleeding volume (1175 vs 1805 ml, p = 0.0020) and greater duration of postoperative thoracic drainage (3 vs 16 days, p < 0.0001). Adjuvant chemotherapy was more common after P/D (81.8%) than after EPP (33.3%; p = 0.0024). For epithelioid-type MPM, overall survival (OS) and recurrence-free survival (RFS) were significantly better in patients who underwent P/D in comparison to those who underwent EPP (p = 0.040 and p = 0.015, respectively), with no difference for the biphasic and sarcomatoid types of MPM. A Cox proportional hazards regression model identified P/D as a significant favorable prognostic factor for OS [hazard ratio (HR), 0.391; 95% confidence interval (CI), 0.175-0.871; p = 0.022] and RFS (HR, 0.418; 95% CI, 0.190-0.920; p = 0.030). CONCLUSIONS: Based on our findings, P/D may be superior to EPP for improving the prognosis of patients with resectable epithelioid-type MPM.

Bridge plating with decortication, autologous bone graft, and tight closure: a "stepwise surgical diamond concept" for treatment of nonunion in a series of fifty five patients.

PURPOSE: This study was conducted to assess a stepwise surgical procedure applied to treat a continuous series of patients with aseptic atrophic nonunion of long bones. METHODS: A retrospective review was performed of the medical files of patients treated by the senior author between January 2014 and January 2021 for aseptic atrophic nonunion of long bones using a standard stepwise surgical procedure consisting of four successive surgical steps: bridge locked plating, aggressive osteoperiosteal decortication, copious autologous iliac bone grafting, and tight closure without drainage. Patients were clinically and radiographically evaluated until bone healing, then at final follow-up for the purpose of the study. The primary objective of the study was to assess completion of bone healing; secondary objectives were the time required reaching bone union, the occurrence of complications at the iliac bone graft donor site, and the achievement of bone consolidation after a second attempt of treatment when indicated following failure of the index procedure. RESULTS: There were a total of 55 patients. One patient died from myocardial infarction before reaching bone healing and another one lost from early follow-up. There were remaining 53 patients with 37 years of mean age. The affected bone was the clavicle in five patients, humerus in 14, ulna in four, radius in one, femur in 13, and tibia in 16. The mean follow-up period was 3.4 years. A total of 52 patients (98.1%) achieved bone healing at a mean of 14.8 weeks from the index procedure. The only patient who did not reach bone healing after the index procedure was successfully revised using decortication-bone graft and new fixation with intra-medullary femoral nailing. Four patients (7.5%) developed local complications at the site of iliac bone harvesting. CONCLUSION: Our stepwise surgical procedure was very effective treating aseptic atrophic nonunion of long bones. However, as this study is a retrospective review of a limited series of one surgeon's experience, prospective comparative studies with large number of patients are suitable to define the advantages and indications of the procedure herein described.

The Effects of Processing on Bioactive Compounds and Biological Activities of Sorghum Grains.

Sorghum is ranked the fifth most commonly used cereal and is rich in many kinds of bioactive compounds. Food processing can affect the accumulation and decomposition of bioactive compounds in sorghum grains, and then change the biological activities of sorghum grains. The present review aims to analyze the effects of processing technologies on bioactive compounds and the biological activities of sorghum grains. Decortication reduces the total phenols, tannins, and antioxidant activity of sorghum grains. The effects of thermal processes on bioactive compounds and potential biological activities of sorghum grains are complicated due to thermal treatment method and thermal treatment conditions, such as extrusion cooking, which has different effects on the bioactive compounds and antioxidant capacity of sorghum due to extrusion conditions, such as temperature and moisture, and food matrices, such as whole grain and bran. Emerging thermal processes, such as microwave heating and high-pressure processing, could promote the release of bound phenolic substances and procyanidins, and are recommended. Biological processes can increase the nutritive and nutraceutical quality and reduce antinutritional compounds, except for soaking which reduces water-soluble compounds in sorghum.

Development and performance evaluation of hand-operated mango seed decorticator.

Mango seed kernel, a by-product of mango fruit can be consumed as the safe food if properly processed. A hand operated mango seed decorticator was developed to substitute the unhygienic and unsafe existing method. The device consisted of four major sections such as frame support, feeding unit, sliding unit and decorticating unit. Provisions were made to position the seeds inside the seed holder and the splitting blades to penetrate and break open the stony endocarp along the cleavage. The performance of the machine was evaluated and was compared to that of traditional method. The device resulted in higher whole kernel recovery (85.95 ± 1.53%), decortication capacity (1.92 ± 0.04 kg h-1) than traditional method with 58.37 ± 1.76% and 1.10 ± 0.09 kg h-1, respectively. Traditional method incurred higher material loss with broken kernels making them unsafe for consumption if not processed quickly. Statistical analysis also indicated that the efficacy of traditional method was dependent on personal skill as there was operational variability in the data set with higher coefficient of variation. Therefore, the developed mango seed decorticator is expected to assist in utilization of mango kernel as safe food as well as to reduce the drudgery of the operation. Supplementary Information: The online version contains supplementary material available at 10.1007/s13197-021-05256-5.

Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cysts: What we learned and a review of the literature.

PURPOSE: To avoid Iatrogenic ureteral injury during retroperitoneal laparoscopy for large renal cyst (diameter > 70 mm), we present two cases of iatrogenic ureteral injury and discuss their clinical courses and final outcomes. PATIENTS AND METHODS: Two male patients (47 years old and 74 years old) with large left simple renal cysts underwent a retroperitoneal laparoscopic operation to treat the cysts. In the first patient, the left proximal ureter was partially transected (Grade 3) during the operation. The injury was identified intraoperatively. The transection was managed with a primary ureteroureterostomy (end to end) along with a double J ureteral stent. In the second patient, the left proximalureter was partially transected (Grade 4). However, the injury was unrecognized postoperatively for two days. After recognition of the complication, the injury was managed with an early primary ureteroureterostomy, which followed a failed attempt to place ureteral stent endoscopically. RESULTS: In the first patient, a postoperative urinary leakage developed and lasted for 13 days. During long term follow-up of the first patient after the urine leak resolved, there were no reports of pain in the lumbar region or other discomfort. No recurrence of the renal cyst occurred, which was confirmed with an ultrasound at one year postoperatively. In the second patient a ureteral fistula and severe perirenal infection occurred and lasted for 86 days. The patient ultimately underwent a left nephrectomy after conservative management for this surgical complication failed. This patient developed a chronic wound infection that lasted for 3.14 months following the nephrectomy. During follow-up post nephrectomy, the patient developed stage 3B moderate chronic kidney disease (CKD) (GFR = 30 -44 ml/min). CONCLUSIONS: For single large (diameter > 70 mm) renal cysts located at the lower pole of the kidney, it is recommended to not completely dissect out and mobilize the entire renal cyst for cyst decortication in order to avoid injuring the ureter. Iatrogenic ureteral injury increases the risk of readmission and serious life-threatening complications. The immediate diagnosis and proper management ureteric injury can reduce complications and long term sequalae.

VATS thoracoscopic decortication for empyema thoracic: A retrospective experience and analysis of 162 cases.

OBJECTIVE: To analyse the experience of empyema thoracis management using video-assisted thoracoscopic surgery. METHODS: The retrospective study was conducted at the Combined Military Hospitals, Rawalpindi and Lahore, Pakistan, and comprised data of empyema thoracis cases who underwent thoracoscopic decortications by the same consultant surgeon between January 2009 and 2018. Uniportal or multiportal video-assisted thoracoscopic decortications was performed. Histopathology and microbiological sampling were done in all cases. RESULTS: Of the 162 cases, 114(70.4%) were males and 48(29.6%) were females. The overall mean age was 44±16.37 years. Three ports were utilised in 58(36%) patients. Hospital stay of 122(75.3%) patients was <5 days post-procedure. Post-thoracotomy neuralgia occurred in 19(11.7%) patients, while 9(5.5%) had surgical site infection. Overall complications were 30(18.5%). There was no mortality. CONCLUSIONS: Video-assisted thoracoscopic decortications was found to be a safe, effective and efficient procedure.

Video-assisted thoracoscopic surgery versus open thoracotomy in the management of empyema: A comparative study.

INTRODUCTION: With a rise in the incidence of thoracic empyema, surgical interventions also have evolved from the traditional open decortication to the current minimally invasive video-assisted thoracoscopic surgery (VATS). In this study, we determine the feasibility of VATS and also put the superiority of VATS over open thoracotomy (OT) to test. SUBJECTS AND METHODS: Prospective single-centre comparative analysis of clinical outcome in 60 patients undergoing either VATS or OT for thoracic empyema was done between 1st September, 2014, and 1st November, 2018. Furthermore, another group of patients, who were converted intraoperatively from VATS to OT, was studied descriptively. RESULTS: Nearly 75% of the patients were male with a mean age of 45.16 years. Every second patient had associated tuberculosis (TB), attributed to the endemicity of TB in India. When compared with OT, VATS had a shorter duration of surgery (268.15 vs. 178.33 min), chest tube drainage (11.70 vs. 6.13 days), post-operative hospital stay (13.56 vs. 7.42 days) and time to return to work (26.96 vs. 12.57 days). Post-operative pain and analgesic requirement were also significantly reduced in the VATS group (P < 0.0001). Conversion rate observed was 14.2%, the most common reason being the presence of dense adhesions. CONCLUSION: We conclude that VATS, a minimally invasive procedure with its substantial advantages over thoracotomy and better functional outcome, should be preferred whenever feasible to do so. Also if needed, conversion of VATS to the conventional open procedure, rather than a failure, is a wise surgical judgement.

How safe and effective is laparoscopic decortication of simple renal cysts in elderly patients?

Objective: To investigate the assessment of feasibility and safety of laparoscopic decortication of simple renal cysts in elderly patients.Methods: The data of 114 patients who underwent laparoscopic decortication for simple renal cyst between October 2011 and May 2019 were retrospectively evaluated. Patients' age, gender and ASA scores; operation time; cyst size and location; complications; hospital stays and success rates of operations were recorded.Results: The mean age of the patients were 73.8 ± 8.2 years. Forty-eight (42.1%) of the patients were female and 66 (57.9%) were male. Cysts were localized on the right side in 61 (53.5%) patients and on the left side in 53 (46.5%) patients; and mean cyst size was 72.83 ± 31.13 mm. Also, they were localized on the anterior in 88 (77.2%) patients and on the posterior of the kidney in 26 (22.8%) patients. Preoperative ASA score distributions were ASA-I in 12 patients (10.5%), ASA-II in 31 patients (27.2%), ASA-III in 68 patients (59.7%), and ASA-IV in 3 patients (2.6%). Mean operative time was 41.4 ± 5.6 min. Clavien grade 1 complications were observed in 5 (10.4%) patients. Median hospitalization time was 1 day. No recurrence was occurred in any patient in the postoperative period.Conclusions: Although laparoscopic surgery has some risks and complications for elderly patients, laparoscopic decortication can be applied safely and effectively in treatment of simple renal cyst in that patient population.

A rare massive presentation of catamenial hemothorax.

Catamenial hemothorax is a rare manifestation of thoracic endometriosis syndrome. It is commonly seen associated with pelvic endometriosis in nulliparous reproductive-age women. Most cases are minor and self-limiting. We present a case of a 32-year-old woman who presented with prolonged worsening dyspnea and was found to have a massive hemothorax on evaluation.

Flavonoids in Decorticated Sorghum Grains Exert Antioxidant, Antidiabetic and Antiobesity Activities.

Eight new genotypes of brown sorghum grain were decorticated and assessed for their antioxidant, antidiabetic and antiobesity activities in vitro. The DPPH and ABTS radical scavenging assays of the soluble fractions were evaluated, followed by digestive enzymes and advanced glycation end-products (AGEs) formation inhibition assays. DSOR 33 and DSOR 11 exhibited the highest DPPH (IC50 = 236.0 ± 1.98 µg/mL and 292.05 ± 2.19 µg/mL, respectively) and ABTS radical scavenging activity (IC50 = 302.50 ± 1.84 µg/mL and 317.05 ± 1.06 µg/mL, respectively). DSOR 17, DSOR 11 and DSOR 33 showed significantly higher inhibitory activity of both α-glucosidase and α-amylase (IC50 = 31.86, 35.10 and 49.40 µg/mL; and 15.87, 22.79 and 37.66 µg/mL, respectively) compared to acarbose (IC50 = 59.34 and 27.73 µg/mL, respectively). Similarly, DSOR 33, DSOR 11 and DSOR 17 showed potent inhibition of both AGEs and lipase with IC50 values of 18.25, 19.03 and 38.70 µg/mL; and 5.01, 5.09 and 4.94 µg/mL, respectively, compared to aminoguanidine (52.30 µg/mL) and orlistat (5.82 µg/mL). Flavonoids were the predominant compounds identified, with flavones being the major subclass in these three extracts. Our findings suggest that decorticated sorghum grains contain substantial amounts of flavonoids and could be promising candidates for the prevention and treatment of diabetes and obesity.

Effect of oat decortication on chemical composition, in vitro digestibility and in situ degradability.

The effect of decortication on chemical composition and degradability characteristics of four Danish oat varieties was investigated. Effective degradability (ED) and post-ruminal disappearance (PRD) were measured by in situ and mobile bag techniques respectively. Decorticated oat showed higher (p = .01) concentrations of crude protein (CP; 134 vs. 108 g/kg DM) and crude fat (71.6 vs. 53.1 g/kg DM) and a higher (p = .001) organic matter digestibility (OMD; 888 vs. 703 g/kg OM) than oat. The content of total fatty acids (FA) in DM was higher in decorticated oat. The proportion of linoleic acid (C18:2 n6) increased (p < .05) due to decortication, while the linolenic acid (C18:3 n3) proportion of total FA decreased in decorticated oat. Decortication increased (p = .01) the concentration of amino acids (AA), but the proportion of lysine in total AA decreased (p < .002). Effective degradability (ED) of both DM and CP was (p < .001) higher in decorticated oat. Decortication increased the total tract disappearance (TTD) and PRD of CP (p < .001). In conclusion, decortication can be used as a practical approach to increase the nutritional value of oat.

Laparoscopic Decortication of Simple Renal Cysts: A Systematic Review and Meta-Analysis to Determine Efficacy and Safety of this Procedure.

OBJECTIVES: To determine the efficacy and safety of laparoscopic deroofing of symptomatic simple renal cysts. METHODS: A Cochrane style systematic review was conducted on published literature from 1990 to 2017, to include case series and randomised controlled trials. A pooled meta-analysis was conducted. RESULTS: A total of 696 patients who had laparoscopic deroofing of their simple renal cysts were identified. Complete radiological resolution was seen in 96% of patients with 95% of patients completely symptoms free. Less than 1% of patients had intra-operative complications and 1.4% developed postoperative complications. CONCLUSIONS: Cumulative analysis of the literature examining the role of laparoscopic decortication in the management of symptomatic simple renal cysts reveals that the procedure is highly efficacious to relieve symptoms. The procedure was also associated with a significant radiological success rate (96.3%). It was also shown to be safe, with a low complication rate. We deduced a protocol following this systematic review for the management of symptomatic renal cyst in an aim to help select patients that would benefit from laparoscopic decortication.

Pediatric empyema thoracis: What has changed over a decade?

OBJECTIVES: The purposes of this paper are to study clinicobacteriological profile, treatment modalities and outcome of pediatric empyema thoracis and to identify changes over a decade. DESIGN: This is a retrospective study. SETTING: Department of Pediatrics of a tertiary care hospital in North India. PATIENTS: We enrolled 205 patients (1 month-12 years) of empyema thoracis admitted over 5 years (2007-11) and compared the profile with that of a previous study from our institute (1989-98). RESULTS: Pleural fluid cultures were positive in 40% (n = 82) cases from whom 87 isolates were obtained. Staphylococcus aureus was the most common isolate (66.7%). Methicillin-sensitive S. aureus accounted for 56%, Methicillin-resistant S. aureus (MRSA) 10% and gram-negative organisms 18.3% of isolates. Intercostal drainage tube (ICDT) was inserted in 97.5%, intrapleural streptokinase was administered in 33.6%, and decortication performed in 27.8% cases. Duration of hospital stay was 17.2 (±6.3) days, duration of antibiotic (intravenous and oral) administration was 23.8 (±7.2) days and mortality rate was 4%. In the index study (compared with a previous study), higher proportion of cases received parenteral antibiotics (51.7% vs. 23.4%) and ICDT insertion (20.5% vs. 7%) before referral and had disseminated disease (20.5% vs. 14%) and septic shock (11.2% vs. 1.6%), less culture positivity (40% vs. 48%), more MRSA (10.3% vs. 2.5%) and gram-negative organisms (18.4% vs. 11.6%), increased use of intrapleural streptokinase and surgical interventions (27.8% vs. 19.7%), shorter hospital stay (17 vs. 25 days) and higher mortality (3.9% vs. 1.6%). CONCLUSIONS: Over a decade, an increase in the incidence of empyema caused by MRSA has been noticed, with increased use of intrapleural streptokinase and higher number of surgical interventions.

Empyema Thoracis in Children: A 5-Year Experience in a Tertiary Care Institute.

OBJECTIVE: Empyema thoracis (ET) in children is a disease of significant morbidity and mortality. In the event of failure to resolute following intercostal chest tube drainage (ICD), thoracotomy decortication (TDC) remains the treatment of choice. We have reviewed the outcome of management of 96 cases of ET with the intent to establish the scope of ICD as primary form of the management. MATERIALS AND METHODS: This is a retrospective study of 96 patients of ET who were managed in pediatric surgery department over a period of 5 years (April 2013 - March 2018). Ninety-six patients at a single center met inclusion criteria for having ET and underwent ICD. We excluded the cases where video-assisted thoracoscopic surgery was provided as primary treatment. The patients were categorized into complicated and uncomplicated groups. Those with pyopneumothorax, encysted empyema, multiloculated empyema, and bilateral ET were assigned as complicated group. There were two treatment groups: (I) those responded with ICD alone (II) those with ICD followed by TDC. RESULTS: All 96 cases received ICD as primary management. There were 54 uncomplicated cases and 42 complicated cases. Out of 42 complicated cases, 26 patients recovered with ICD alone and 16 patients needed TDC. A total of 80 (83.33%) patients (54 uncomplicated ± 26 complicated) recovered with ICD alone. Significant complications were encountered in follow-up of patients who underwent delayed thoracotomy in the form of overriding of the ribs (n = 3) and postoperative air leak (n = 4). There was no mortality in our series. CONCLUSION: Early initiation of management of ET with intercostal tube drainage is simple, safe, effective even in complicated cases, and has less complications. Thoracotomy with decortication should be reserved for ICD failure cases.

Intrapleural streptokinase is effective and safe for children with multi-loculated empyema regardless of the time from disease onset.

AIM: This study compared the efficacy of administering intrapleural streptokinase to children with multi-loculated empyema within 14 days or at any time after disease onset. METHODS: We studied children under 12 years with multi-loculated empyema who were admitted to a teaching hospital in Chandigarh, India, from July 2013 to June 2017. They received antibiotics, pleural drainage and intrapleural streptokinase. The first group received three doses within 14 days of disease onset, the second received three doses regardless of time after onset and the third group received four to six doses regardless of time after onset. The three phases lasted 18, 18 and 12 months, respectively. RESULTS: Of 195 children, 133 (68%) received streptokinase within 14 days, 46 (24%) beyond 14 days and 16 (8%) did not receive it. There was no difference in surgical decortication (14/133 versus 7/46, p > 0.05) and median hospitalisation duration (15 versus 14 days, p > 0.05) between administration before versus after 14 days. Median hospitalisation was shorter with four to six doses than three doses (11 versus 16 days, p < 0.01). CONCLUSION: Intrapleural streptokinase was effective for multi-loculated empyema even when it was administered more than 14 days after disease onset and four to six doses were superior to three doses.

Non-incisional pleurectomy-decortication for malignant pleural mesothelioma.

Pleurectomy-decortication (P/D) is lung-sparing surgery with curative intent for malignant pleural mesothelioma (MPM). Visceral pleurectomy is the most challenging step in this procedure. At the beginning of pleurectomy, a sharp pleural incision through the tumor is usually made to create the dissection plane between the visceral pleura and the lung parenchyma, which may cause the spread of tumor cells into the operation field. Here, we describe a sophisticated surgical technique of P/D without any pleural incision ("non-incisional P/D") to achieve en bloc removal of the entire pleura and tumor, which may improve postoperative survival by preventing tumor spread.