Surgical anatomy of the internal thoracic arteries and their branching pattern: a cadaveric study.

BACKGROUND: The purpose of this study is to review the anatomic characteristics of internal thoracic artery (ITA) and its branches, in order to pursue the extension of its utilization and avoid intraoperative and postoperative complications. METHODS: The study was carried out on anterior chest walls obtained during routine autopsies of 50 specimens (30 male, 20 female). Macroscopic and microscopic dissection was performed and the following were studied: origin, length and termination of ITA, size and distance from the sternum, and types of branches. RESULTS: From the origin to the termination point, the length of the left internal thoracic artery (LITA) varied from 159 to 220 mm; with a mean of 182.60 mm. The length of the right internal thoracic artery (RITA) varied from 150 to 231 mm; with a mean of 185 mm. Four types of branches were distinguished. The RITA mean diameter was 2.31 mm, measured at the 2(nd) intercostal space, while the distance from the sternum was 12.77 mm, measured at the 3(rd) intercostal space. The LITA mean diameter was 1.98 mm with the distance from the sternum measured at 12.01 mm. CONCLUSIONS: ITA has become the primary conduit for cardiac bypass surgery; many studies have generated fundamental anatomical knowledge for its clinical utilization, which is always useful in order to avoid intraoperative and postoperative complications.

Double primary non-small cell lung cancer with synchronous small cell lung cancer N2 nodes: a case report.

Synchronous multiple primary lung cancer (SMPLC) is rare and very hard to distinguish from metastatic disease. Recent studies indicate the presence of this entity in the lung, with no mention to the involvement of the mediastinum. An extremely rare case of a 68-year-old male with double primary non-small cell lung cancer (NSCLC) in the left upper lobe and N2 positive nodes for small cell lung cancer (SCLC) is presented. Modern diagnostic criteria as well as aggressive curative strategies are encouraged, in order to achieve better survival rates for such patients.

Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis.

BACKGROUND AND OBJECTIVE: The aim of this study is to compare usefulness of Semi-Fowler position vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis. MATERIALS AND METHODS: From January 2009 to January 2010, 263 consecutive patients with palmar and axillar hyperhidrosis underwent thoracoscopic sympathectomy Th2-Th4. Patients were divided into two groups: group A (n=133) underwent thoracoscopic sympathectomy through lateral decubitus using double lumen endotracheal intubation, and group B (n=130) underwent thoracoscopic sympathectomy through Semi-Fowler supine position (semi sitting with arm abducted) using single lumen endotracheal intubation without insufflation of CO2, but with short apnea period. All operations were performed through two 5 mm operating ports, videothoracoscopic camera 0° and endoscopic ultrasound activated harmonic scalpel. RESULTS: There were 107 males and 156 females with median age 30.31±8.35 years. Two groups were comparable in gender, age, severity of sweating. All operations were successfully performed with no complications or perioperative morbidity. For group A average operation time for both sides was 31.2±3.87 min and for group B average time was 14.19±4.98 min. In group B apnea period per one lung lasts 2.86±1.15 min and during that period observed saturation was 92.65%±5.66% without significant cardiorespiratory disturbances. Pleural drains were taken off on operation table after forced manually lung reexpansion. Patients were discharged from hospital for few hours, after the operation and radiologic confirmation of complete lung reexpansion. CONCLUSIONS: Based on this data (shorter operating time, lack of incomplete lung collapse, insignificant apnea and better reexpansion of lungs) we concluded that thoracoscopic sympathectomy through Semi-Fowler supine position is highly effective and easy to perform for primary hyperhidrosis.

Open thoracotomy for pneumothorax.

A thoracotomy is an incision into the pleural space of the chest. It is performed by surgeons (or emergency physicians under certain circumstances) to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. This surgical procedure is a major surgical maneuver it is the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation, rigid bronchoscope can be also used if necessary. Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia. In the current review we will present the steps of this procedure.

Video-assisted thoracic surgery and pneumothorax.

Video-assisted thoracoscopic surgery (VATS) is a type of thoracic surgery performed using a small video camera that is introduced into the patient's chest via a scope. It is considered a minimally invasive technique where the surgeon is able to view the instruments that are being used along with the anatomy on which the surgeon is operating. The camera and instruments are inserted through separate holes in the chest wall also known as "ports", depending on the patient and problem there are surgeries with one port "uniport", two or three ports. These small ports have the advantage that fewer infections are observed. This allows for a faster recovery. Traditionally, thoracic surgery performed for diagnosis or treatment of chest conditions has required access to the chest through thoracotomy or sternotomy incisions. Vats minimally invasive technique has replaced in many cases thoracotomy or sternotomy. In our current review we will present this technique in detail.

Postoperative pain management.

Postoperative pain is a very important issue for several patients. Indifferent of the surgery type or method, pain management is very necessary. The relief from suffering leads to early mobilization, less hospital stay, reduced hospital costs, and increased patient satisfaction. An individual approach should be applied for pain control, rather than a fix dose or drugs. Additionally, medical, psychological, and physical condition, age, level of fear or anxiety, surgical procedure, personal preference, and response to agents given should be taken into account. The major goal in the management of postoperative pain is minimizing the dose of medications to lessen side effects while still providing adequate analgesia. Again a multidisciplinary team approach should be pursued planning and formulating a plan for pain relief, particularly in complicated patients, such as those who have medical comorbidities. These patients might appear increase for analgesia-related complications or side effects.

Enhancement of Intratumoral Chemotherapy with Cisplatin with or without Microwave Ablation and Lipiodol. Future Concept for Local Treatment in Lung Cancer.

Novel therapies for lung cancer are being explored nowadays with local therapies being the tip of the arrow. Intratumoral chemotherapy administration and local microwave ablation have been investigated in several studies. It has been previously proposed that lipiodol has the ability to modify the microenvironment matrix. In our current study we investigated this theory in BALBC mice. In total 160 BALBC mice were divided in eight groups: a) control, b) cisplatin, c) microwave, d) microwave and lipiodol, e) cisplatin and lipiodol, f) microwave and cisplatin, g) lipiodol and h) lipiodol, cisplatin and microwave. Lewis lung carcinoma cell lines (10(6)) were injected into the right back leg of each mouse. After the 8th day, when the tumor volume was about 100mm(3) the therapy application was initiated, once per week for four weeks. Magnetic resonance imaging was performed for each tumor when a mouse died or when sacrificed if they were still alive by the end of the experiment (8-Canal multifunctional spool; NORAS MRI products, Gmbh, Germany). Imaging and survival revealed efficient tumor apoptosis for the groups b,c,d,e and f. However; severe toxicity was observed in group h and no follow up was available for this group after the second week of therapy administration. Lipiodol in its current form does assist in a more efficient way the distribution of cisplatin, as the microwave apoptotic effect. Future modification of lipiodol might provide a more efficient method of therapy enhancement. Combination of drug and microwave ablation is possible and has an efficient apoptotic effect.

Use of proteins as biomarkers and their role in carcinogenesis.

SUMMARY: Improved diagnostic methods and medical therapies are necessary for early detection and treatment and an improved prognosis. It is thus vital to both examine and evaluate the role of the various existing proteins as biomarkers in carcinogenesis and to assess the contribution of these proteins in anti-cancer activity, for consideration in therapeutic strategies. It is essential to both examine and evaluate the role of the various existing proteins as biomarkers in carcinogenesis and to assess the contribution of these proteins in anti-cancer activity, for consideration in therapeutic strategies. The purpose of this review is twofold. Firstly, it is to evaluate recent data about which proteins can be utilized as biomarkers in carcinogenesis. The proteins reviewed include: CPTP, IL-6, CCN, and S100. Secondly, it is to evaluate the contribution of dietary proteins in cancer activity. Specifically, how whey protein, soy proteins and lectin, a phytochemical could be useful in cancer prevention and treatment. RECENT FINDINGS: Whey protein, present in dairy products, is an excellent source of the sulphur amino acid cysteine, the rate limiting substrate in glutathione synthesis. Notably, this protein survives digestion and has been shown to have anti-carcinogenic properties in animal studies. Lectins are phytochemicals present in plant foods, and have active components which alters cancer initiation, promotion and progression. Lectins have been characterized as a useful tool in biochemistry, cell biology, immunology and in diagnostic and therapeutic purposes in cancer research. Soy proteins contain various compounds, including isoflavones, protease inhibitors and protein kinase inhibitors, which have been proven effective in tumor growth inhibition. They have therefore, been greatly emphasized in cancer prevention and treatment. It has been proved that soy food consumption was associated with decreased risk of death and recurrence of breast cancer. CPTP is a recently discovered protein whose main role is to transport C1P, a pro-inflammatory molecule. The discovery of CPTP may shine a light on the mechanism of inflammatory diseases, and hopefully offer a potential target for therapeutic purposes in cancer research. Interleukin-6 is a multifunctional cytokine that affects the activity of cancer cells. It is involved in tumor growth, and elevated levels is associated with an increased risk of cancer. S100B is a well-established biomarker for malignant melanoma, and useful in assessing tumor load, stage and prognosis for patients with this disease. Other members of this family of proteins include S100A4, which has been associated with several malignancies and S100A2, which has been found to be decreased in some cancers. CCN are a group of regulatory proteins, located in the extracellular matrix (maricellular). They are involved in cellular adhesion, mitogenesis, chemotaxis, cell survival, and wound healing. CCN proteins are also able to modulate the signals of several proteins, which may also influence skeletal development and angiogenesis. Many of the functions of these proteins are thus also related to tumor growth. Furthermore, CCN interacts with estrogen in the development of cancer, and is implicated in some breast and ovarian cancers.

Preoperative evaluation for lung cancer resection.

During the last decades lung cancer is the leading cause of death worldwide for both sexes. Even though cigarette smoking has been proved to be the main causative factor, many other agents (e.g., occupational exposure to asbestos or heavy metals, indoor exposure to radon gas radiation, particulate air pollution) have been associated with its development. Recently screening programs proved to reduce mortality among heavy-smokers although establishment of such strategies in everyday clinical practice is much more difficult and unknown if it is cost effective compared to other neoplasms (e.g., breast or prostate cancer). Adding severe comorbidities (coronary heart disease, COPD) to the above reasons as cigarette smoking is a common causative factor, we could explain the low surgical resection rates (approximately 20-30%) for lung cancer patients. Three clinical guidelines reports of different associations have been published (American College of Chest Physisians, British Thoracic Society and European Respiratory Society/European Society of Thoracic Surgery) providing detailed algorithms for preoperative assessment. In the current mini review, we will comment on the preoperative evaluation of lung cancer patients.

Airway inflammation in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is an inflammatory airway disease whose incidence and mortality increases every year. It is associated with an abnormal inflammatory response of the lung to toxic particles or gases (usually cigarette smoke). A central role in the pathophysiology has been shown to play a chronic inflammation of the airways that is expressed primarily by hypersecretion of mucus, stenosis of the smaller airways and the establishment of pulmonary emphysema. There is an increasing trend for assessing the inflammatory pattern of inflammatory airway diseases through mediators measured by noninvasive techniques. Markers in biological fluids and exhaled air have been the subject of intense evaluation over the past few years, with some of them reaching their introduction into clinical practice, while others remain as research tools. Of particular interest for the scientific community is the discovery of clinically exploitable biomarkers associated with specific phenotypes of the disease. Studying the effects of therapeutic interventions in these biomarkers may lead to targeted therapy based on phenotype and this is perhaps the future of therapeutics in COPD.

Surgical management of cardiac implantable electronic device infections.

PURPOSE: The infection of cardiac implantable electronic devices (CIED) is a serious and potentially lethal complication. The population at risk is growing, as the device implantation is increasing especially in older patients with associated comorbid conditions. Our purpose was to present the management of this complicated surgical condition and to extract the relevant conclusions. METHODS: During a 3-year period 1,508 CIED were implanted in our hospital. We treated six cases of permanent pacemaker infection with localized pocket infection or endocarditis. In accordance to the recent AHA/ACC guidelines, complete device removal was decided in all cases. The devices were removed under general anaesthesia, with a midline sternotomy, under extracorporeal circulation on the beating heart. Epicardial permanent pacing electrodes were placed on the right atrium and ventricle before the end of the procedure. RESULTS: The postoperative course of all patients was uncomplicated and after a follow up period of five years no relapse of infection occurred. CONCLUSIONS: Management protocols that include complete device removal are the only effective measure for the eradication of CIED infections. Although newer technologies have emerged and specialized techniques of percutaneous device removal have been developed, the surgical alternative to these methods can be a safe solution in cases of infected devices.

Thirteen years follow-up of heart myxoma operated patients: what is the appropriate surgical technique?

BACKGROUND: Cardiac myxoma is a benign neoplasm that represents the most prevalent primary tumor of the heart. If not treated with the right surgical technique recurrence occurs. Aim of our study is to present our surgical approach and the histology of the tumors resected. METHODS: All patients, except for one, underwent extracorporeal circulation and mild hypothermia, right atrial or both atrial incision and excision of the fossa ovalis, followed by prosthetic patch suturing. All specimens were submitted for microscopic evaluation (haematoxylin-eosin). We contacted personally each patient and asked them to complete a standardized questionnaire, concerning their peri-operative characteristics. RESULTS: Six cases were "active" myxomas, 3 were "mildly active" and 3 were "inactive". "Normal differentiation" was seen in 6, "medium" in 1 and "poor" in 5 cases. In our series there were no recurrences recorded during the follow-up period. CONCLUSIONS: The ideal approach, according to our experience is right atrial or both atrial incision as described by Shumacker and King, with excision of the fossa ovalis and the surrounding tissues and closure with a pericardial patch. Such a technique provides an excellent long-term survival in these patients.

Cerebral oximetry in cardiac anesthesia.

Cerebral oximetry based on near-infrared spectroscopy (NIRS) is increasingly used during the perioperative period of cardiovascular operations. It is a noninvasive technology that can monitor the regional oxygen saturation of the frontal cortex. Current literature indicates that it can stratify patients preoperatively according their risk. Intraoperatively, it provides continuous information about brain oxygenation and allows the use of brain as sentinel organ indexing overall organ perfusion and injury. This review focuses on the clinical validity and applicability of this monitor for cardiac surgical patients.

Effect of lornoxicam in lung inflammatory response syndrome after operations for cardiac surgery with cardiopulmonary bypass.

BACKGROUND: The establishment of Extracorporeal Circulation (EC) significantly contributed to improvement of cardiac surgery, but this is accompanied by harmful side-effects. The most important of them is systemic inflammatory response syndrome. Many efforts have been undertaken to minimize this problem but unfortunately without satisfied solution to date. MATERIALS AND METHODS: Lornoxicam is a non steroid anti-inflammatory drug which temporally inhibits the cycloxygenase. In this clinical trial we study the effect of lornoxicam in lung inflammatory response after operations for cardiac surgery with cardiopulmonary bypass. In our study we conclude 14 volunteers patients with ischemic coronary disease undergoing coronary artery bypass grafting with EC. In seven of them 16 mg lornoxicam was administered iv before the anesthesia induction and before the connection in heart-lung machine. In control group (7 patients) we administered the same amount of normal saline. RESULTS: Both groups are equal regarding pro-operative and intra-operative parameters. The inflammatory markers were calculated by Elisa method. We measured the levels of cytokines (IL-6, IL-8, TNF-a), adhesion molecules (ICAM-1, e-Selectin, p-Selectin) and matrix metaloproteinase-3 (MMP-3) just after anesthesia induction, before and after cardiopulmonary bypass, just after the patients administration in ICU and after 8 and 24 hrs. In all patients we estimated the lung's inflammatory reaction with lung biopsy taken at the begging and at the end of the operation. We calculated hemodynamics parameters: Cardiac Index (CI), Systemic Vascular Resistance Index (SVRI), Pulmonary Vascular Resistance Index (PVRI), Left Ventricular Stroke Work Index (LVSWI), Right Ventricular Stroke Work Index (RVSWI), and the Pulmonary arterial pressure, and respiratory parameters too: alveolo-arterial oxygen difference D (A-a), intrapulmonary shunt (Qs/Qt) and pulmonary Compliance. IL-6 levels of lornoxicam group were statistical significant lower at 1st postoperative day compared to them of control group (113±49 and 177±20 respectively, P=0.008). ICAM-1 levels were statistical significant lower at the patient admission in ICU, compared to them of control group (177±29 and 217±22 respectively, P=0.014), and the 1st postoperative day compared to them in control group (281±134 and 489±206 respectively, P=0.045). P-selectin levels were statistical significant lower, compared to them in control group in four measurements (97±23 and 119±7 respectively, P=0.030, 77±19 and 101±20 respectively, P=0.044, 86±4 and 105±13 respectively, P=0.06, 116±13 and 158±17 respectively, P=0.000). CONCLUSIONS: Hemodynamics and respiratory parameters were improved compared to control group, but these differences was not statistical significant. Eosinofil adhesion and sequestration in intermediate tissue of lung parenchyma were significantly lower compared to control group. Also, alveolar edema was not noted in lornoxicam's group. Lornoxicam reduce the inflammatory response in patients undergone coronary artery bypass grafting with extracorporeal circulation. This calculated from levels reduction of IL-6, ICAM-1 και p-Selectin, and from lung pathologoanatomic examination (absence of alveolar edema, reduce in eosinofil adhesion and sequestration in intermediate tissues). Despite the favorable effect of lornoxicam on the hemodinamics and respiratory parameters these improvement did not seem to be statistical significant.

Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance.

Transthoracic needle biopsy (TTNB) is done with imaging guidance and most frequently by a radiologist, for the aim is to diagnose a defined mass. It is integral in the diagnosis and treatment of many thoracic diseases, and is an important alternative to more invasive surgical procedures. FNAC is a method of aspiration cytopathology, which with transthoracic biopsy ("core biopsy") is a group of percutaneous minimally invasive diagnostic procedures for exploration of lung lesions. Needle choice depends mostly upon lesion characteristics and location. A recent innovation in biopsy needles has been the introduction of automatic core biopsy needle devices that yield large specimens and improve the diagnostic accuracy of needle biopsy. Both computed tomography and ultrasound may be used as imaging guidance for TTNB, with CT being more commonly utilized. Common complications of TTNB include pneumothorax and hemoptysis. The incidence of pneumothorax in patients undergoing TTNB has been reported to be from 9-54%, according to reports published in the past ten years, with an average of around 20%. Which factors statistically correlate with the frequency of pneumothorax remain controversial, but most reports have suggested that lesion size, depth and the presence of emphysema are the main factors influencing the incidence of pneumothorax after CT-guided needle biopsy. On the contrary, gender, age, and the number of pleural passes have not been shown to correlate with the incidence of pneumothorax. The problem most responsible for complicating outpatient management, after needle biopsy was performed, is not the presence of the pneumothorax per se, but an increase in the size of the pneumothorax that requires chest tube placement and patient hospitalization. Although it is a widely accepted procedure with relatively few complications, precise planning and detailed knowledge of various aspects of the biopsy procedure is mandatory to avert complications.

Intensive care unit and lung cancer: when should we intubate?

Lung cancer still remains the leading cause of cancer death among males. Several new methodologies are being used in the everyday practise for diagnosis and staging. Novel targeted therapies are being used and others are being investigated. However; early diagnosis still remains the cornerstone for efficient treatment and disease management. Lung cancer patients requires in many situations intensive care unit (ICU) admission, either due to the necessity for supportive care until efficient disease symptom control (respiratory distress due to malignant pleural effusion) or disease adverse effect management (massive pulmonary embolism). In any case guidelines indicating the patient that has to be intubated have not yet been issued. In the current review we will present current data and finally present an algorithm based on the current published information for lung cancer patients that will probably benefit from admission to the ICU.

Therapeutic procedure in small cell lung cancer.

Small cell lung cancer (SCLC) represents 12.95% of all lung cancer diagnoses and continues to be a major clinical problem, with an aggressive clinical course and short disease-free duration after 1st line therapy. Treatment of SCLC remains challenging because of its rapid growth and development of drug resistance during the course of the disease. Chemotherapy remains the current optimal treatment and radical thoracic radiotherapy representing the best treatment option for fit patients with LD. Platinum-based chemotherapy is the treatment of choice in patients with good performance status, and the effect of cisplatin is important for concurrent chemoradiotherapy in LD cause of his radiosensitivity. Patients with progress disease after first-line chemotherapy have poor prognosis. Second-line therapy may produce a modest clinical benefit. A number of targeted agents have been investigated in LD and ED, mostly in unselected populations, with disappointing results. Prophylactic cranial irradiation (PCI) is recommended only for patients who had full response to first line chemotherapy, as target of improving overall survival and decreasing possibilities of brain metastases. New factors for target therapy are the hope for the management of this systematic disease. If we identify these targets for treatment of SCLC and overcome drug-resistance mechanisms, we will create new chemo-radiotherapy schedules for future.

Lung cancer surgery: an up to date.

According to the International Agency for Research on Cancer (IARC) GLOBOCAN World Cancer Report, lung cancer affects more than 1 million people a year worldwide. In Greece according to the 2008 GLOBOCAN report, there were 6,667 cases recorded, 18% of the total incidence of all cancers in the population. Furthermore, there were 6,402 deaths due to lung cancer, 23.5% of all deaths due to cancer. Therefore, in our country, lung cancer is the most common and deadly form of cancer for the male population. The most important prognostic indicator in lung cancer is the extent of disease. The Union Internationale Contre le Cancer (UICC) and the American Joint Committee for Cancer Staging (AJCC) developed the tumour, node, and metastases (TNM) staging system which attempts to define those patients who might be suitable for radical surgery or radical radiotherapy, from the majority, who will only be suitable for palliative measures. Surgery has an important part for the therapy of patients with lung cancer. "Lobectomy is the gold standard treatment". This statement may be challenged in cases of stage Ia cancer or in patients with limited pulmonary function. In these cases an anatomical segmentectomy with lymph node dissection is an acceptable alternative. Chest wall invasion is not a contraindication to resection. En-bloc rib resection and reconstruction is the treatment of choice. N2 disease represents both a spectrum of disease and the interface between surgical and non-surgical treatment of lung cancer Evidence from trials suggests that multizone or unresectable N2 disease should be treated primarily by chemoradiotherapy. There may be a role for surgery if N2 is downstaged to N0 and lobectomy is possible, but pneumonectomy is avoidable. Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. The efficacy of surgical intervention for SCLC is not clear. Lung cancer resection can be performed using several surgical techniques. Video-assisted thoracoscopic surgery (VATS) lobectomy is a safe, efficient, well accepted and widespread technique among thoracic surgeons. The 5-year survival rate following complete resection of lung cancer is stage dependent. Incomplete resection rarely is useful and cures the patient.

Video assisted thoracoscopic plication of the left hemidiaphragm in symptomatic eventration in adulthood.

Diaphragmatic eventration is a rare congenital developmental defect of the muscular portion of the diaphragm, which appears attenuated and membranous, maintaining its normal attachments and its anatomical continuity. It has been attributed to abnormal myoblast migration to the septum transversum and the pleuroperitoneal membrane. Eventration can be unilateral or bilateral, partial or complete. It is more common in males, and involves more often the left hemidiaphragm. Eventration results in diaphragmatic elevation (cephalad displacement). Most adults are asymptomatic and the diagnosis is incidentally made by chest radiography. The commonest symptom in the adults is dyspnoea, while orthopnoea, mild hypoxemia, tachypnoea, respiratory alkalosis, palpitations, and non specific gastrointestinal symptoms may be present. Surgery is indicated only in the presence of symptoms. The established surgical treatment is diaphragmatic plication. Various techniques and approaches have been employed. We present a simple surgical technique of a 3-port video assisted thoracoscopic plication of the left hemidiaphragm in the adult.

Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature.

OBJECTIVE: Spontaneous recurrent pneumothorax during menstruation is reported as catamenial pneumothorax. It is encountered in 3-6% of spontaneous pneumothorax cases among menstruating women. The percentage among women referred for surgery is significantly higher (25-30%). Although it usually involves the right-side (85-95%) it can be left-sided or bilateral. It is associated with diaphragmatic perforations and/or thoracic endometriosis. There is pelvic endometriosis in up to 30-51% of cases. The lesions that are not always found may present as small or larger holes at the central tendon of the diaphragm, as red, blueberry, brown spots or larger nodules at the diaphragm, the visceral or parietal pleura. Lesion histology may reveal endometriosis. We present 5 cases of catamenial pneumothorax treated surgically during the last 6 years. PATIENTS AND METHODS: Five women, with a mean age of 34+/-9.9 years (median 38, range, 19-45 years) presented with right-sided recurrent catamenial pneumothorax. In 3 patients diaphragmatic perforation(s) were found; perforation suturing (n=1), and diaphragmatic plication reinforced with bovine pericardial patch (n=1) were performed. All patients underwent atypical resection of upper and/or middle lobe segments of lung parenchyma that appeared abnormal (haemorrhagic/emphysematous or blebs). Four patients underwent pleurodesis and 1 patient underwent pleurectomy. Four interventions were performed through video assisted thoracoscopic surgery, while diaphragmatic plication was performed through a video assisted mini-thoracotomy. Histology did not reveal endometriosis tissue. RESULTS: The postoperative course was uneventful. The patients were extubated in theatre and were discharged home at a mean of 7+/-4 days (median 6 days, range, 4-14 days). Two of them received hormonal therapy [Gonadotropin Releasing Hormone (GnRH) analogue] postoperatively. At a follow-up of 14.16 patient-years (mean 2.83+/-1.08 years, range, 1.33-3.83 years) there was recurrence, 6.5 months postoperatively, in one patient that had not undergone closure of a tiny diaphragmatic hole and had not received hormonal treatment postoperatively. She was treated medically (amenorrhea for 6 months with GnRH analogue) and had no further recurrences (in 3.3 years). CONCLUSIONS: Surgery is the treatment of choice of catamenial pneumothorax. It should aim to complete management of all lesions. The most common complication is recurrence. Early diagnosis and multidisciplinary treatment including hormonal therapy may be beneficial in high risk patients.