Advancements in the Management of Postoperative Air Leak following Thoracic Surgery: From Traditional Practices to Innovative Therapies.

Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient's needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice.

Poor preoperative quality of life predicts prolonged hospital stay after VATS lobectomy for lung cancer.

OBJECTIVES: The aim of this study was to assess whether quality of life (QoL) scales are associated with postoperative length of stay (LoS) following video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer. METHODS: This is a single-centre retrospective analysis on 250 consecutive patients submitted to VATS lobectomies (233) or segmentectomies (17) over a period of 3 years. QoL was assessed in all patients by the self-administration of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 questionnaire. The individual QoL scales were tested for possible association with LoS along with other objective baseline and surgical parameters using univariable and multivariable analyses. RESULTS: Thirty-day cardiopulmonary and mortality rates were 22% and 2.4%. The median LoS was 4 days [interquartile range (IQR) 3-7]. Fifty-one (20%) patients remained in hospital longer than 7 days after surgery (upper quartile). General health [global health score (GHS)] (P = 0.019), physical function (P = 0.014) and role functioning (P = 0.016) scales were significantly worse in patients with prolonged stay. They were highly correlated between each other and tested separately in different logistic regression analyses. The best model resulted the one containing GHS (P = 0.032) along with age, low force expiratory volume in 1 s and carbon monoxide lung diffusion capacity and history of cerebrovascular disease. Fifty-nine patients had GHS <58 (lower interquartile value). Thirty-one percent of them experienced prolonged hospital stay (vs 17% of those with higher GHS, P = 0.027). CONCLUSIONS: Preoperative patient-reported QoL was associated with prolonged postoperative hospital stay. Baseline QoL status should be taken into consideration to implement psychosocial supportive programmes in the context of enhanced recovery after surgery.

Ninety-day hospital costs associated with prolonged air leak following lung resection.

OBJECTIVES: Our goal was to assess the postoperative 90-day hospital costs of patients with prolonged air leak (PAL) including costs incurred after discharge from the initial index hospitalization. METHODS: We performed a retrospective analysis of 982 patients undergoing lobectomy (898) or segmentectomy (78) (April 2014-August 2018). A total of 167 operations were open, 780 were video-assisted thoracoscopic surgery and 28 were robotic. A PAL was defined as an air leak >5 days. The 90-day postoperative costs included all fixed and variable costs incurred during the 90 days following surgery. The postoperative costs of patients with and without PAL were compared. The independent association of PAL with postoperative 90-day costs was tested after adjustment for patient-related factors and other complications by a multivariable regression analysis. RESULTS: PAL occurred in 261 patients (27%). Their postoperative stay was 4 days longer than that of those without PAL (9.6 vs 5.7; P < 0.0001). Compared to patients without PAL, those with PAL had 27% higher index postoperative costs [7354€, standard deviation (SD) 7646 vs 5759€, SD 7183, P < 0.0001] and 40% higher 90-day postoperative costs (18 340€, SD 23 312 vs 13 102€, SD 10 264; P < 0.0001). The relative postoperative costs (the difference between 90-day and index postoperative costs) were 50% higher in PAL patients compared to non-PAL patients (P < 0.0001) and accounted for 60% of the total 90-day costs. Multivariable regression analysis showed that PAL remained an independent factor associated with 90-day costs (P < 0.0001) along with the occurrence of other cardiopulmonary complications (P < 0.0001), male gender (P = 0.018), low carbon monoxide lung diffusion capacity (P = 0.043) and thoracotomy approach (P = 0.022). CONCLUSIONS: PAL is associated not only with increased index hospitalization costs but also with increased costs after discharge. Evaluation of the cost-effectiveness of measures to prevent air leaks should also include post-discharge costs.

Ninety-day hospital costs for anatomic lung resections†.

OBJECTIVES: The study aimed to assess the total cost (TC) and relative cost (RC) of 90-day postoperative care at the hospital after anatomic lung resection. METHODS: Six hundred and forty lung resections (April 2014-September 2016) were performed at a single centre (547 lobectomies, 55 pneumonectomies and 38 segmentectomies). TC was calculated up to 90 days from the date of surgery and included the postoperative cost of the index hospitalization and the costs of hospital or emergency department readmissions, clinic appointments, medications and radiology post-discharge up to 90 days from the operation. RC was calculated as the difference between the TC and the postoperative cost of the index hospitalization. Bivariate comparisons were performed by using the Mann-Whitney test. Multivariable regression analysis was used to identify the factors associated with TC. RESULTS: Median TC was €12 389.5 [interquartile range (IQR) 8455-23 043] for pneumonectomy, €9192.1 (IQR 6897-17 274) for open lobectomy, €7932.5 (IQR 5806-12 697) for video-assisted thoracoscopic surgery (VATS) lobectomy and €6609.9 (IQR 5215-13 907) for VATS segmentectomy. Median RCs were €4461.4 (IQR 1240-11 828) for pneumonectomy, €3326.8 (IQR 1626-8271) for open lobectomy, €2729.3 (IQR 1348-6312) for VATS lobectomy and €2771.5 (IQR 1229-9705) for segmentectomy. RC accounted for 36% of the TC for pneumonectomy, 36% for open lobectomy, 34% for VATS lobectomy and 42% for segmentectomy. Generalized linear models showed that age (P = 0.024), carbon monoxide lung diffusion capacity (P = 0.030) and body mass index (P = 0.015) were inversely associated with TC, whereas male gender (P = 0.054) was associated with increased cost. CONCLUSIONS: Cost-saving measures should be implemented to target not just the in-hospital but also the post-discharge period, particularly in patients with risk factors associated with increased cost.

Ipsilateral pulmonary infarction after major lung resection.

Background Lung infarction is a rare complication of lung resection, developing mainly because of technical errors. In some cases, a specific reason cannot be identified. This study aimed to investigate the occurrence, characteristics, and outcome of this pathology in a series of patients. Methods The medical records of patients who underwent reoperation for lung infarction without an apparent cause (based on imaging, reoperation findings, and histopathology) after major lung resection at our institution from 2006 to 2015, were investigated. Results Seven patients were identified. The mean age was 62.2 years (range 51-75 years), and 5 were male. Copious dissection or adverse events during surgery were recorded in all but 2 cases. The main presenting symptom was unsettling frank hemoptysis (4 cases) with a variable time of onset of symptoms (4-164 h). All reoperations necessitated further lung resection (4 patients had a further lobectomy and 3 had a completion pneumonectomy). During reoperation, all vessels and bronchi were intact. No apparent cause of infarction could be identified according to the histopathology report. Morbidity after reoperation was atrial fibrillation in 3 cases and bronchopleural fistula in 2, one of which required a transsternal pneumonectomy and this was the only mortality. Length of stay ranged from 8 to 90 days. Conclusion Ipsilateral lung infarction after lobectomy is a rare complication and the reason may not be identifiable. Treatment usually requires reoperation. Extensive manipulation or adverse events during surgery could induce this rare complication.

Do pleural adhesions influence the outcome of patients undergoing major lung resection?

OBJECTIVES: Our goal was to investigate whether pleural adhesions identified during an operation can induce adverse events. We investigated the outcome of major lung resection in patients with pleural adhesions encountered on entry into the pleural cavity. METHODS: We conducted a retrospective analysis of 144 patients undergoing major lung resection over a period of 9 months. Recorded data included demographics, comorbidities, surgical data, fluid volume drainage (on postoperative days [POD] 1 and 2 and in total), the overall and pleural space-associated morbidity (empyema, prolonged air leak or drainage, space issues), 30-day and late mortality rates. Patients were grouped according to the presence or not of adhesions observed when we entered the chest. RESULTS: Differences between patients without versus patients with adhesions were recorded for operative time (138 vs 169.3 min, P < 0.02), postoperative drainage on POD1 and POD2 (328.6 vs 478.5 ml, P < 0.01 and 214 vs 378 ml, P < 0.01 respectively), duration of air leak (1 vs 2 days, P = 0.03), duration of chest tube stay (2 vs 4 days, P < 0.01) and pleural morbidity (21.1% vs 38.8%, P = 0.02). There were no differences recorded in the 2 groups on conversion rates (2.5% vs 14.3%, P = 0.46), 30-day (1.1% vs 4.1%, P = .73) and late deaths (log-rank, P = 0.70). Pleural morbidity differed if the chest tube was removed on or earlier than POD2 (57.9% vs 36.9%, P = 0.02). We also calculated differences between those patients with adhesions involving the lower chest (55.1%) versus the rest of the group and specifically drainage on POD1 and POD2 (540.9 vs 372.1 ml, P < 0.01 and 392.5 vs 261 ml, P = 0.02, respectively) and pleural morbidity (46.4% vs 28.6%, P < 0.01). Logistic regression identified that firm, extensive adhesions, present in the lower third of the pleural cavity, are important predictors of pleural morbidity. CONCLUSIONS: Patients undergoing major lung resection who have pleural adhesions have an increased incidence of adverse surgical outcomes and higher pleural morbidity.

Totally Endoscopic (VATS) First Rib Resection for Thoracic Outlet Syndrome.

BACKGROUND: Thoracic outlet syndrome (TOS) causes neurologic symptoms in 95% of cases and vascular symptoms in 5% of cases. Surgical resection is curative. Endoscopic-assisted transaxillary first rib resection has been previously reported. In this study we report a totally endoscopic video-assisted thoracoscopic surgery (VATS) approach using tailored endoscopic instruments. METHODS: Ten patients (8 women; average age, 32.3 ± 5.6 years) with TOS underwent VATS first rib resection following failure of symptom improvement with physiotherapy. Symptoms were: unilateral neurogenic (n = = 7), bilateral neurogenic (n = = 2), and bilateral arterial compression (n = = 1). Three standard VATS ports were utilized. The parietal pleura and periosteum overlying the first rib were stripped avoiding injury to the neurovascular bundle. The rib was transected with an endoscopic rib cutter and resected completely in a piecemeal fashion using endoscopic bone nibblers. All periosteal remnants were trimmed releasing the neurovascular bundle completely. RESULTS: Patients were discharged within 72 hours following surgery. One patient had the contralateral side treated 18 months later and another patient is awaiting the second surgery. At follow-up, 9 patients had complete resolution of their main symptoms. One patient with neurogenic TOS developed mild functional and sensational loss of the non-dominant hand that improved within 8 months with physiotherapy. CONCLUSIONS: VATS first rib resection for TOS provides, unlike the classic approaches, a superior, magnified, and well-illuminated view of the thoracic inlet. It allows good posterior trimming of the first rib, release of brachial plexus, and an aesthetically pleasing result, especially in female patients.

Operating room scheduling is not associated with early outcome following elective anatomic lung resections: a propensity score case-matched analysis.

Objectives: To investigate the effect of operating room scheduling on the outcome of patients undergoing elective lung resection. Methods: In total, 420 patients submitted to anatomical pulmonary resections (363 lobectomies, 35 pneumonectomies, 22 segmentectomies) (April 2014-November 2015) were analysed. Ninety-two patients (22%) were operated on during weekends (Friday or Saturday) and 161 patients (38%) in the afternoon. Propensity score matching was performed to account for possible selection bias between the groups. The matched groups (weekdays versus weekends; morning versus afternoon) were compared in terms of cardiopulmonary complications, in-hospital mortality and length of stay (LOS). Results: In total, 102 (24%) patients developed cardiopulmonary complications and 56 (13%) patients developed major complications. In-hospital mortality was 3.1% (13 patients). The case-matched comparison between patients operated on during the week versus those operated on during weekends (92 pairs) showed no differences of cardiopulmonary morbidity (22 vs 24, P = 0.8), major complications (14 in both groups), mortality (2 vs 4, P = 0.7) and LOS (7 vs 7.5 days, P = 0.6). The case-matched comparison between patients operated on in the morning versus those operated on in the afternoon (161 pairs) showed no differences of cardiopulmonary morbidity (32 vs 33, P = 0.9), major morbidity (17 vs 19, P = 1), mortality (7 vs 4, P = 0.5) and LOS (7.2 vs 5.9 days, P = 0.2). Conclusions: In our setting, operating room scheduling did not affect early outcome following elective lung resections, confirming the appropriate structural and procedural characteristics of a dedicated Thoracic Unit.

Performance of wider parenchymal lung resection than preoperatively planned in patients with low preoperative lung function performance undergoing video-assisted thoracic surgery major lung resection.

OBJECTIVES: Pulmonary assessment before major lung resections is used to determine patient's operability. In marginal cases, extensive pulmonary assessment is additionally important under the fear of a more radical parenchymal removal. This study investigates the outcome of wider lung parenchymal resections in patients with low lung functional status undergoing video-assisted thoracic surgery (VATS) major lung resection. METHODS: The medical records of patients who underwent VATS major lung resection for cancer, over a period of 5 years (August 2009-August 2014), were retrospectively reviewed. Patients with postoperative forced expiratory volume in first second (ppoFEV1) or postoperative diffusional capacity for carbon monoxide (ppoDLCO) <40% who underwent wider lung resection than preoperatively planned (Group A) were compared with patients with ppoFEV1 or ppoDLCO <40% who underwent the planned operation (Group B) and patients with ppoFEV1 and ppoDLCO >40% who underwent wider resection than preoperatively planned (Group C). Data analysed included demographics, past medical history, the surgery planned and performed, the reason for higher parenchymal resection, the clinical and pathological stage, the length of stay (LOS), the morbidity, the 30-day mortality and the survival. RESULTS: Overall, 73 patients were analysed (15 patients in Group A, 50 patients in Group B and 8 patients in Group C). The mean age was 68.5 years and 31.5% were males. The wider lung resection regarded 7 patients who underwent bilobectomy instead of lobectomy and 16 patients who underwent pneumonectomy instead of lobectomy. The main reason for higher resection was the wider invasion of the mass (21 patients). The age, gender and body mass index between three groups were similar, whereas ppoFEV1 and ppoDLCO were different (P < 0.001 and P < 0.001 respectively). Conversions, pulmonary morbidity and the 30-day mortality between groups were similar (P = 0.67, P = 0.88 and P = 0.33, respectively). LOS between groups was not different (P = 0.46). Survival rate between groups was also similar (log-rank, P = 0.79). CONCLUSIONS: Wider lung parenchymal resection than preoperatively anticipated may be performed, even in patients with low lung functional status, without increased adverse outcome when compared with patients with good lung function. This finding indicates that the preoperative risk stratification based on lung function tests is questionable.

A risk-adjusted financial model to estimate the cost of a video-assisted thoracoscopic surgery lobectomy programme.

OBJECTIVE: To develop a clinically risk-adjusted financial model to estimate the cost associated with a video-assisted thoracoscopic surgery (VATS) lobectomy programme. METHODS: Prospectively collected data of 236 VATS lobectomy patients (August 2012-December 2013) were analysed retrospectively. Fixed and variable intraoperative and postoperative costs were retrieved from the Hospital Accounting Department. Baseline and surgical variables were tested for a possible association with total cost using a multivariable linear regression and bootstrap analyses. Costs were calculated in GBP and expressed in Euros (EUR:GBP exchange rate 1.4). RESULTS: The average total cost of a VATS lobectomy was €11 368 (range €6992-€62 535). Average intraoperative (including surgical and anaesthetic time, overhead, disposable materials) and postoperative costs [including ward stay, high dependency unit (HDU) or intensive care unit (ICU) and variable costs associated with management of complications] were €8226 (range €5656-€13 296) and €3029 (range €529-€51 970), respectively. The following variables remained reliably associated with total costs after linear regression analysis and bootstrap: carbon monoxide lung diffusion capacity (DLCO) <60% predicted value (P = 0.02, bootstrap 63%) and chronic obstructive pulmonary disease (COPD; P = 0.035, bootstrap 57%). The following model was developed to estimate the total costs: 10 523 + 1894 × COPD + 2376 × DLCO < 60%. The comparison between predicted and observed costs was repeated in 1000 bootstrapped samples to verify the stability of the model. The two values were not different (P > 0.05) in 86% of the samples. A hypothetical patient with COPD and DLCO less than 60% would cost €4270 more than a patient without COPD and with higher DLCO values (€14 793 vs €10 523). CONCLUSIONS: Risk-adjusting financial data can help estimate the total cost associated with VATS lobectomy based on clinical factors. This model can be used to audit the internal financial performance of a VATS lobectomy programme for budgeting, planning and for appropriate bundled payment reimbursements.

Real-time monitoring of a video-assisted thoracoscopic surgery lobectomy programme using a specific cardiopulmonary complications risk-adjusted control chart†.

OBJECTIVES: To implement internal monitoring using a risk-adjusted model specific for video-assisted thoracoscopic surgery (VATS) lobectomy. METHODS: Retrospective analysis on prospectively collected data of 348 patients submitted to VATS lobectomy (August 2012-August 2014). Baseline and surgical variables were tested for a possible association with postoperative cardiopulmonary complications. Logistic regression and bootstrap resampling analyses were used to develop the risk-adjusted model to obtain the predicted morbidity of 50 consecutive patients (September 2014-November 2014). A risk-adjusted control chart was constructed to track down practice variation during this period. Patients were ordered by date of operation and assigned a score represented by the individual predicted morbidity: the plotted line goes up in case of absence of complications and goes down by the predicted morbidity minus 1 in case of complications. Over time, if outcomes are as expected based on the risk-adjusted model, the plotted line will tend to be close to zero. RESULTS: Cardiopulmonary complications and in-hospital/30-day mortality rates were 14% (47 cases) and 1.8% (6 cases), respectively. Age (P = 0.006, coefficient 0.55, bootstrap frequency 76%) and predicted postoperative forced expiratory volume in 1 s (ppoFEV1) (P < 0.001, coefficient -0.38, bootstrap frequency 98%) remained independently associated with cardiopulmonary morbidity after logistic regression and bootstrap analyses. The following risk logit model for cardiopulmonary morbidity after VATS lobectomy was generated: -3.17 -0.038XppoFEV1 +0.55Xage. The risk-adjusted control chart showed a downward trend indicating a worse than expected performance in the audited period. CONCLUSION: The present analysis offers a methodological template for VATS lobectomy that helps to evaluate the surgical programme. It aims to give a real-time monitoring with the possibility to confront the performance of the centre with the population-specific expectancies. Moreover, being reactive with time, this method allows early detection of underperformance and implementation of critical change in clinical practice.

Major morbidity after video-assisted thoracic surgery lung resections: a comparison between the European Society of Thoracic Surgeons definition and the Thoracic Morbidity and Mortality system.

BACKGROUND: The thoracic morbidity and mortality (TM&M) classification system univocally encodes the postoperative adverse events by their management complexity. This study aims to compare the distribution of the severity of complications according to the TM&M system versus the distribution according to the classification proposed by European Society of Thoracic Surgeons (ESTS) Database in a population of patients submitted to video assisted thoracoscopic surgery (VATS) lung resection. METHODS: A total of 227 consecutive patients submitted to VATS lobectomy for lung cancer were analyzed. Any complication developed postoperatively was graded from I to V according to the TM&M system, reflecting the increasing severity of its management. We verified the distribution of the different grades of complications and analyzed their frequency among those defined as "major cardiopulmonary complications" by the ESTS Database. RESULTS: Following the ESTS definitions, 20 were the major cardiopulmonary complications [atrial fibrillation (AF): 10, 50%; adult respiratory distress syndrome (ARDS): 1, 5%; pulmonary embolism: 2, 10%; mechanical ventilation >24 h: 1, 5%; pneumonia: 3, 15%; myocardial infarct: 1, 5%; atelectasis requiring bronchoscopy: 2, 10%] of which 9 (45%) were reclassified as minor complications (grade II) by the TM&M classification system. According to the TM&M system, 10/34 (29.4%) of all complications were considered minor (grade I or II) while 21/34 (71.4%) as major (IIIa: 8, 23.5%; IIIb: 4, 11.7%; IVa: 8, 23.5%; IVb: 1, 2.9%; V: 3, 8.8%). Other 14 surgical complications occurred and were classified as major complications according to the TM&M system. CONCLUSIONS: The distribution of postoperative complications differs between the two classification systems. The TM&M grading system questions the traditional classification of major complications following VATS lung resection and may be used as an additional endpoint for outcome analyses.

High-risk patients and postoperative complications following video-assisted thoracic surgery lobectomy: a case-matched comparison with lower-risk counterparts†.

OBJECTIVES: To assess the postoperative incidence of major complications in high-risk patients following video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer compared with their lower risk counterparts. METHODS: A retrospective analysis on prospectively collected data of 348 consecutive patients subjected to VATS lobectomy (August 2012-September 2014) was performed. Patients were defined as high risk if one or more of the following characteristics were present: age >75 years, forced expiratory volume in 1 s (FEV1) <50%, carbon monoxide lung diffusion capacity (DLCO) <50%, history of coronary artery disease (CAD). Severity of complications was graded using the Thoracic Morbidity and Mortality (TM&M) score; major complications were defined if the TM&M score was greater than 2. The propensity score was used to match high-risk patients with their lower risk counterparts in order to minimize the influence of other confounders on outcome. The following variables were used to construct the propensity score: gender, side of operation, body mass index, American Society of Anaesthesiologists score, Eastern Cooperative Oncology Group score, Charlson's Comorbidity Index, number of functioning segments resected. RESULTS: The high-risk group consisted of 141 patients (age >75 years: 84 patients; FEV1 <50: 14 patients; DLCO <50: 25 patients; history of CAD: 37 patients). The propensity score yielded two groups of 135 patients (high-risk vs low-risk) well matched for several baseline characteristics except for a lower performance status in the higher-risk group. Compared with their low-risk counterparts, high-risk patients had a higher incidence of cardiopulmonary complications (28 cases, 21% vs 14 cases, 10%; P < 0.0001) and major cardiopulmonary complications (12 cases, 9% vs 3 cases, 2%; P < 0.0001). Postoperative stay was 3 days longer in high-risk patients (8.6 vs 5.5 days, P = 0.0031). The 30-day or in-hospital mortality rates were not different between the two groups (2 cases, 1.5% vs 3 cases, 2.2%, P = 0.93). CONCLUSIONS: The incidence of major complications after VATS lobectomy in high-risk patients is low, but not negligible. This information can be used when discussing surgical risk with the patient during preoperative counselling.

Novel technique in managing bronchobiliary fistula in adults: Endobronchial embolization using silicone spigots in 2 cases.

Bronchobiliary fistula (BBF) can complicate most hepatic pathologies. This is a challenging group of patients, especially when surgery is precluded. The bronchoscopic application of silicon spigots is a recognized technique for the treatment of massive hemoptysis and the management of patients with bronchopleural fistula following lung resection. Their role in the treatment of BBF has never been described. In this paper we report the successful embolization using silicon spigots in two patients with BBF secondary to malignant disease, when all surgical options were exhausted.

Adrenocortical oncocytic carcinoma with recurrent metastases: a case report and review of the literature.

BACKGROUND: Adrenal cortex oncocytic carcinoma (AOC) represents an exceptional pathological entity, since only 22 cases have been documented in the literature so far. CASE PRESENTATION: Our case concerns a 54-year-old man with past medical history of right adrenal excision with partial hepatectomy, due to an adrenocortical carcinoma. The patient was admitted in our hospital to undergo surgical resection of a left lung mass newly detected on chest Computed Tomography scan. The histological and immunohistochemical study revealed a metastatic AOC. Although the patient was given mitotane orally in adjuvant basis, he experienced relapse with multiple metastases in the thorax twice in the next year and was treated with consecutive resections. Two and a half years later, a right hip joint metastasis was found and concurrent chemoradiation was given. Finally, approximately five years post disease onset, the patient died due to massive metastatic disease. A thorough review of AOC and particularly all diagnostic difficulties are extensively stated. CONCLUSION: Histological classification of adrenocortical oncocytic tumours has been so far a matter of debate. There is no officially established histological scoring system regarding these rare neoplasms and therefore many diagnostic difficulties occur for pathologists.

Massive bronchogenic cyst mimicking ischaemic chest pain.

The presentation of the bronchogenic cyst is variable making preoperative diagnosis difficult. The majority are either asymptomatic or discovered incidentally. The most common presenting symptoms are cough, fever and dyspnoea. We discuss the case of a large bronchogenic cyst in the posterior mediastinum mimicking ischaemic cardiac pain in a patient with known heart disease. This case demonstrates the need for detailed investigations prior to the treatment of an assumed acute coronary syndrome as a bronchogenic cyst may be the rare cause of such symptoms.

Simultaneous bilateral carotid endarterectomy under local anesthesia.

A 75-year-old man with bilateral carotid stenosis and severe coronary artery disease underwent successful simultaneous bilateral carotid endarterectomy under local anesthesia. A few days later, coronary artery bypass grafting was performed with no complications.