Vagal nerve endings in visceral pleura and triangular ligaments of the rat lung.

The inner thoracic cavity is lined by the parietal pleura, and the lung lobes are covered by the visceral pleura. The parietal and visceral plurae form the pleural cavity that has negative pressure within to enable normal respiration. The lung tissues are bilaterally innervated by vagal and spinal nerves, including sensory and motor components. This complicated innervation pattern has made it difficult to discern the vagal vs. spinal processes in the pulmonary visceral pleura. With and without vagotomy, we identified vagal nerve fibres and endings distributed extensively in the visceral pleura ('P'-type nerve endings) and triangular ligaments ('L'-type nerve endings) by injecting wheat germ agglutinin-horseradish peroxidase as a tracer into the nucleus of solitary tract or nodose ganglion of male Sprague-Dawley rats. We found the hilar and non-hilar vagal pulmonary pleural innervation pathways. In the hilar pathway, vagal sub-branches enter the hilum and follow the pleural sheet to give off the terminal arborizations. In the non-hilar pathway, vagal sub-branches run caudally along the oesophagus and either directly enter the ventral-middle-mediastinal left lobe or follow the triangular ligaments to enter the left and inferior lobe. Both vagi innervate: (i) the superior, middle and accessory lobes on the ventral surfaces that face the heart; (ii) the dorsal-rostral superior lobe; (iii) the dorsal-caudal left lobe; and (iv) the left triangular ligament. Innervated only by the left vagus is: (i) the ventral-rostral and dorsal-rostral left lobe via the hilar pathway; (ii) the ventral-middle-mediastinal left lobe and the dorsal accessory lobe that face the left lobe via the non-hilar pathway; and (iii) the ventral-rostral inferior lobe that faces the heart. Innervated only by the right vagus, via the non-hilar pathway, is: (i) the inferior (ventral and dorsal) and left (ventral only) lobe in the area near the triangular ligament; (ii) the dorsal-middle-mediastinal left lobe; and (iii) the right triangular ligament. Other regions innervated with unknown vagal pathways include: (i) the middle lobe that faces the superior and inferior lobe; (ii) the rostral-mediastinal inferior lobe that faces the middle lobe; and (iii) the ventral accessory lobe that faces the diaphragm. Our study demonstrated that most areas that face the dorsal thoracic cavity have no vagal innervation, whereas the interlobar and heart-facing areas are bilaterally or unilaterally innervated with a left-rostral vs. right-caudal lateralized innervation pattern. This innervation pattern may account for the fact that the respiratory regulation in rats has a lateralized right-side dominant pattern.

Inhibitory responses in Aplysia pleural sensory neurons act to block excitability, transmitter release, and PKC Apl II activation.

Expression of the 5-HT(1Apl(a)) receptor in Aplysia pleural sensory neurons inhibited 5-HT-mediated translocation of the novel PKC Apl II in sensory neurons and prevented PKC-dependent synaptic facilitation at sensory to motoneuron synapses (Nagakura et al. 2010). We now demonstrate that the ability of inhibitory receptors to block PKC activation is a general feature of inhibitory receptors and is found after expression of the 5-HT(1Apl(b)) receptor and with activation of endogenous dopamine and FMRFamide receptors in sensory neurons. Pleural sensory neurons are heterogeneous for their inhibitory response to endogenous transmitters, with dopamine being the most prevalent, followed by FMRFamide, and only a small number of neurons with inhibitory responses to 5-HT. The inhibitory response is dominant, reduces membrane excitability and synaptic efficacy, and can reverse 5-HT facilitation at both naive and depressed synapses. Indeed, dopamine can reverse PKC translocation during the continued application of 5-HT. Reversal of translocation can also be seen after translocation mediated by an analog of diacylglycerol, suggesting inhibition is not through blockade of diacylglycerol production. The effects of inhibition on PKC translocation can be rescued by phosphatidic acid, consistent with the inhibitory response involving a reduction or block of production of this lipid. However, phosphatidic acid could not recover PKC-dependent synaptic facilitation due to an additional inhibitory effect on the non-L-type calcium flux linked to synaptic transmission. In summary, we find a novel mechanism downstream of inhibitory receptors linked to inhibition of PKC activation in Aplysia sensory neurons.

Novel insights in the neurochemistry and function of pulmonary sensory receptors.

Afferent nerves in the airways and lungs contribute to optimisation of the breathing pattern, by providing local pulmonary information to the central nervous system. Airway sensory nerve terminals are consequently tailored to detect changes readily in the physical and chemical environment, thereby leading to a variety of respiratory sensations and reflex responses. Most intrapulmonary nerve terminals arise from fibres travelling in the vagal nerve, allowing a classification of "sensory airway receptors", based on their electrophysiologically registered action potential characteristics. Nowadays, at least six subtypes of electrophysiologically characterised vagal sensory airway receptors have been described, including the classical slowly and rapidly adapting (stretch) receptors and C-fibre receptors. The architecture of airways and lungs makes it, however, almost impossible to locate functionally the exact nerve terminals that are responsible for transduction of a particular intrapulmonary stimulus. With the advances in immunohistochemistry in combination with confocal microscopy, airway sensory receptor end organs can now be examined and evaluated objectively. Based on their "neurochemical coding", morphology, location and origin, three sensory receptor end organs are currently morphologically well characterised: smooth muscle-associated airway receptors (SMARs), neuroepithelial bodies (NEBs) and visceral pleura receptors (VPRs). The present information on the functional, morphological and neurochemical characteristics of these sensory receptors leads to important conclusions about their (possible) function. Currently, ex vivo lung models are developed that allow the selective visualisation of SMARs, NEBs and VPRs by vital staining. The described ex vivo models will certainly facilitate direct physiological studies of the morphologically and neurochemically identified airway receptors, thereby linking morphology to physiology by identifying in situ functional properties of a given receptor end organ.

Anatomy of the pleura.

The pleura is a monolayer of mesothelial cells covering the lung and inner surface of the chest cavity, creating the pleural space. The mesothelial cells rest on a matrix of collagen, elastic fibers, blood vessels, and lymphatics, which allow the lung and chest to expand and contract, protected from friction by the pleural fluid and properties of the mesothelial cells. With a rich blood supply and lymphatic system just deep to the mesothelial layer, the pleura is a dynamic layer protecting the lung and pleural cavity from infection while transmitting the forces of respiration without damage to the underlying lung parenchyma.

Ultrasound-Guided Midpoint Transverse Process to Pleura Nerve Block for Medical Thoracoscopy: A Case Report.

We performed the midpoint transverse process to pleura (MTP) block in a patient with a recurrent pleural effusion requiring medical thoracoscopy, drainage of pleural effusion, talc poudrage, and placement of tunneled pleural catheter under sedation while in the left lateral decubitus position. Forty milliliters of a combination of bupivacaine hydrochloride and lidocaine, with dexamethasone and clonidine as adjuvants, was injected at the T6 level under ultrasound guidance with satisfactory intra- and postoperative analgesia.

Effects of Catheter Tip Location on the Spread of Sensory Block Caused by a Continuous Thoracic Paravertebral Block: A Prospective, Randomized, Controlled, Double-Blind Study.

Single injections in the anterior region of the thoracic paravertebral space (TPVS) have been reported to generate a multisegmental longitudinal spreading pattern more frequently than those in the posterior region of the TPVS. In this trial, we examined the hypothesis that a continuous thoracic paravertebral block (TPVB) administered through a catheter inserted into the anterior region of the TPVS allows a wider sensory block dispersion. Fifty consecutive patients undergoing video-assisted thoracic surgery were enrolled. Before the surgery, an infusion catheter was inserted into the TPVS through a needle placed adjacent to either the parietal pleura (group A) or internal intercostal membrane (group P) using an ultrasound-guided intercostal transverse approach according to a randomized allocation schedule. A chest radiograph was obtained postoperatively after injection of 10 mL of radiopaque dye through the catheter. Thereafter, 20 mL of 0.375% levobupivacaine was injected via the catheter, followed by commencement of continuous TPVB with 0.25% levobupivacaine at 8 mL/h. The primary outcome was the number of blocked dermatomes at 24 h after surgery. The secondary outcomes included radiopaque dye spreading patterns, the number of segments reached by the radiopaque dye, the number of blocked dermatomes at 2 h after surgery, and pain scores. The median (interquartile range [range]) number of blocked dermatomes 24 h after surgery was 3 (2.75-4 [1-6]) in group A (n = 22) and 2 (1.5-3 [0-7]) in group P (n = 25; p = 0.037). No significant differences in the other outcomes were found between the groups. In conclusion, a continuous TPVB administered using a catheter supposedly inserted into the anterior region of the TPVS allows a wider sensory block dispersion than a catheter inserted into the posterior region of the TPVS. This trial is registered with the UMIN Clinical Trials Registry (UMIN000018578).

Evidence of innervation in talc-induced pleural adhesions.

STUDY OBJECTIVES: To conduct a detailed morphologic and ultrastructural study of pleural adhesions following talc pleurodesis. METHODS: Talc with a main particle size of 8.36 +/- 0.2 mum (mean +/- SEM) and at a dose of 200 mg/kg in a 2-mL slurry was instilled via a small catheter into the pleural cavity of 10 male rabbits. Five rabbits were killed at 1 week, and five rabbits were killed at 1 month after instillation. At autopsy, after macroscopically observing the pleural cavity, adhesions were excised from opposing pleural surfaces and processed for histopathologic, immunocytochemical, and ultrastructural study. RESULTS: At 1 week, all adhesions examined were mesothelium-covered fibrovascular bands containing well-developed blood and lymphatic vessels establishing a structural continuity between both pleural layers. Nerves were present in adhesions from 20% of the rabbits. They consisted of a single fascicle containing 5 to 20 thin myelinated axons of various diameters (1 to 6 microm) uniformly distributed throughout the nerve section. The anatomic location of the adhesion did not appear to influence its overall morphology. CONCLUSIONS: As early as at 1 week, adhesions are well-formed structures more resembling newly formed pleural tissue than a simple scar. Nerve fibers in pleural adhesions are reported for the first time, which suggests that these adhesions are potentially capable of conducting pain stimuli. Further studies are required in order to confirm our results in human pleural adhesions.

Spinal afferent neurons projecting to the rat lung and pleura express acid sensitive channels.

BACKGROUND: The acid sensitive ion channels TRPV1 (transient receptor potential vanilloid receptor-1) and ASIC3 (acid sensing ion channel-3) respond to tissue acidification in the range that occurs during painful conditions such as inflammation and ischemia. Here, we investigated to which extent they are expressed by rat dorsal root ganglion neurons projecting to lung and pleura, respectively. METHODS: The tracer DiI was either injected into the left lung or applied to the costal pleura. Retrogradely labelled dorsal root ganglion neurons were subjected to triple-labelling immunohistochemistry using antisera against TRPV1, ASIC3 and neurofilament 68 (marker for myelinated neurons), and their soma diameter was measured. RESULTS: Whereas 22% of pulmonary spinal afferents contained neither channel-immunoreactivity, at least one is expressed by 97% of pleural afferents. TRPV1+/ASIC3- neurons with probably slow conduction velocity (small soma, neurofilament 68-negative) were significantly more frequent among pleural (35%) than pulmonary afferents (20%). TRPV1+/ASIC3+ neurons amounted to 14 and 10% respectively. TRPV1-/ASIC3+ neurons made up between 44% (lung) and 48% (pleura) of neurons, and half of them presumably conducted in the A-fibre range (larger soma, neurofilament 68-positive). CONCLUSION: Rat pleural and pulmonary spinal afferents express at least two different acid-sensitive channels that make them suitable to monitor tissue acidification. Patterns of co-expression and structural markers define neuronal subgroups that can be inferred to subserve different functions and may initiate specific reflex responses. The higher prevalence of TRPV1+/ASIC3- neurons among pleural afferents probably reflects the high sensitivity of the parietal pleura to painful stimuli.

Respiratory and circulatory effects of parietal pleural afferent stimulation in rabbits.

Respiratory symptoms accompanying pleural diseases combine dyspnea, tachypnea, rapid shallow breathing, and sometimes hypotension. There are no experimental data on the changes in respiratory and circulatory functions elicited by the activation of pleural afferents. After removal of all muscles covering the 5th to 10th intercostal spaces, we investigated in paralyzed, vagotomized rabbits the changes in phrenic discharge, transpulmonary pressure, and systemic arterial pressure in response to an outwardly directed force exerted on the parietal pleura or the local application of solutions containing lactic acid or inflammatory mediators. Mechanical stimulation of the pleura induced an immediate decrease in both integrated phrenic discharge and arterial blood pressure, the responses being positively correlated with the magnitude of force applied on the pleura. No accompanying changes in ventilatory timing, transpulmonary pressure, or heart rate were measured. Lactic acid solution also elicited an inhibition of phrenic activity and a fall in blood pressure. Section of the internal intercostal nerves supplying the stimulated intercostal spaces totally abolished the responses to mechanical stimulation or lactic acid. An inflammatory mixture elicited only modest respiratory and circulatory effects. We concluded that an acute mechanical distension of the parietal pleura as well as its chemical stimulation by lactic acid elicit a marked inhibition of phrenic motoneurons combined to a reduction of the sympathetic outflow to the circulatory system.

The contribution of the pleural type 12 interneuron to swim acceleration in Clione limacina.

The pteropod mollusc, Clione limacina, swims by alternate dorsal-ventral flapping movements of its wing-like parapodia. The basic swim rhythm is produced by a network of pedal swim interneurons that comprise a swim central pattern generator (CPG). Serotonergic modulation of both intrinsic cellular properties of the swim interneurons and network properties contribute to swim acceleration, the latter including recruitment of type 12 interneurons into the CPG. Here we address the role of the type 12 interneurons in swim acceleration. A single type 12 interneuron is found in each of the pleural ganglia, which contributes to fast swimming by exciting the dorsal swim interneurons while simultaneously inhibiting the ventral swim interneurons. Each type 12 interneuron sends a single process through the pleural-pedal connective that branches in both ipsilateral and contralateral pedal ganglia. This anatomical arrangement allowed us to manipulate the influence of the type 12 interneurons on the swim circuitry by cutting the pleural-pedal connective followed by a "culture" period of 48 h. The mean swim frequency of cut preparations was reduced by 19% when compared to the swim frequency of uncut preparations when stimulated with 10(-6) M serotonin; however, this decrease was not statistically significant. Additional evidence suggests that the type 12 interneurons may produce a short-term, immediate effect on swim acceleration while slower, modulatory inputs are taking shape.

Serotoninergic varicosities make synaptic contacts with pleural sensory neurons of Aplysia.

Serotonin is a modulatory neurotransmitter that produces many of the cellular changes associated with sensitization of reflexes in Aplysia. These changes have been carefully documented in sensory neurons located in the abdominal ganglion that mediate the gill-siphon withdrawal reflex and in sensory neurons located in the pleural ganglion that mediate the tail-siphon withdrawal reflex. Although serotonin appears to be necessary for sensitization, there is no direct evidence that serotoninergic neurons make synaptic contacts with sensory neurons. In this study, the immunoperoxidase technique was used to label serotonin-immunoreactive neurites surrounding the cell bodies of sensory neurons in the pleural ganglion. Serotonin-immunoreactive neurites had varicosities whose mean short axis diameter was 1.1 +/- 0.6 microns (mean +/- S.D.). The shape of the size distribution was skewed toward larger sizes, however, suggesting that there were multiple subpopulations of varicosities. One subpopulation was that of varicosities located at branch points whose average short axis diameter was larger than normal (1.7 +/- 0.5 microns). Serotonin-immunoreactive varicosities were directly apposed to the sensory neurons without intervening glial cells. In most contacts, serotonin-immunoreactive neurites invaginated into the plasma membranes of the sensory neurons. There were also a few contacts onto spinelike processes, but these were flat rather than invaginated. Serotoninergic neurons whose activity produces changes in the electrophysiological properties of sensory neurons have been identified, but this study provides the first direct evidence for synaptic connections between serotoninergic neurons and sensory neurons in Aplysia.

Distribution and developmental changes in GABA-like immunoreactive neurons in the central nervous system of pond snail, Lymnaea stagnalis.

We examined three-dimensionally the arrangement of gamma-aminobutyric acid (GABA)-like immunoreactive neurons in the central nervous system (CNS) of the pond snail, Lymnaea stagnalis, by a combination of immunohistochemistry and confocal laser scanning microscopy on whole-mount preparations. GABA-like immunoreactivity was detected in all ganglia of the adult CNS. The following distribution of immunoreactive cell bodies was noted in the adult snail. Buccal ganglia: one cell body and five pairs of cell bodies, cerebral ganglia: one pair of cell bodies, pedal ganglia: two single cell bodies, two pairs of cell bodies, and three pairs of cell clusters, and pleural ganglia: one pair of cell bodies. In the asymmetrical parietal ganglia, three cell bodies were located in the left parietal ganglion; three cell bodies and three cell clusters were located in the right parietal ganglion. In the single visceral ganglion, a few scattered individual cell bodies and a cell cluster were GABA-like immunoreactive. Our results showed that the occurrence of GABA is widely spread in the CNS of adult L. stagnalis. GABA-like immunoreactivity in the CNS was not detected in the embryo but was observed after hatching, although the number of stained cells was less than in the adult, with the exception of those in the cerebral ganglia where their number decreased with maturation. Our results provide detailed maps of the central GABA-like immunoreactive neurons in juveniles, immatures, and adults of L. stagnalis.

Long-term changes in synthesis of intermediate filament protein, actin and other proteins in pleural sensory neurons of Aplysia produced by an in vitro analogue of sensitization training.

Electrical stimulation of peripheral nerves of isolated pleural-pedal ganglia, an in vitro analogue of long-term behavioral training in Aplysia, produced changes in the synthesis of specific proteins in pleural sensory neurons. The changes in incorporation of [35S]methionine into proteins occurring 24 h after electrical stimulation (late) were determined and compared with changes occurring immediately after stimulation (early). Eight proteins were affected 24 h after electrical stimulation. Three of these proteins were also affected immediately after electrical stimulation. Two of the proteins affected late are components of the cytoskeleton. One protein was identified as actin. The other protein was purified from preparative 2D-gels and partial amino acid sequences of 3 peptides derived from this protein were determined. The peptide sequences were found to be identical to those of an Aplysia intermediate filament protein.

Monoamine-containing neurons in the Aplysia brain.

The localization of monoamine-containing neurons in the CNS of Aplysia depilans has been studied by fluorescent histochemistry (the glyoxylic acid condensation method) and microspectrofluorimetry. Yellow fluorescent nerve cells and fibers show the emission maximum at 515-520 nm which corresponds to that of serotonin fluorophore in a model system. Green fluorescent nerve cells have the emission maximum at 485 nm which corresponds to that of catecholamine. Central catecholamine-containing neurons were found in cerebral, buccal, pedal and unpaired abdominal ganglia. The majority of them were revealed in cerebral ganglia (about 40). Serotonin-containing neurons are abundant in cerebral and pedal ganglia. More than 30 serotonin-containing nerve cells were localized in cerebral ganglia. In the right pedal ganglion approximately 100 neurons were revealed; in the left one about 150. In the abdominal ganglion all nerve cells of this chemical type (except one) are located in the right hemiganglion. The results are summarized in corresponding schemes.

Role of kinins and sensory neurons in the rat pleural leukocyte migration induced by Phoneutria nigriventer spider venom.

The leukocyte migration induced by Phoneutria nigriventer spider venom (PNV) has been investigated in rats using the pleurisy model. Intrapleural injection of PNV (10-100 microg/cavity) caused a dose- and time-dependent leukocyte accumulation. The bradykinin B(2) receptor antagonist Hoe 140 (0.5 mg/kg) substantially inhibited PNV-induced cell accumulation, whereas the angiotensin-converting enzyme inhibitor captopril (2 mg/kg) potentiated by 80% this effect. The non-specific kallikrein inhibitor aprotinin and the plasma kallikrein inhibitor soybean trypsin inhibitor greatly reduced PNV-induced leukocyte migration, whereas the selective tissue kallikrein inhibitor P(ac)-F-S-R-EDDnp failed to affect PNV-induced responses. Treatment of rats with capsaicin (50 mg/kg) at the neonatal stage resulted in 67% inhibition of the PNV-induced cell migration. The neurokinin NK(1) receptor antagonist SR140333, but not the NK(2) receptor antagonist SR48968, reduced by 55% venom-induced cell accumulation. We conclude that bradykinin generation is involved in the PNV-induced pleural leukocyte migration in rats, where it can directly activate sensory nerves contributing to a neurogenic inflammatory mechanism.

Cholinergic nerves in the parietal pleura.

Using the cholinesterase histochemical technique we investigated the innervation pattern of parietal pleura both in normal and chemically sympathectomized rats. AChE containing nerve fiber-like structures were observed within the parietal pleura. The apex, costal, and mediastinal surfaces of the pleura are poorly innervated, while the diaphragmatic pleura shows the richest innervation. In relation with thicker nerve fiber-like structures the existence of some elbow shaped AChE positive formation was observed. The chemical sympathectomy does not causes alterations in the distribution of AChE containing nerves in the pleura. The meaning of cholinergic innervation of parietal pleura is discussed.

Widespread anatomical projections of the serotonergic modulatory neuron, CB1, in Aplysia.

Although sensitization-related changes in the neural circuitry of withdrawal reflexes in Aplysia are well studied, relatively few studies address the organization of the modulatory components of sensitization. In particular, it is not known whether individual modulatory loci can simultaneously influence multiple reflex circuits. There is, however, evidence that a single modulatory transmitter, serotonin, plays a pivotal role in facilitating different reflex circuits during sensitization. Furthermore, it is known that activation of a pair of serotonergic neurons, the CB1s, produces heterosynaptic facilitation of the sensorimotor connections of one of these reflex circuits. These data together raise the possibility that the CB1s may produce sensitizing changes in the neural elements of multiple reflex systems simultaneously. In the present study, we utilized immunocytochemistry and intracellular labeling to obtain anatomical evidence of CB1's possible role in modulating multiple reflex circuits. We found that two distinct neurons satisfy previously published physiological criteria for CB1. One of these, CB1, is immunoreactive to serotonin. The second cell, here named CB2, has a different neuroanatomy and is not serotonin immunoreactive. Focusing on CB1, we found (1) profuse fine processes given off by its axons in the posterior neuropil of the cerebral ganglion, (2) extensive branching and fine processes in the pleural ganglion, and (3) a branch of CB1 that projects into the pedal ganglion. These three observations are consistent with the hypothesis that, in addition to its already established role in modulating the siphon withdrawal circuit, CB1 may also modulate synaptic connections between (1) the sensory and motor neurons of the tentacle withdrawal reflex (2) the sensory neurons and interneurons of the tail and tail-elicited siphon withdrawal reflex, and (3) the sensory and motor neurons of the tail withdrawal reflex. These observations support further physiological investigations of a possible global role of CB1 in modulating the tail and tentacle withdrawal reflexes.

Pleuro-buccal projections in pulmonate molluscs.

Using a nickel lysine axonal filling technique, neurons of the CNS that project to the cerebro-buccal connective in pulmonate snails and slugs were stained. In all species examined, a symmetrical, supposedly homologous pair of small neurons situated in the pleural ganglia have been identified. These neurons possess a unique axonal pathway which traverses the ipsilateral pedal ganglion on its way to the cerebral ganglia. The list of species includes both basomatophoran, fresh-water molluscs (Lymnaea stagnalis, L. auricularia, Planorbarius corneus) and stylommatophoran, terrestrial ones (Fruticicola fruticum, Helix pomatia, H. lucorum, Limax cinerea-niger). It is suggested that the paired pleural cells might be involved in the neuronal mechanism for co-ordination of defensive withdrawal with inhibition of feeding.

[The monoaminergic innervation of the mediastinal pleura in human fetuses]. / Monoaminergicheskaia innervatsiia mediastinal'noi plevry plodov cheloveka.

Mediastinal pleura was studied in pregnancy second part abortive human fetuses using histological and histochemical technique. It was found to have a well-developed monoaminergic apparatus that includes adrenergic axons and mast cells. Electron microscope study confirmed monoaminergic and single peptidergic vesicles presence in axons. Luminescent method revealed that mast cells of nerve plexuses and blood vessels contain catecholamines and indolalkylamines. Monoaminergic axons and mast cells were shown to constitute a functionally integrative apparatus that regulates local hemodynamics and trophics.

Cervical incision thoracic endoscopic surgery: a minimally invasive endoscopic approach in thoracic surgery.

Cervical incision thoracic surgery has recently been described. Currently, there is a move to increase the role of flexible endoscopy in surgery. The use of a flexible endoscope through a natural orifice into the thoracic cavity still remains ethically doubtful. The authors present a surgical experimental study using a flexible endoscope through a cervical incision for the exploration of both the mediastinum and the thoracic cavity in a cadaver. An experimental work on 10 refrigerated and non-embalmed cadavers was initiated. We used a unique device - a standard double-channel flexible video gastroscope. Through a small cervical incision, we performed simultaneous exploration of the mediastinum and both pleural cavities. Identification and biopsies of mediastinal lymph nodes at levels 2R, 4R, 7 and 4L were easy to perform in all subjects. In eight cadavers, we performed an assessment of bilateral pleural cavities and multiple pleural biopsies as well as bilateral thoracic sympathectomy. A chest tube was placed in the thoracic cavity at the end of all pleural procedures. The potential advantages of this approach are simultaneous exploration of the mediastinum and pleura and the performance of several thoracic interventions through a small cervical incision. The flexible endoscope could become a surgical tool for thoracic surgery.