Paravertebral tumours of the cervicothoracic junction extending into the mediastinum: surgical strategies in a no man's land.

PURPOSE: Cervicothoracic paravertebral neoplasms extending into the mediastinum pose a surgical challenge due the complex regional anatomy, their biological nature, rarity and surgeon's unfamiliarity with the region. We aim to define a surgical access framework addressing the aforementioned complexities whilst achieving oncological clearance. METHODS: We carried out a retrospective review of 28 consecutive patients operated in two tertiary referral centres between 1998 and 2015. Pathology was located paravertebrally from C6 to T4 with superior mediastinum invasion. Patients were operated jointly by a spinal and a thoracic surgeon. RESULTS: Tumours were classified according to subclavian fossa involvement as anteromedial, anterolateral and posterior and according to histology in benign nerve sheath tumour group (n = 10) and malignant bone or soft tissue tumours (n = 18). Three surgical routes were utilised: (1) median sternotomy (n = 11), (2) anterior cervical transsternal approach (n = 7) and (3) high posterolateral thoracotomy (n = 10). Resection was en bloc with wide margins in 22 cases, marginally complete in 3 and incomplete in 3. Complications included Horner's syndrome (n = 3), infection (n = 2) and transient neurological deficit (n = 4). In the nerve sheath tumour group, no recurrence or reoperation took place with a median follow-up of 4.5 years. In the malignant bone and soft tissue group, 96% of the patients were alive at 1 year, 67% at 2 years and 33% at 5 years. No vascular injuries or operative related deaths were observed. CONCLUSIONS: Classification of cervicothoracic paravertebral neoplasms with mediastinal extension according to the relationship with the subclavicular fossa and dual speciality involvement allows for a structured surgical approach and provides minimal morbidity/maximum resection and satisfactory oncological outcomes. These slides can be retrieved under Electronic Supplementary Material.

Molecular profiling of colorectal pulmonary metastases and primary tumours: implications for targeted treatment.

This study aimed to molecularly characterise colorectal pulmonary metastases (PM) and investigate whether their molecular profiles were concordant with those of the primary tumour. Clinical data and archival formalin fixed paraffin embedded tissue samples were retrospectively collected from patients who underwent ≥ 1 pulmonary metastasectomies for colorectal cancer between 1997-2012. Primary tumour and metastatic samples were analysed using a targeted capture sequencing panel of 46 cancer-associated genes. The 5-year progression-free and overall survival rates for the 81 patients in this study were 32% (95% CI 22-42%) and 77% (95% CI 66-85%) respectively. Fifty-four patients had samples available from ≥ 1 PM, and sequencing data were successfully obtained from 33 PM from 24 patients. The most frequently mutated genes were APC (71%), KRAS (58%) and TP53 (46%). Seventy-three percent of the 15 patients with matched primary and PM samples and 6 of the 7 patients (86%) with data from ≥ 2 PM had concordant molecular profiles. The concordance for KRAS and NRAS was 100%. At our institutions, patients with resectable colorectal PM had a favourable prognosis. RAS mutations were commonly detected in PM and the molecular profiles of colorectal PM were highly concordant with the primary tumour.

Increasing frequency of non-smoking lung cancer: Presentation of patients with early disease to a tertiary institution in the UK.

BACKGROUND: Never-smokers with lung cancer often present late as there are no established aetiological risk factors. The aim of the study is to define the frequency over time and characterise clinical features of never-smokers presenting sufficiently early to determine if it is possible to identify patients at risk. METHODS: We retrospectively analysed data from a prospectively collected database of patients who underwent surgery. The frequency was defined as number of never-smokers versus current and ex-smokers by year. Clinical features at presentation were collated as frequency. RESULTS: A total of 2170 patients underwent resection for lung cancer from March 2008 to November 2014. The annual frequency of developing lung cancer in never-smokers increased from 13% to 28%, attributable to an absolute increase in numbers and not simply a change in the ratio of never-smokers to current and ex-smokers. A total of 436 (20%) patients were never-smokers. The mean age was 60 (16 SD) years and 67% were female. Presenting features were non-specific consisting of cough in 34%, chest infections in 18% and haemoptysis in 11%. A total of 14% were detected on incidental chest film, 30% on computed tomography, 7% on positron-emission tomography/computed tomography and 1% on MRI. CONCLUSIONS: We observed more than a double of the annual frequency of never-smokers in the last 7 years. Patients present with non-specific symptoms and majority were detected on incidental imaging, a modality that is likely to play an increasingly important role for early detection in this cohort that does not have any observable clinical risk factors.

Follicular dendritic cell tumour/sarcoma: a commonly misdiagnosed tumour in the thorax.

AIMS: Follicular dendritic cell sarcoma is a rare tumour reported to occur occasionally in association with the hyaline-vascular type of Castleman's disease (HVCD). Most cases arise in lymph nodes, although extranodal presentation is described. METHODS AND RESULTS: Clinical, radiological and histological characteristics, including diagnosis on pre-resection material, were assessed in seven intrathoracic cases from five males and two females with a median age of 38 years. Clinical symptoms were related to mass location, six cases presenting within central and/or posterior mediastinal compartments and one within the lungs. Positron emission tomography-computed tomography demonstrated marked fluoro-deoxy-glucose avidity and the prominent vessels traversing the lesions. Four of six cases (67%) were misdiagnosed initially. HVCD was present in three cases. Two cases with high mitotic rates recurred after resection. All were positive for at least one of the follicular dendritic cell markers (CD21, CD35 and CD23). Six of seven cases (86%) show cyclin D1 expression ranging from 5% to 90%. CONCLUSIONS: Follicular dendritic cell sarcoma is often misdiagnosed on biopsy and pathologists need to be aware of the tumour to request the relevant immunohistochemistry, especially in masses presenting in the central/posterior mediastinum with high vascularity and standardized uptake values. Background HVCD appears more common than previously thought.

Selection for adjuvant chemotherapy in completely resected stage I non-small cell lung cancer: external validation of a Chinese prognostic risk model.

BACKGROUND: The ability to sub-stratify survival within stage I is an important consideration as it is assumed that survival is heterogeneous within this sub-group. Liang et al. recently published a nomogram to predict post-operative survival in patients undergoing lung cancer surgery. The aim of our study is external validation of their published nomogram in a British cohort focusing on stages IA and IB to determine applicability in selection of adjuvant chemotherapy within stage I. METHODS: Patient variables were extracted and the score individually calculated. Receiver operative characteristics curve (ROC) was calculated and compared with the original derivation cohort and the discriminatory ability was further quantified using survival plots by splitting our (external) validation cohort into three tertiles and Kaplan Meier plots were constructed and individual curves tested using Cox regression analysis on Stata 13 and R 3.1.2 respectively. RESULTS: A total of 1,238 patients were included for analysis. For all patients from stage IA to IIB the mean (SD) score was 9.95 (4.2). The ROC score comparing patients who died versus those that remained alive was 0.62 (95% CI: 0.58 to 0.67). When divided into prognostic score tertiles, survival discrimination remained evident for the entire cohort, as well as those for stage IA and IB alone. The P value comparing survival between the middle and highest score with baseline (low score) was P=0.031 and P=0.034 respectively. CONCLUSIONS: Our results of external validation suggested lower survival discrimination than reported by the original group; however discrimination between survival remained evident for stage I.

Management of resectable colorectal lung metastases.

Lung metastases occur in 10-20 % of patients with colorectal cancer. The biology of colorectal lung metastases is poorly understood, however lung metastases are more common in patients with rectal cancer and in patients with RAS mutations. Although the majority of patients have extrapulmonary disease, a small proportion of patients with lung metastases are suitable for lung metastasectomy and surgical resection has become a standard of care, based on data from retrospective series demonstrating a 5-year overall survival of 40-68 %. However, there remains uncertainty regarding the optimal management approach for these patients due to the lack of evidence from randomized controlled trials and current practice varies between institutions. For example, the role for neoadjuvant and adjuvant chemotherapy is not yet defined and there are no randomized trials comparing surgery with alternative treatment options such as radiofrequency ablation and stereotactic ablative radiotherapy. Further research is needed to improve the selection of patients for surgery, but favourable prognostic factors include a normal pre-operative CEA, solitary metastasis, complete resection and a long disease-free interval. There is also evidence that patients with resectable liver and lung metastases may benefit from resection of both sites of disease, and that re-resection may be of benefit in selected patients who relapse with resectable lung metastases. This article summarizes the biology of colorectal lung metastases and discusses the management of patients with lung metastases.

Type A and AB thymomas: histological features associated with increased stage.

AIMS: The current WHO classification of thymic epithelial neoplasms describes type A and type AB thymomas as behaving 'like benign neoplasms'. However, recent published data suggest that rare cases may show more aggressive behaviour. The aim of this study was to assess the frequency of atypical cases, and to determine whether atypia is associated with more advanced disease. METHODS AND RESULTS: One hundred and twenty-one thymomas (type A, n = 68; type AB, n = 53) were retrospectively reviewed for 'atypical' features (nuclear pleomorphism, mitotic activity, and necrosis). Logistic regression was used to ascertain the association with increasing Masaoka-Koga stage. Where available, follow-up data were also reviewed. There were 72 stage I, 42 stage II, five stage III and two stage IV tumours. Only the presence of necrosis showed a significant association with increased stage in univariate and multivariate analysis. Nuclear atypia and increased mitotic activity were not associated with increasing stage of disease. CONCLUSIONS: Our data support the concept of there being more aggressive atypical variants of both type A and type AB thymoma, and suggest that the presence of necrosis could be used to predict aggressive behaviour.

Solitary lung meningioma with synchronous brain nodules: clinical and pathological features.

Meningiomas are tumours arising from the meninges that ensheath the central nervous system. They are benign tumours, but can very rarely metastasize. We report a case of pulmonary meningioma diagnosed incidentally with concurrent brain masses in an ex-smoker and discuss the difficulties in surgical decision making in a mass that may have represented lung cancer with brain metastases. We also review the literature reporting pulmonary meningiomas.

Peri-operative chemotherapy in the management of resectable colorectal cancer pulmonary metastases.

BACKGROUND: Surgery is often advocated in patients with resectable pulmonary metastases from colorectal cancer (CRC). Our study aims to evaluate peri-operative chemotherapy in patients with metastastic CRC undergoing pulmonary metastasectomy. METHODS: Patients treated for CRC who underwent pulmonary metastasectomy by a single surgeon were identified. Outcome measures included survival, peri-operative complications, radiological and histological evidence of chemotherapy-induced lung toxicities. RESULTS: Between 1997 and 2009, 51 eligible patients were identified undergoing a total of 72 pulmonary resections. Thirty-eight patients received peri-operative chemotherapy, of whom 9 received an additional biological agent. Five-year overall survival rate was 72% in the whole cohort - 74% and 68% in those who received peri-operative chemotherapy (CS) and those who underwent surgery alone (S) respectively. Five-year relapse free survival rate was 31% in the whole cohort - 38% and ≤18% in CS and S groups respectively. Only 8% had disease progression during neoadjuvant chemotherapy. There were no post-operative deaths. Surgical complications occurred in only 4% of patients who received pre-operative chemotherapy. There was neither radiological nor histological evidence of lung toxicity in resected surgical specimens. CONCLUSIONS: Peri-operative chemotherapy can be safely delivered to CRC patients undergoing pulmonary metastasectomy. Survival in this selected group of patients was favourable.

Predicting risk of intensive care unit admission after resection for non-small cell lung cancer: a validation study.

A model for predicting the risk of emergency, unplanned intensive care unit (ICU) admission after lung resection for lung cancer has been reported. However, it has not been validated outside of the derivation cohort, and the aim of our study was to undertake external validation at our institution. We reviewed a series of consecutive patients who underwent major lung resection for non-small cell lung cancer over a 6-year period. Test performance was evaluated by area under the receiver operator characteristic (ROC) curve. Between 2003 and 2008, 425 patients underwent major lung resections for lung cancer. The mean age (SD) was 65 (10) years and 241 (57%) were men. A total of 77 (18%) patients were admitted to ICU, 47 for elective admission and 30 (7%) for treatment of post-procedure complications. Of the 30 patients admitted for complications, the median length of ICU (interquartile range) stay was 3 days (1-15 days). The mortality rate among these patients was 17%. The area under the ROC curve was 0.66 (95% CI 0.53-0.79). The Brunelli scoring system had moderate discriminating ability to predict the risk of ICU admission after lung resection in our institution.

Prognostic factors for survival after surgical palliation of malignant pleural effusion.

INTRODUCTION: To investigate prognostic factors for patient survival after surgical palliation of malignant pleural effusion (MPE). METHOD: We reviewed 278 consecutive nonoverseas patients (108 men, median age: 60 years [range 26-89]) undergoing 310 surgical procedures for palliation of MPE over a 72-month period. There were 195 thoracoscopic talc pleurodesis, 39 pleuroperitoneal shunts, 38 pleurodesis by an intercostal drain, 29 pleural biopsies alone, and nine long-term drains. Referring physicians provided survival data. The significance of prognostic factors was examined with the log-rank test (Kaplan-Meier), those significant entered a Cox logistic multivariate regression analysis. RESULTS: Follow-up was complete until death (following 264 procedures) and for a median 648 days (range 173-2135) for surviving patients. Overall median postoperative survival was 211 days (95% confidence interval: 169-253). Survival was not significantly different for tumor type or method of palliation. In univarate analysis, preoperative leucocytosis, hypoxemia, raised alanine transaminase, body mass index below 18 and hypoalbuminemia were associated with a significantly reduced postoperative survival. In multivariate analysis, leucocytosis (p < 0.0001), hypoxemia (p = 0.014), and hypoalbuminemia (p < 0.0001) maintained significance. CONCLUSIONS: The survival reported demonstrates the necessity of an active approach to palliation of MPE. The identification of prognostic factors will assist the choice of palliative technique. In addition, an appreciation of the influence of selection on survival after surgical palliation of malignant pleural mesothelioma, especially that of unforeseen prognostic factors, is useful when evaluating the results of aggressive treatment such as chemoradiotherapy and radical surgery for these diseases.

A prospective, randomized trial comparing BioGlue and Vivostat for the control of alveolar air leak.

OBJECTIVE: BioGlue (CryoLife, Europa Ltd, Surrey, UK) is effective in reducing alveolar air leak after pulmonary resection. However, concerns exist regarding the use of bovine-derived products. Vivostat (Vivostat A/S, Alleroed, Denmark) is an autologous fibrin sealant that confers certain advantages. It shows superior elastic properties, a faster absorption time, and the absence of risk of transmission of blood-borne diseases. METHODS: We conducted a randomized, single blind controlled study to compare BioGlue and Vivostat in the control of postoperative air leak. Primary endpoints were duration of air leak, time to intercostal drain removal, and length of hospital stay. Secondary endpoints related to postoperative complications. RESULTS: Between December 2005 and December 2007, 103 patients were randomized. The analysis included 102 patients; 67% were male. Median age was 56 +/- 19 years. Indications for surgery were primary lung cancer in 41 patients (40%), secondary malignancy in 48 patients (47%), carcinoid in 6 patients (6%), and 7 patients underwent surgery for benign disease (7%). Bilobectomy was performed in 2 patients (2%), lobectomy in 41 patients (40%), lobectomy with lesser resection in 3 patients (3%), segmentectomy in 16 patients (16%), precision excision in 34 patients (33%), and 6 patients underwent other resections (6%). Median duration of air leak was 3 (0-32) days versus 2 (0-33) days for patients who received BioGlue and Vivostat, respectively (P = .677). Time to intercostal drain removal was 5 (1-32) days in the BioGlue group compared with 5 (1-34) days for the Vivostat group (P = .473). Median hospital stay was 8 (3-22) days versus 7 (2-29) days for the BioGlue and Vivostat groups, respectively (P = .382). There was no significant difference in the incidence of complications between the 2 groups (20 patients receiving BioGlue versus 19 patients receiving Vivostat, P = .839). CONCLUSIONS: There were no significant differences in the 3 clinical outcome measures of duration of air leak, time to intercostal drain removal, and length of hospital stay in those patients receiving BioGlue or Vivostat. Given the inherent advantages of our institutional preference is to use Vivostat in the control of postoperative air leaks after pulmonary resection.

Secondary vascular changes in pulmonary sequestrations.

AIMS: Whilst parenchymal changes in pulmonary sequestrations are well described, there are comparatively little data on associated vascular changes and their extent. The aim of this study was to retrospectively review morphological changes within sequestrations, concentrating on vascular changes and associations with clinical parameters. METHODS AND RESULTS: Twenty-seven resected cases of sequestrations (intralobar n = 20, extralobar n = 7) showed a male predominance (n = 16) and an age range of 2 months-60 years (average 13 years). Plexogenic vascular changes (medial hypertrophy and intimal fibrosis) were seen in 15 of 27 cases, as well as plexiform lesions in seven cases. Patients with plexogenic changes had a higher mean age compared with those lacking vascular changes (19 versus 6 years) and were more commonly female. Respiratory tract infections were associated solely with intralobar sequestrations. No other associations between presenting symptoms and histopathological parameters were identified. Adjacent lung showed lesser plexogenic changes in six of 22 intralobar cases. There were features of type 2 congenital cystic adenomatoid lesions in 63% of cases. Dissection of the supplying systemic artery (n = 1), intralesional aspergilloma (n = 1) and coexistent lymphangiomatosis (n = 1) were also identified. CONCLUSIONS: Hypertensive vascular changes are not uncommon in both intrapulmonary and extrapulmonary sequestrations, although their relative severity seems unrelated to presenting symptoms.

Sternal/para-sternal resection for parasternal local recurrence in breast cancer.

BACKGROUND: Locoregional recurrence occurs in a significant number of patients with breast cancer. This can result in substantial morbidity and mortality. Chest wall resection is well-documented for palliation and local control in chest wall relapse; an extension of this surgery is parasternal or sternal resection. METHODS: A retrospective review of medical records of eighteen women who underwent sternal or parasternal resection with curative intent between 1998 and 2007 was undertaken. RESULTS: 12 patients had total sternal resection, five patients had sub-total sternal resection and one patient had resection of tumour and ribs. 17 patients required the insertion of a composite Marlex(®) methyl-methacrylate chest wall prosthesis, followed by soft tissue reconstruction with a pectoralis major or latissimus dorsi flap, in the majority of cases. In-hospital and 30-day mortality was 0%. One and two-year overall survival was 87% and 80% respectively. The median recurrence-free survival was 18 months (95% CI 4-31 months). There was local and distant recurrence in one patient (5%), local recurrence in two patients (11%) and distant recurrence in eight patients (44%), with 15 out of 18 patients (77%) remaining free from local recurrence at 5 years. CONCLUSIONS: En bloc sternal resection for parasternal recurrence in breast cancer involves extensive surgery but in our experience can be performed with very low mortality and morbidity. In selected patients it provides good long term local control, relief of pain and improved cosmesis.

The mortality from acute respiratory distress syndrome after pulmonary resection is reducing: a 10-year single institutional experience.

OBJECTIVE: Acute respiratory distress syndrome (ARDS) is a major cause of death following lung resection. At this institution we reported an incidence of 3.2% and a mortality of 72.2% in a review of patients who underwent pulmonary resection from 1991 to 1997 [Kutlu C, Williams E, Evans E, Pastorino U, Goldstraw P. Acute lung injury and acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg 2000;69:376-80]. The current study compares our recent experience with this historical data to assess if improved recognition of ARDS and treatment strategies has had an impact on the incidence and mortality. METHODS: We identified and studied all patients who developed ARDS following a lung resection of any magnitude between 2000 and 2005 using the 1994 consensus definition: characteristic chest X-ray or CT, PaO2/FiO2 < 200 mmHg, pulmonary capillary wedge pressure < 18 mmHg and clinical acute onset. Overall incidence and mortality were recorded. Univariate analyses (t-test or chi(2), as appropriate) were carried out to identify correlations between pre-, peri- and postoperative variables and outcomes. RESULTS: We performed 1376 lung resections during the study period. Of these 705 (51.2%) were for lung cancer and 671 (48.8%) for other diseases. Twenty-two patients fulfilled the criteria for ARDS with 10 deaths in this group. The incidence and mortality from ARDS had fallen significantly over the two study periods (incidence from 3.2% to 1.6%, p=0.01; mortality from 72% to 45%, p=0.05). Although no significant correlations with incidence and mortality were identified, we found a number of significant trends. In keeping with the ARDS network study recommendations, postoperative tidal volumes were maintained at a lower level when a higher number of pulmonary segments were excised (p=0.001). Furthermore, consistent with findings in previous studies, the highest incidence and death from ARDS were in pneumonectomy patients (incidence 11.4%; mortality 50%). Although the incidence and mortality from ARDS following pneumonectomy were not significantly different between the two study periods (p=0.08, p=0.35), we found that fewer pneumonectomies were performed in the later period (pneumonectomy rate of 6.4% vs 17.4%). CONCLUSIONS: The incidence and mortality of ARDS have decreased in our institution. We postulate that this is due to more aggressive strategies to avoid pneumonectomy, greater attention to protective ventilation strategies during surgery and to the improved ICU management of ARDS.

Thyroid transcription factor 1 immunohistochemistry as an intraoperative diagnostic tool at frozen section for distinction between primary and secondary lung tumors.

CONTEXT: Intraoperative distinction between primary and metastatic carcinomas in the lung at frozen section remains problematic. OBJECTIVE: To assess the value and practicality of immunohistochemistry for thyroid transcription factor 1 at the time of intraoperative frozen section. DESIGN: Thirty-three patients presented with either a solitary pulmonary mass or 2 pulmonary masses and a history of carcinoma in a different organ. In addition to routine frozen section for assessment of tumor type, we looked for expression of thyroid transcription factor 1, using the EnVision system with abridged methodology. RESULTS: Ten cases were positive for thyroid transcription factor 1, which was confirmed on subsequent paraffin sections. Nine of these were confirmed as primary pulmonary adenocarcinomas, but 1 case proved to be a rare false-positive metastatic colonic carcinoma. Twenty-three cases were negative on frozen section and reported as favoring metastatic disease. In all cases, additional immunohistochemical data increased diagnostic confidence, but particularly in cases of positive primary pulmonary tumors and in cases with disease metastatic from sites other than the large bowel. The average time in addition to that of the basic frozen section was 24 minutes per test with a cost of 32 pounds sterling (US$57). CONCLUSIONS: Frozen section immunohistochemistry for thyroid transcription factor 1 shows specificity and sensitivity similar to those seen for formalin-fixed tissues and is feasible within the time frame of a thoracotomy. Diagnostic confidence is increased, especially with positive primary pulmonary tumors. However, its practice should be properly planned within an operative procedure as liberal usage will likely have significant staff and cost implications.

Incidence, duration and causes of intensive care unit admission following pulmonary resection for malignancy.

BACKGROUND: We assessed the overall incidence and duration of ICU admission following pulmonary resection and attempted to identify patients requiring prolonged ICU stay. METHODS: Analysis of prospectively collected data on all patients undergoing pulmonary resection for suspected malignant disease that subsequently required ICU admission between March 2002 and October 2003. RESULTS: Of 170 patients 52 (30%) needed intensive care post-operatively: 21 (12%) for less than 24 h and 31 (18%) for more, for which group the average length of stay was 11.3 days. There was no significant difference between the patient groups at ICU admission in terms of median APACHE II scores (12 vs. 14), gas exchange (PaO2/FIO2, 441 vs. 364 mmHg), estimated post-operative absolute FEV1 (1.62 vs. 1.31 l) or predicted percentage FEV1 (61.8% vs. 44.3%). Mean ICU cost was 1,838 sterling pounds vs. 25,974 sterling pounds per admission, respectively. CONCLUSIONS: Following pulmonary resection some 18% of patients need a protracted ICU stay at considerable cost. Neither severity of illness scoring, indices of gas exchange at ICU admission, nor predicted post-operative FEV1 identifies such patients.

A prospective, randomized, controlled trial of the effectiveness of BioGlue in treating alveolar air leaks.

OBJECTIVE: The use of tissue glues has been advocated to reduce post-thoracotomy alveolar air leaks, but outcomes have been inconclusive. The aim of this study was to determine the effectiveness of BioGlue (CryoLife Europa Ltd, Hampshire, United Kingdom) in eliminating post-thoracotomy alveolar air leaks. METHODS: A prospective, randomized, single-blind, controlled trial was conducted in which patients were stratified according to the severity of post-thoracotomy air leak that could not be controlled by conventional surgical techniques. They were allocated to a control arm (surgical treatment only) or an interventional arm (surgical treatment and BioGlue). Duration of air leak, intercostal drainage, and hospital stay comprised primary study end points. RESULTS: From December 2002 to January 2005, 52 patients were randomized, 29 (56%) of whom were men. The mean age was 59 +/- 15 years, and other characteristics were comparable in both groups. Indications for surgery were malignancy in 46 patients (88%), carcinoid tumor in 2 patients (4%), and infective disease in 4 patients (8%). Patients in the BioGlue arm had shorter median duration of air leaks, 1 (0-2) versus 4 (2-6) days (P < .001); intercostal chest drainage, 4 (3-4) versus 5 (4-6) days (P = .012); and hospital stay, 6 (5-7) versus 7 (7-10) days (P = .004), compared with controls. No major complications were encountered using BioGlue. CONCLUSIONS: This study demonstrates clear benefit from BioGlue in the treatment of alveolar air leaks through reduction of air leak duration, chest drainage time, and hospital stay. Systematic use of BioGlue may be warranted in adult thoracic surgical procedures (except pneumonectomy and decortication) when an air leak remains after all other steps to control it have failed.

Nuss procedure improves the quality of life in young male adults with pectus excavatum deformity.

OBJECTIVE: The Nuss procedure is a minimally invasive pectus repair. This study represents an attempt towards exploring the changes in quality of life and overall satisfaction in young male adults who underwent a Nuss procedure. METHODS: We have included 20 male patients with a median age of 18 years (range: 14-37 years). We have used two specific questionnaires: the two-step Nuss evaluation Questionnaire modified for Adults (NQ-mA) and a new Single Step Questionnaire (SSQ). The data was analysed using Wilcoxon signed rank test to determine statistical significance of differences, with a <0.05 level of significance. Spearman's correlation coefficient was used to assess the correlation between the answers. RESULTS: The primary indication for surgery was cosmetic. Both questionnaires were adequate to measure disease-specific quality-of-life changes after surgery and were able to confirm the positive impact of surgery on both the physical and the physiological well-being of young adults. Statistical analysis of the scoring of the individual questions and the total score of individual patients revealed a statistically significant improvement (p<0.05) following surgery. The SSQ had a highly significant correlation to the NQ-mA questionnaire (correlation coefficient=0.682, p=0.001). Overall, the SSQ revealed a statistically significant improvement (p=0.001) in self-esteem and a high level of satisfaction following the Nuss procedure. Only two patients fell into a low satisfaction group. CONCLUSION: The Nuss procedure has already been shown to have a positive impact on both the physical and psychosocial well-being of children who are suffering from pectus excavatum deformity. We have shown a similar positive impact in young male adults, in the short term.