A. P. C. Yim

Pulmonary ischaemia-reperfusion injury: role of apoptosis

The central role of lung ischaemia–reperfusion injury in pulmonary dysfunction after cardiac surgery, particularly thoracic organ transplantation, has been well recognised. Lung tissue necrosis after prolonged ischaemia is known to worsen lung function, which was believed to be due largely to adjacent tissue inflammation. Recent studies suggest that lung apoptosis following ischaemia–reperfusion could be equally important in the development of post-operative lung dysfunction. The current literature on the mechanism and pathways involved in pulmonary dysfunction and, in particular, its relationship with apoptosis after lung ischaemia–reperfusion is briefly reviewed here. A better understanding of lung apoptosis, as well as the upstream pathways, may help in the development of therapeutic strategies that could benefit patients undergoing cardiac and lung transplantation.

Video assisted thoracic surgery in the management of spontaneous pneumothorax: the current status

Over the past decade, video assisted thoracic surgery (VATS) has changed the way spontaneous pneumothorax (SP) is managed. Benefits of VATS include less postoperative pain, shorter hospital stay, and attenuated postoperative inflammatory response are evident compared with open thoracic procedures. Furthermore, the increasing acceptance by patients and referring physicians is testament to its success. Recent studies and the authors decade of experience in management of SP by VATS show that it is quick, safe, and effective, with recurrence rates generally comparable to open procedures, with some exceptions. However, selecting the correct procedure and patient, as well as knowing the limitations of the surgeons and techniques are paramount for success. Even to this day, there are considerable variations in the treatment of SP and large scale controlled studies are needed to better define timing of surgery and the role of the different procedures in the treatment and prevention of SP.

Giant pulmonary bulla

The present report describes a case of a giant pulmonary bulla in a 32-year-old man that progressed to occupy almost the entire left hemithorax. This report is unique in documenting the natural history of progression of this condition. Bullectomy was performed using the video-assisted thoracoscopic surgery approach.

Idiopathic localised bladder amyloidosis: Rare cause of haematuria

Idiopathic Localised Bladder Amyloidosis is arare cause of haematuria and urinary tractsymptoms. A review of the literature highlightsthe varied presentations and the appropriateinvestigations for this condition, withemphasise on the exclusion of a secondarycause. In addition, the range of treatmentoptions is fully discussed. Our report on a 65-yearold gentleman illustrates that a highindex of suspicion is required for itsdiagnosis. Furthermore, conservative managementcan be an effective strategy in selectedpatients.

Video-assisted thoracic surgery and extramedullary haematopoiesis

To the Editors: We read with interest the article by Kugler et al. 1 on paravertebral intrathoracic extramedullary haematopoiesis (EMH). Intrathoracic EMH was first noted by Guizetti as early as 1912 during an autopsy, and is typically located in the lower retropleural paravertebral region 2. In addition to the congenital haemolytic anaemias, myeloproliferative syndromes and bone marrow insufficiencies described, EMH can also occur as a reactive process to chronic anaemic conditions such as pernicious anaemia, …

Cystic lesions of the lung: a forgotten menace

To the Editors: We read with interest the article by Battistini et al. 1 concerning a young female with spontaneous pneumothorax as the presenting feature of pulmonary lymphangioleiomyoma, which appeared in a previous issue of the European Respiratory Journal . The differential diagnoses, which included lymphangioleiomyoma, tuberous sclerosis and Langerhans cell histiocytosis or eosinophilic granuloma, were based on bilateral cystic pulmonary lesions on high-resolution computed tomography, which were slow …

Hypoglycaemia and pleural tumours

To the Editors: We read with interest the article by Metintas et al. 1 on nonmalignant pleural lesions and their association with asbestos exposure. It is worth noting that another form of pleural-based tumour, solitary fibrous tumour, remains a distinct entity and interestingly has not been linked to asbestos exposure 2, 3. Asbestos usually causes more diffuse forms of pleural lesions 4. Solitary fibrous tumours are rare tumours with a 12–13% rate …

Iatrogenic causes of hilar radiopaque densities

To the Editors: We read with interest the case by Vandooren et al . 1, which highlighted one unusual cause of iatrogenic lung hilar densities. Embolisation of cement following percutaneous application and, indeed, embolisation of other foreign material (for example, cyanoacrylate glue and sclerotherapy …

Importance of transesophageal echocardiography in directing the surgical approach to atrial myxomas

The optimal operative approach to an atrial myxoma should provide good exposure for complete resection of the tumor and its attachment, allow inspection of heart chambers for multiple tumors, and be safe and efficacious [2]. There is still controversy concerning the best surgical approach to achieve this, and various incisions have been used including left atriotomy, biatrial, transseptal, and the superior transseptal approach. Each of these approaches has its drawbacks; for example, a left atriotomy alone may impede obtaining adequate excisional margins [3] while the biatrial approach is responsible for a high incidence of arrhythmias and conduction disturbances [2]. Furthermore, although the superior transseptal approach allows good visualization of the interatrial septum, it is associated with an increased risk of postoperative bleeding and of damage to the blood supply to the sinus node [5]. It is the variability in the attachment point of atrial myxomas that offers a challenge to the surgeon. While almost every approach can provide adequate access to myxomas that arise from the interatrial septum, difficulties in surgical exposure can arise in the 15% to 40% of the atrial tumors that are attached elsewhere [2]. Clearly, therefore, there is no single approach that is ideal for every situation, and the technique may have to be individualized for each case. Intraoperative transesophageal echocardiography (TEE) has become an integral part of cardiac surgical practice, and its application continues to evolve as more data become available [4]. TEE plays an important role in the diagnosis of atrial myxomas as well as in confirming the complete removal of the tumor before closing the chest [1, 4]. However, the importance of TEE in directing the surgical approach to an atrial myxoma has not received enough emphasis. Intraoperative TEE can be used to localize the site of origin of the tumor; thus, the most appropriate line of incision is selected so that this can be excised. This is illustrated by the following examples: In case 1, a 65-year-old man was diagnosed to have an atrial myxoma by transthoracic echocardiography. On intraoperative TEE (Fig. 1), the transverse plane of the left atrium showed a pedunculated left atrial myxoma arising via a narrow stalk from the interatrial septum. Therefore, this tumor was easily excised through the right atrium by excising a disc of the interatrial septum completely with the stalk and the tumor attached to it. In case 2, however, intraoperative TEE (Fig. 2) in a 71-year-old woman demonstrated a myxoma that had a broad-based attachment to the roof of the left atrium, immediately posterior to the superior vena cava and the aorta. The tumor had to be removed en bloc together with the full thickness of the atrial wall. This was performed through a vertical left atriotomy anterior to the right pulmonary veins, extended superiorly behind the superior vena cava, anterior to the tumor attachment. The roof of the left atrium was excised as a whole with the myxoma and was repaired with a Dacron patch. In both cases histological examination documented complete excision of the tumor. Another advantage of intraoperative TEE is that it is no longer necessary for the surgical incision to provide access to all heart chambers. With TEE, all four chambers can be accurately inspected, which obviates the need for a visual inspection. This is particularly beneficial if a minimally invasive approach (for example, through a parasternal incision) is elected. TEE has been established as a useful tool which can significantly enhance the cardiac surgeon’s diagnostic and