Patterns of Regional Failure after Pancreaticoduodenectomy in Patients with Distal Extrahepatic Cholangiocarcinoma: Suggestion of the Clinical Target Volume for Elective Nodal Irradiation.

AIMS: To evaluate the pattern of locoregional recurrence (LRR) after pancreaticoduodenectomy in patients with distal extrahepatic cholangiocarcinoma (DEHC) and to identify an optimal target volume for elective nodal irradiation. MATERIALS AND METHODS: We analysed the medical records of DEHC patients who underwent pancreaticoduodenectomy and had LRR between 1991 and 2015. Among these patients, 30 received adjuvant chemotherapy alone, 14 underwent radiotherapy with or without chemotherapy and 28 received no treatment. After reviewing computed tomography or magnetic resonance imaging scans, the sites of LRR were identified and mapped to the corresponding locations on the representative computed tomography images. RESULTS: In total, 136 LRRs were identified in 72 patients from four institutions. Local recurrences were observed at 44 sites (32.4%): tumour bed in 15, choledochojejunostomy in 25 and pancreaticojejunostomy in four. Regional recurrences were observed at 92 sites (67.6%); the most common site was the portal vein area (n = 18), followed by the para-aortic area (n = 17). Based on the mapped plots of regional recurrence, a clinical target volume covering 90% of regional recurrences was generated using the appropriate margin for the vascular structures of the portal vein, celiac axis, superior mesenteric artery, left gastric artery and aorta. CONCLUSIONS: Given the pattern of LRR, we showed that the nodal clinical target volume based on vascular structures could appropriately cover high-risk regions of nodal involvement. These findings may help physicians construct a target volume in postoperative radiotherapy for DEHC patients undergoing pancreaticoduodenectomy.

Comparison of outcomes of treatment for ranula: a proportion meta-analysis.

Treatment for ranula is classified into three categories depending on how the leaking saliva is managed: removal of the leaking site by intraoral or transcervical resection of the sublingual gland; formation of a drainage tract through the wall of the pseudocyst by micromarsupialisation or marsupialisation; or sealing of the site of the leak by inducing fibrosis with a sclerosing agent. Resection of the sublingual gland is probably the option most likely to be curative for both oral and plunging ranula considering their pathophysiology. Although alternative treatments have been introduced to avoid the invasiveness of resection of the gland, their outcomes have been inconsistent. The objective of this study therefore was to help decision-making by providing more integrated rates of cure, consistency of treatment, and morbidity, depending on types of treatment used in previous series of cases. We used proportion meta-analysis of 39 such published series, and the most curative treatment for oral ranula was intraoral resection of the sublingual gland. Micromarsupialisation and its modification showed cure rates comparable with those of resection of the gland, but these were moderately inconsistent. In the treatment of plunging ranula, there was no significant difference in cure rate between the intraoral and transcervical approaches, although they both showed higher cure rates than injection of OK-432. Comparisons of morbidity were available for patients who had developed nerve dysfunction and haematoma after the intraoral and transcervical approaches and there was no significant difference between the two, though the morbidity was higher after the transcervical than that after the intraoral approach. In conclusion, intraoral resection of the sublingual gland is sufficient treatment with a tendency to have fewer complications than that in the transcervical approach.

Efficacy and safety of transarterial chemoembolisation with cone-beam CT in patients with hepatocellular carcinoma within the Milan criteria: a retrospective cohort study.

AIM: To compare the therapeutic efficacy and safety of transarterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC) within the Milan criteria with or without the use of cone-beam computed tomography (CBCT). MATERIALS AND METHODS: Patients with HCC within the Milan criteria who underwent conventional angiography-guided TACE (Angio-TACE group: 58 patients from January 2010 to December 2011) were compared with those who underwent CBCT-guided TACE (CBCT-TACE group: 55 patients from January 2013 to December 2014). Local progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were compared. Adverse events after TACE were also investigated. RESULTS: Baseline characteristics were balanced between the two groups. LPFS was significantly longer in the CBCT-TACE group than in the Angio-TACE group (median: not reached for 36 versus 19.2 months, respectively; Log-rank p=0.029). In multivariable Cox regression analysis, CBCT guidance had a significantly lower risk of local progression or death (adjusted hazard ratio: 0.585; 95% confidence interval, 0.344-0.995; p=0.048); however, there was no significant difference in PFS (3-year PFS: 15.9% versus 26.8%, respectively; p=0.122) or OS (3-year OS: 85% versus 88.2%, respectively; p=0.761) between the Angio-TACE and CBCT-TACE groups. Post-embolisation syndrome occurred significantly less frequently in the CBCT-TACE group (p=0.002). CONCLUSION: CBCT-guided TACE could improve local tumour control for HCC within Milan criteria and showed fewer cases of post-embolisation syndrome.

Prognostic relevance of lymph node status for patients with ampullary adenocarcinoma after radical resection followed by adjuvant treatment.

PURPOSE: Attempts have been made to revise the nodal stage due to simplicity of current N staging system in ampullary adenocarcinoma. However, because of the disease rarity, there have only been a few studies assessing the prognostic impact of lymph node (LN) parameters. METHODS: We retrospectively analyzed 120 patients who underwent radical resection followed by adjuvant chemoradiotherapy for ampullary adenocarcinoma. The effect of LN parameters (number of total harvest LNs, number of metastatic LN (MLN), lymph node ratio (LNR), and log odds of positive LNs (LODDS)) on overall survival (OS), locoregional relapse-free survival (LRFS) and distant metastasis-free survival were evaluated. Cutoff points of MLN, LNR and LODDs were determined using maximal χ2 method. RESULTS: Fifty-seven patients (48%) were staged as pN1 and their survival was not significantly decreased compared with pN0 patients. There was also no significant difference between patients with MLN 0 vs. 1. In univariate analyses, MLN (0-1 vs. ≥2), LNR (≤17% vs. >17%) and perineural invasion were common prognosticators for OS and LRFS. Distant metastasis-free survival was not influenced by LN status. In addition, multivariate analysis revealed that among the LN parameters, LNR was able to independently predict both OS and LRFS. CONCLUSIONS: LNR performs better than other LN related parameters for predicting survival. After radical resection followed by adjuvant treatment, survival of patients with one positive LN does not seem to differ from patients without LN metastasis.

Facile Synthesis of Iron Oxide/Graphene Nanocomposites Using Liquid Phase Plasma Method.

Liquid phase plasma (LPP) method was applied, for the first time, to the impregnation of iron oxide nanoparticles onto graphene sheet. Iron oxide nanoparticles with the size of 50 nm were precipitated with uniform dispersion on the surface of graphene sheet. The amount of iron oxide nanoparticles precipitated on graphene sheets increased with increasing LPP process times. The XPS, Raman and EDX analyses showed that the iron oxide/graphene composites synthesized by the LPP process.

Accidental displacement of a dental implant into the submandibular space during explantation.

Dental implants are reliable and widely used, but complications such as peri-implantitis occasionally necessitate their removal. Accidents during removal are similar to those that may occur during extraction, including displacement into another structure in the maxillofacial region. We present a rare case of accidental displacement into the submandibular space, which happened during an attempt to remove an implant.

DNA methylation analysis for the diagnosis of thyroid nodules - a pilot study with reference to BRAF(V) (600E) mutation and cytopathology results.

OBJECTIVE: Promoter hypermethylation and the BRAF(V) (600E) mutation are both involved in thyroid tumorigenesis. We conducted a pilot study on the diagnosis of thyroid nodules by analysis of promoter hypermethylation status with reference to BRAF(V) (600E) mutation and cytopathology results using formalin-fixed, paraffin-embedded (FFPE) tissues and liquid-based preparation (LBP) thyroid fine needle aspiration (FNA) samples to predict more reliably the possibility of papillary carcinoma. METHODS: We initially performed MethyLight analysis for 30 genes that are known to be hypermethylated in malignancies using 164 papillary carcinomas and 77 benign tissue samples. Five genes selected from the tissue analysis were subsequently analysed in 75 surgically proven benign and 66 surgically proven papillary carcinoma LBP FNA samples. Samples that showed two or more positive results among the five genes were classified as methylation positive. We also analysed the BRAF(V) (600E) mutation status of the FNA samples. RESULTS: We identified five genes that were significantly hypermethylated in malignant tissues: PTGS2, HOXA1, TMEFF2, p16 and PTEN. With respect to diagnostic potential, results obtained using the BRAF(V) (600E) mutation test combined with cytological examination were not significantly different from those obtained with cytological examination only. Combining methylation analyses with cytological examination or performing all three tests for diagnoses did not improve significantly the negative predictive values and sensitivity, but a significant decrease in positive predictive value and specificity was observed. CONCLUSION: Further studies are needed on larger samples to assess the potential value of methylation analysis of thyroid FNA.

Population-based epidemiology of primary biliary cirrhosis in South Korea.

BACKGROUND: As a rare disease, only a few population-based epidemiology studies of primary biliary cirrhosis (PBC) have been reported. AIMS: To elucidate the nationwide prevalence, incidence, complications, fatality and direct medical costs of PBC in South Korea. METHODS: The nationwide Health Insurance Review and Assessment Service claims data and Rare Intractable Disease registration data on PBC, identified with the International Classification of Diseases (ICD) 10 code of K74.3, were obtained from 2009 to 2013. Age- and gender-specific prevalence and incidence rates of PBC were calculated, and data on complications, comorbidities, prescribed drugs, therapeutic procedures and direct medical costs were analysed. RESULTS: A total of 2824 patients over 20 years old with PBC were identified in 2009-2013 (female-to-male ratio 6.2, median age 57 years old). The average age- and sex-adjusted incidence from 2011 to 2013 was 8.57 per million per year, and the average age- and sex-adjusted prevalence from 2009 to 2013 was 47.50 per million population. About 10% of patients presented with complications such as ascites (10.3%), variceal bleeding (5.8%) and/or hepatocellular carcinoma (HCC) (1.3%). Liver transplantation was undertaken in 71 patients (2.5%) for 5 years. Case fatality was 2.2% and the transplantation-free survival was 95.4% for 5 years. CONCLUSIONS: This is the first report on the nationwide epidemiology of primary biliary cirrhosis in South Korea, demonstrating lower incidence and prevalence rates than those of Western countries, but a considerable disease burden, representing at least 10% were complicated with decompensated cirrhosis or hepatocellular carcinoma requiring liver transplantation.

Low pulmonary function is related with a high risk of sarcopenia in community-dwelling older adults: the Korea National Health and Nutrition Examination Survey (KNHANES) 2008-2011.

UNLABELLED: Sarcopenia is the age-related reduction of skeletal muscle mass in older individuals. Respiratory muscle strength may be related to skeletal muscle mass and, thus, the present study attempted to estimate the risk of sarcopenia relative to decreased pulmonary function. The present findings demonstrated that low pulmonary function was associated with low muscle mass in community-dwelling older adults. INTRODUCTION: Lean body mass is related to pulmonary function in patients with chronic obstructive pulmonary disease (COPD). However, the relationship between muscle mass and pulmonary function in healthy older adults has yet to be clarified. Thus, the present study investigated the association of pulmonary function with muscle mass in an older community-dwelling Korean population. METHODS: This study included 463 disease-free subjects over 65 years of age who underwent anthropometric measurements, laboratory tests, spirometry, and the estimation of appendicular skeletal muscle (ASM) mass in the 2008-2011 Korea National Health and Nutrition Examination Survey (KNHANES). Low muscle mass was defined as the value of ASM divided by height squared (ASM/height(2)) that was less than two standard deviations (SD) below the sex-specific mean of the young reference group. RESULTS: Forced expiratory volume in 1 s (FEV1[L]) and forced vital capacity (FVC[L]) were positively correlated with ASM/height(2) in males (p < 0.001 and p = 0.001, respectively) but not in females (p = 0.360 and p = 0.779, respectively). A univariate logistic regression analysis revealed that males with low FEV1 or FVC were more likely to have low muscle mass (odds ratio [OR] = 3.11, 95% confidence interval [CI] 1.62-5.99 for FEV1; OR = 1.99, 95% CI 1.13-3.53 for FVC); similar results were found for females, but the significance was lower (OR = 11.37, 95% CI 0.97-132.91 for FEV1; OR = 7.31, 95% CI 1.25-42.74 for FVC). After adjusting for age, smoking, and moderate physical activity, a low FEV1 value was associated with low muscle mass in both males (OR = 2.90, 95% CI 1.50-5.63) and females (OR = 9.15, 95% CI 1.53-54.77). CONCLUSIONS: Using nationally representative data from the 2008-2011 KNHANES, low pulmonary function was found to be associated with low muscle mass in community-dwelling older Korean adults.

Pathway analysis of genome-wide association datasets of personality traits.

Although several genome-wide association (GWA) studies of human personality have been recently published, genetic variants that are highly associated with certain personality traits remain unknown, due to difficulty reproducing results. To further investigate these genetic variants, we assessed biological pathways using GWA datasets. Pathway analysis using GWA data was performed on 1089 Korean women whose personality traits were measured with the Revised NEO Personality Inventory for the 5-factor model of personality. A total of 1042 pathways containing 8297 genes were included in our study. Of these, 14 pathways were highly enriched with association signals that were validated in 1490 independent samples. These pathways include association of: Neuroticism with axon guidance [L1 cell adhesion molecule (L1CAM) interactions]; Extraversion with neuronal system and voltage-gated potassium channels; Agreeableness with L1CAM interaction, neurotransmitter receptor binding and downstream transmission in postsynaptic cells; and Conscientiousness with the interferon-gamma and platelet-derived growth factor receptor beta polypeptide pathways. Several genes that contribute to top-ranked pathways in this study were previously identified in GWA studies or by pathway analysis in schizophrenia or other neuropsychiatric disorders. Here we report the first pathway analysis of all five personality traits. Importantly, our analysis identified novel pathways that contribute to understanding the etiology of personality traits.

Peripheral artery questionnaire improves ankle brachial index screening in symptomatic patients with peripheral artery disease.

AIM: The peripheral artery questionnaire (PAQ) is a disease-specific health status measure of patients with peripheral artery disease (PAD). Whether the PAQ scores are associated with a PAD diagnosis among patients with symptoms suspicious for PAD is unknown and could help increase the pretest probability of ankle brachial index (ABI) screening among patients with suspicious symptoms. METHODS: The PAQ was completed by 567 patients evaluated for potential intermittent claudication at six tertiary centres. Demographics, medical history, physical examination findings and the PAQ domain scores were compared with ABI. A diagnostic threshold < 0.90 for a PAD diagnosis was assessed with a ROC of PAQ scores. The correlation between the PAQ Summary Score and ABI was also calculated. RESULTS: The PAQ Summary Score was significantly lower in patients with low ABI as compared with those having a normal ABI (37.6 ± 19.0 vs. 70.1 ± 22.7, p < 0.001). The PAQ Summary Score and ABI were highly correlated (r = 0.56, p < 0.001) and the optimal PAQ Summary Score for predicting low ABI was 50.3 (AUC = 0.86, sensitivity 80.3%, specificity 78.3%). CONCLUSIONS: The PAQ Summary Score was associated with an increased likelihood of PAD in patients with suspected PAD symptoms, and a low summary score (≤ 50.3) was an optimal threshold for predicting PAD among patients referred for ABI.

Evaluation of ABX Pentra DX 120 and Sysmex XE-2100 in umbilical cord blood.

INTRODUCTION: Cord blood (CB) is an important source of hematopoietic stem cells and reflects the hematologic status of neonates. ABX Pentra DX 120 (Horiba Medical, Montpellier, France) and Sysmex XE-2100 (Sysmex, Kobe, Japan) were compared in 200 CB specimens. METHODS: Complete blood count parameters including white blood cell (WBC) differential counts were compared between the two analyzers. Double differential matrix (DDX) by ABX Pentra DX 120 and hematopoietic progenitor cell (HPC) by Sysmex XE-2100 were compared with CD34(+) cells by flow cytometry. RESULTS: Most of the parameters showed acceptable correlation between the two analyzers. Although WBC differential of both analyzers showed acceptable correlation with manual counts, mononuclear cells (MNC) by ABX Pentra DX 120 better correlated with manual count than MNC by Sysmex XE-2100. NRBC by Sysmex XE-2100 better correlated with manual count than NRBC by ABX Pentra DX 120. ABX Pentra DX 120 showed better flagging performances. DDX better correlated with CD34(+) cells than HPC. CONCLUSION: Although the results from both analyzers are mostly interchangeable and reliable in CB specimens, flagging performance of ABX Pentra DX 120 seems to be superior to that of Sysmex XE-2100. DDX by ABX Pentra DX 120 would be valuable to evaluate the quality of CB for further therapeutic utilization.

Recurrent deep vein thrombosis and pulmonary embolism in a patient with Klinefelter's syndrome.

Klinefelter's syndrome, which is characterized by small testes, gynecomastia, hypogonadism, and infertility, is the most common cause of primary testicular failure, and commonly has an XXY karyotype. Deep vein thrombosis and thomboembolic events are a rare occurrence in these patients. Although the exact mechanism is not completely understood, it is thought that increased thromboembolic risk in hypogonadic men can be explained by hypofibrinolysis resulting from androgen deficiency. We present the case of a 48-year-old man with Klinefelter's syndrome who experienced recurrent episodes of deep venous thrombosis and pulmonary embolism while undergoing therapeutic anticoagulation. Our report discusses this association and management of the prothrombotic state in patients with Klinefelter's syndrome.

Performance and microbial diversity of palm oil mill effluent microbial fuel cell.

AIM: To evaluate the bioenergy generation and the microbial community structure from palm oil mill effluent using microbial fuel cell. METHODS AND RESULTS: Microbial fuel cells enriched with palm oil mill effluent (POME) were employed to harvest bioenergy from both artificial wastewater containing acetate and complex POME. The microbial fuel cell (MFC) showed maximum power density of 3004 mW m(-2) after continuous feeding with artificial wastewater containing acetate substrate. Subsequent replacement of the acetate substrate with complex substrate of POME recorded maximum power density of 622 mW m(-2). Based on 16S rDNA analyses, relatively higher abundance of Deltaproteobacteria (88.5%) was detected in the MFCs fed with acetate artificial wastewater as compared to POME. Meanwhile, members of Gammaproteobacteria, Epsilonproteobacteria and Betaproteobacteria codominated the microbial consortium of the MFC fed with POME with 21, 20 and 18.5% abundances, respectively. CONCLUSIONS: Enriched electrochemically active bacteria originated from POME demonstrated potential to generate bioenergy from both acetate and complex POME substrates. Further improvements including the development of MFC systems that are able to utilize both fermentative and nonfermentative substrates in POME are needed to maximize the bioenergy generation. SIGNIFICANCE AND IMPACT OF THE STUDY: A better understanding of microbial structure is critical for bioenergy generation from POME using MFC. Data obtained in this study improve our understanding of microbial community structure in conversion of POME to electricity.

Surgical treatment of necrotic scleral calcification using combined conjunctival autografting and an amniotic membrane inlay filling technique.

PURPOSE: To introduce a novel technique to treat necrotic scleral calcification caused by previous regional conjunctivectomy using conjunctival autografting and amniotic membrane inlay filling, and to evaluate the clinical outcome. METHODS: Ten patients (11 eyes, 12 regions) who had undergone regional conjunctivectomy with postoperative mitomycin C (MMC) for pterygia or pingueculae were included. Scleral calcification was removed using a bevel-down crescent knife. After the conjunctival donor tissue was harvested from the upper bulbar conjunctiva, the tissue was grafted to the scleral defect and secured with sutures. Amniotic membrane was inserted randomly into spaces between the conjunctival graft and the scleral bed. Protective amniotic membrane was transplanted over the graft, with stromal side up. RESULTS: Scleral calcification developed in ischaemic areas in 11 of the 12 regions; 50% of cases had a surface defect seen with a fluorescent dye. The grafted conjunctiva epithelialized successfully in all cases. In 10 regions, the epithelialization occurred in 1 or 2 weeks. In the remaining two regions, one region required another surgery because of graft failure, and epithelialization occurred in the last region in 9 weeks. Vascular growth into the graft from the surrounding tissue occurred in all cases in 1 to 10 weeks. The surgical wound stabilized 3 weeks postoperatively. CONCLUSION: The combined technique had high success rates of graft survival and good revitalization of the necrotic area of scleral calcification, eliminated the need for invasive and time-consuming scleral autografting or allografting, and provided good cosmesis. Scleral ischaemia, which was caused by MMC, may induce scleral calcification.

Health behaviour and quality of life in Korean adults with respiratory disease: National Health Survey, 2005.

OBJECTIVES: To describe disease management, health behaviour, psychological health and quality of life (QOL) in people with chronic respiratory disease (CRD). METHODS: We analysed data from 798 adults with CRD drawn from the Korean National Health and Nutrition Examination Survey (KNHANES) 2005: 514 subjects with asthma alone, 258 with chronic obstructive pulmonary disease (COPD) alone, and 56 with asthma and COPD. RESULTS: Disease management and health behaviour in this cohort were poor. One third of the cohort was not seeking any medical treatment, although many were currently experiencing respiratory symptoms. Twenty-six per cent of the subjects were current smokers who averaged 0.8 packs/day. More than half of the subjects did not exercise, only half of the subjects had regular health examinations and one third of the subjects did not get enough sleep. The study population exhibited poor psychological indices, functional health status and QOL. The combined asthma and COPD group was characterised by an increased frequency of problems related to functional status and QOL. CONCLUSIONS: People with CRD are at high risk for functional limitations, unhealthy behaviour, poor mental status and poor QOL. A comprehensive disease management programme for people with CRD should be developed using collaborative team efforts.

The benzoxathiolone LYR-71 down-regulates interferon-gamma-inducible pro-inflammatory genes by uncoupling tyrosine phosphorylation of STAT-1 in macrophages.

BACKGROUND AND PURPOSE: Benzoxathiolone derivatives have shown anti-inflammatory and immunomodulatory potential in acne and psoriatic disorders. However, little is known about the molecular basis for these pharmacological effects. In this study, we decided to investigate the anti-inflammatory actions of a benzoxathiolone derivative LYR-71, 6-methyl-2-propylimino-6,7-dihydro-5H-benzo[1,3]oxathiol-4-one, in interferon (IFN)-gamma-activated macrophages. EXPERIMENTAL APPROACH: RAW 264.7 macrophages or primary macrophages, derived from bone marrow of C3H/HeJ mice, were stimulated with IFN-gamma in the presence of LYR-71. Nitric oxide (NO) or chemokine production was measured by Griess reaction or enzyme-linked immunosorbent assay. RAW 264.7 cells were used to examine the molecular mechanisms of LYR-71 in modulating IFN-gamma-induced inflammatory responses. KEY RESULTS: LYR-71 down-regulated IFN-gamma-induced transcription of inducible NO synthase, IFN-gamma-inducible protein-10 and the monokine induced by IFN-gamma genes in macrophages. This effect was mediated by uncoupling tyrosine phosphorylation of the signal transducer and activator of transcription (STAT)-1 in response to IFN-gamma. LYR-71 directly inhibited the in vitro catalytic activity of Janus kinase (JAK)-2. Further, the inhibitory actions of LYR-71 on IFN-gamma-induced STAT-1 phosphorylation and NO production were consistently abolished in the presence of peroxyvanadate, implying another target dependent on protein tyrosine phosphatase. CONCLUSIONS AND IMPLICATIONS: Taken together, LYR-71 could restrain IFN-gamma-induced inflammatory responses through uncoupling the tyrosine phosphorylation of STAT-1, an activation index of JAK-STAT-1 signalling, in macrophages. These results may provide a molecular mechanism underlying anti-inflammatory actions shown by benzoxathiolone derivatives.

Regulation of megakaryocytic differentiation of K562 cells by FosB, a member of the Fos family of AP-1 transcription factors.

The regulation of megakaryocytic differentiation is poorly understood. Using K562 cells, which can partly recapitulate the process in response to phorbol 12-myristate 13-acetate (PMA), we performed microarray-based gene expression profiling to identify genes that play significant roles in megakaryopoiesis. Here, we describe the function of FosB, an AP-1 transcription factor. FosB is induced in PMA treated K562 cells in a sustained manner and forms an active AP-1 protein-DNA complex. Down-regulation of FosB with specific shRNAs inhibited the induction of CD41, a specific cell surface marker of megakaryocytes. We also show that activation of the PKC-MEK-ERK signaling pathway is required for induction of FosB and CD41. Finally, we cross-examined the microarray data in conjunction with gene function annotation data to identify additional target genes of FosB. We define 3 genes, INHBA, CD9, and ITGA2B as regulatory targets of FosB and show that CD9, in particular, is a direct target of FosB.

Staple line covering procedure after thoracoscopic bullectomy for the management of primary spontaneous pneumothorax.

BACKGROUND: Thoracoscopic bullectomy together with a pleural adhesive procedure is generally accepted as the standard for the definitive treatment of primary spontaneous pneumothorax (PSP). The purpose of this study was to evaluate whether the results of a thoracoscopic bullectomy followed by coverage of the staple line with cellulose mesh and fibrin glue could be comparable with those of adhesive procedures described in the literature. METHODS: Between May 2000 and February 2003, we performed 227 thoracoscopic surgeries on 219 patients with PSP using a single technique. After the bullectomy, the staple line was covered with cellulose mesh and fibrin glue. The postoperative status was evaluated with a mean follow-up of 46 months. RESULTS: The mean patient age was 24.3 years and 90.9 % of the 219 patients were male. Recurrent pneumothorax (37.4 %) was the most common operative indication, followed by persistent air leakage of more than 5 days (28.2 %). The mean duration of postoperative chest tube drainage was 1.6 days and the mean postoperative hospital stay was 3.8 days. Six patients experienced surgical complications (2.2 %); there was air leakage of more than 3 days in two cases, a small apical dead space in one case, a fever-associated wound problem in one case, and a reoperation due to air leakage of more than 7 days in two cases. Eleven patients (4.8 %) suffered a recurrence of pneumothorax during the follow-up period. Of these, nine cases required readmission and three (1.3 %) of these cases required a reoperation. CONCLUSIONS: Given the nature of a meticulous thoracoscopic bullectomy followed by coverage with cellulose mesh and fibrin glue, good surgical results can be expected without the need for a pleural adhesive procedure.