Objective: Video-assisted thoracoscopic surgery (VATS) has been a surgical intervention of choice for the treatment of spontaneous pneumothorax (SP) with lung bulla. Our objective was to introduce a uniportal VATS approach for simultaneous bilateral bullectomy and to evaluate its therapeutic efficacy. Methods: Between May of 2011 and January of 2012, five patients underwent bilateral bullectomy conducted using this approach. All of the patients presented with bilateral SP. Preoperative HRCT revealed that all of the patients had bilateral apical bullae. We reviewed the surgical indications, surgical procedures, and outcomes. Results: All of the patients were successfully submitted to this approach for bilateral bullectomy, and there were no intraoperative complications. The median time to chest tube removal was 4.2 days, and the median length of the postoperative hospital stay was 5.2 days. The median postoperative follow-up period was 11.2 months. One patient experienced recurrence of left SP three weeks after the surgery and underwent pleural abrasion. Conclusions: Bilateral bullectomy through uniportal VATS combined with contralateral access to the anterior mediastinum is technically reliable and provides favorable surgical outcomes for patients with bilateral SP who develop bilateral apical bullae. However, among other requirements, this surgical procedure demands that surgeons be experienced in VATS and that the appropriate thoracoscopic instruments are available.

Keywords: Pneumothorax; Thoracic surgery, video-assisted; Pleural cavity; Mediastinum.

Ectopic thyroid is a rare condition, and its location in the anterior mediastinum is even rarer, there having been only 5 reported cases in the past 30 years. Here, we describe 2 clinical cases and present a review of the literature regarding the etiology, embryology and clinical manifestations of ectopic thyroid.

Keywords: Thyroid dysgenesis; Mediastinum; Goiter.

Objective: To evaluate the impact of an aggressive treatment approach using muscle flaps or omentopexy in infections of the sternum and anterior mediastinum following sternotomy on mortality, as compared to that of a conservative treatment approach. Methods: Data were collected prior to, during and after the surgical procedures. Group A (n = 44) included patients submitted to conservative treatment- debridement together with resuture or continuous irrigation with polyvinylpyrrolidone-iodine solutions, or even with second-intention wound healing (retrospective data). Group B (n = 9) included patients in whom infection was not resolved with conservative treatment, and who therefore underwent aggressive treatment (intermediate phase). Group C (n = 28) included patients primarily submitted to aggressive treatment (prospective data). Results: Postoperative hospital stays were shorter in the patients submitted to aggressive treatment (p < 0.046). There were 7 deaths in group A, 1 in group B, and 2 in group C. However, the classical level of significance of α = 0.05 was not reached. Conclusion: Aggressive treatment also proved to be effective when the infection was not resolved with conservative treatment. These findings demonstrate that the proposed treatment provides excellent results.

Keywords: Surgical flaps; Osteomyelitis; Mediastinitis; Thoracic surgery.

Objective: To compare the outcomes of thoracotomy and video-assisted thoracoscopic surgery (VATS) in the treatment of recurrence of primary spontaneous pneumothorax. Methods: Medical records of patients presenting recurrence of primary spontaneous pneumothorax were retrospectively reviewed. Patients were divided into two groups: those who underwent conservative thoracotomy (n = 53, thoracotomy group); and those who underwent VATS (n = 47, VATS group). Results: Although there were no deaths in either group and the length of hospital stays was similar between the two, there was greater morbidity in the thoracotomy group. Patients in the thoracotomy group required more pain medication for longer periods than did those in the VATS group (p < 0.05). In the thoracotomy group, the rate of recurrence was 3%. Pain was classified as insignificant at one month after the operation by 68% of patients in the VATS group and by only 21% of those in the thoracotomy group (p < 0.05). At three years after the surgical procedure, 97% of the VATS group patients considered themselves completely recovered from the operation, compared with only 79% in the thoracotomy group (p < 0.05). Chronic or intermittent pain, requiring the use of analgesics more than once a month, was experienced by 90% of the thoracotomy group patients and 3% of the VATS group patients. In addition, 13% of the thoracotomy group patients required clinical pain management. Conclusions: We recommend VATS as the first-line surgical treatment for patients with recurrent primary spontaneous pneumothorax.

Keywords: Thoracoscopy; Thoracic surgery, video-assisted; Recurrence; Pneumothorax.

The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases.

Keywords: Thoracic surgery, video-assisted; Bronchoscopy; Thoracoscopy; Radiology, interventional.

Background: The relationship between myasthenia and the thymus is evident and the current treatment of this condition includes thymectomy. However, a revision of our experience with thymectomy has revealed the necessity of a more radical technique. Objective: To analyze, retrospectively, myasthenia gravis patients who underwent videothoracoscopic radical thymectomy, emphasizing the advantages and drawbacks of the methodology, pathological findings and results related to disease control. Material and methods: Twenty-one myasthenic patients (18 females and 3 males, aged 17 to 51 years), underwent videothoracoscopic bilateral thymectomy associated to transverse cervicotomy for removal of the thymus gland and surrounding tissues, and right and left pericardiac fat tissues. Those tissues were separately sent to pathology analysis. The mean time of follow-up was 39.2 months. Results: There were no intra-operative deaths. Two patients (9.5%) suffered vascular injury, and one patient (4.8%) presented a low level permanent dysphonia. Nineteen patients (90.4%) are doing well, with none or low dose medications. Pathology studies showed 10 hyperplastic thymuses, 6 with involution and 5 with normal aspect. Ectopic thymic tissue was found in six patients (28.6%). Conclusion: Videothoracoscopic radical thymectomy offered a good control of myasthenia gravis. Additionally, ectopic thymus tissue was removed from some patients.

Keywords: Thorax. Surgery, video-assisted. Myastenia gravis. Thymectomy.

In poor and underdeveloped countries, including Brazil, pulmonologists have great difficulty in maintaining a level of service that keeps pace with advances in current knowledge, in keeping up to date with newly developed techniques, and in pursuing research. Due to the rising costs of scientific journal subscriptions, one of the main problems is lack of access to the scientific literature. The term "digital divide" refers to the gap between those who can and those who cannot effectively use new information technology and tools such as the Internet to communicate within and between countries. In this report, we call attention to some solutions to this situation. In particular, the SciELO Project, the CAPES Periodicals portal and the HINARI project, as well as several others, provide access at little or no cost. These options are explained in detail herein.

Keywords: Pulmonary Disease (Specialty), Internet. Bibliography. Resource Guides.

Cystic lymphangioma is a rare congenital benign tumor. It results from focal proliferation of well-differentiated lymphatic tissue originating from abnormal development of the lymphatic system. Most cystic lymphangiomas occur in the primitive lymph sacs of children or young adults. They generally appear in the neck (75%) and axillary region (20%). Only 1% are located in the mediastinum. Acquired lymphangiomas, which are principally seen in middle-aged adults, are caused by a process of chronic lymphatic obstruction secondary to surgery, chronic infection, or radiation. Here, we present the case of a 50-year-old male with cystic lymphangioma of the mediastinum, detected on a routine chest X-ray.

Keywords: Lymphangioma, cystic; Mediastinum; Incidental findings.

Hard metal pneumoconiosis, first described in 1964, is a diffuse disease caused by the inhalation of cobalt particles. The disease can manifest as occupational asthma, interstitial disease or allergic alveolitis. We report the case of a young male, working as a tool sharpener, who presented with dry cough and progressive dyspnea for one year, as well as with spontaneous bilateral pneumothorax at admission. The diagnosis was confirmed by open lung biopsy.

Keywords: Lung diseases, interstitial; Pneumoconiosis; Pneumothorax.

Benign schwannoma tumors are the most common primary tumors of the posterior mediastinum. They may develop into a dumbbell-shaped involvement of the medullar channel, but rarely reach the tracheobronchial tree. The authors report a case of a 45-year-old female patient with a benign schwannoma in the posterior mediastinum, with a dumbbell-shaped lesion that traverses the intercartilaginous septa of the trachea. The tumor was resected by endoscopy in the endotracheal portion and afterwards by thoracotomy of the mediastinal tumor. Eight months after the surgery, there has been no recurrence of the lesion.

Keywords: Mediastinal neoplasms. Thoracotomy. Thoracoscopy. Mediastinal cyst.

Objective: To determine whether a low level of education is a risk factor for uncontrolled asthma in a population of patients who have access to pulmonologists and to treatment. Methods: This was a cross-sectional study involving outpatients > 10 years of age diagnosed with asthma who were followed by a pulmonologist for at least 3 months in the city of Jundiai, located in the state of São Paulo, Brazil. The patients completed a questionnaire specifically designed for this study, the 6-item Asthma Control Questionnaire (to assess the control of asthma symptoms), and a questionnaire designed to assess treatment adherence. Patients underwent spirometry, and patient inhaler technique was assessed. Results: 358 patients were enrolled in the study. Level of education was not considered a risk factor for uncontrolled asthma symptoms (OR = 0.99; 95% CI: 0.94-1.05), spirometry findings consistent with obstructive lung disease (OR = 1.00; 95% CI: 0.99-1.01), uncontrolled asthma (OR = 1.03; 95% CI: 0.95-1.10), or the need for moderate/high doses of inhaled medication (OR = 0.99; 95% CI: 0.94-1.06). The number of years of schooling was similar between the patients in whom treatment adherence was good and those in whom it was poor (p = 0.08), as well as between those who demonstrated proper inhaler technique and those who did not (p = 0.41). Conclusions: Among asthma patients with access to pulmonologists and to treatment, a low level of education does not appear to be a limiting factor for adequate asthma control.

Keywords: Asthma; Educational status; Spirometry; Treatment adherence and compliance.

Objective: To compare the bronchodilatory effect of salbutamol delivered by metered-dose inhaler connected to spacers with and without previous antistatic treatment. Design: Prospective, randomized, open, crossover study. Setting: Outpatients from The Pulmonary Clinic of Hospital Júlia Kubitschek-FHEMIG, Belo Horizonte, Minas Gerais, Brazil. Patients and methods: Eleven patients, with stable mild to moderate asthma were randomized to four inhalation tests of 100 mg of salbutamol: (A) open mouth, (B) non antistatic small volume spacer (50 ml), (C) antistatic small volume spacer (50 ml) and (D) antistatic Fisonair® (750 ml). The antistatic treatment consisted in soaking the spacer in a solution of water and detergent for ten minutes and letting it to drip dry without rinsing. Main outcome measure: The peak expiratory flow (PEF) variation 15 minutes after each test in absolute, % of predicted and % of baseline values. Results: The median (Min-Max) PEF absolute variation was 25 (5-85), 40 (0-70), 70 (25-83) and 60 (15-90) l/min for tests A, B, C and D, respectively. The median PEF % baseline variation was 7.6, 11.0, 15.0, 13.3, and median PFE % predicted variation was 6.0, 8.7, 12.7 and 10.7 for tests A, B, C and D, respectively. The results of tests C and D were significantly superior to those of tests A and B (p < 0.01) based on the three methods evaluated. There was no significant difference between the results of tests C and D. Conclusion: The antistatic treatment of a small volume spacer device using a solution of water and detergent can improve the antiasthmatic effect of inhaled drugs delivered by metered-dose inhaler, as occurred with the salbutamol in this study. This fact can be more relevant concerning the treatment with inhaled steroids for asthma.

Keywords: Asthma. Respiratory therapy. Aerosols. Albuterol.

A 30 year old Caucasian male from São Paulo was admitted to the hospital He had been complaining about constant, moderate pain in the anterior and lateral left hemi-thoracic region for the last three months as well as associated great effort dyspnea over the last month.Investigation with chest X-rays, CT scans and MRI revealed a large anterior and medial mediastinal tumor suggesting large vessel invasion. The patient was submitted to a left side parasternal mediastinostomy and a biopsy of the mediastinal mass which was complicated by severe bleeding. An immediate median full sternotomy was elected in addition to a left anterior-lateral thoracotomy for total tumor resection and control of the bleeding. Evolution was good, with hospital discharge on the ninth postoperative day. The anatomical-pathological essay disclosed a hemangioendothelioma of the mediastinum.

Keywords: Hemangioendothelioma/diagnosis. Mediastinal neoplasms.

The mediastinum, made up by many organs and structures, comprises a wide range of affections, from simple cysts to low differentiated neoplasias and lymphomas. In their day-to-day activities, the diagnosis of these affections represent a real challenge to the pathologists. Furthermore, one of the main approaches to diagnosis includes mediastinoscopy. Therefore, the representation of the specimen for studies, as well as some artifacts to obtain the specimen, may pose some difficulty for a final diagnosis. This article will focus mainly on the problems faced to diagnose entities from the specimens obtained by mediatinoscopy in the surgical room, during the extraction of the material and at examination by freezing. The article will also update current criteria used to classify the tumors and the use of the immunohistochemistry to complement the diagnosis, criteria of invasion, and metastases. The purposes of this article are: recognize the main affections of the mediastinum, classify the main tumors, apply malignancy criteria, identify prognostic markers, and evaluate when there is need to establish a clinical, radiological and morphological correlation.

Keywords: Mediastinum. Mediastinum pathology. Prognostic markers.