A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the intraoperative use of surgical adhesives in patients undergoing lung resection would reduce the incidence and length of postoperative air leaks. The reported search strategy identified 261 papers of which 12 were considered to represent the best evidence available. The author, journal, publication date, patient groups studied, study types, relevant outcomes, results and study weaknesses were tabulated. We conclude that six of the identified randomised trials found a significant reduction in air leak duration, but five found no significant difference. In contrast to significant reductions in air leak, only two studies identified a reduction in time to chest drain removal. Also, only two studies found a significant reduction in length of stay. There are multiple issues surrounding these studies ranging from identifying the optimal glue and delivery system, dealing with the learning curve of surgeons and robust protocols for chest drain removal to selection of patients suitable for surgical adhesive usage. Thus, routine usage of surgical adhesive for all operations cannot yet be recommended, although there is a wide range of adhesives available to surgeons which may be useful in selected situations.

Figure 2. Histologic examination demonstrated pink islands of osteoid with malignant cells showing atypical mitosis. There was no identifiable epithelial component and no mesothelioma.

Systemic arterial embolism is a potentially lethal complication of bronchopulmonary venous fistula in trauma patients with blunt chest trauma or isolated penetrating lung injury on positive pressure ventilation. A high index of suspicion, early diagnosis and management in specialized centres are keys to a successful outcome.

Tuberculosis (TB) is a significant public health problem in many developing countries. In many cases, tuberculosis may present a significant diagnostic challenge. A 32-year-old male Chinese immigrant presented to our institution with a fever and non-productive cough. He was found to have a right pleural effusion, for which a chest drain was inserted. His tuberculin skin test was unreactive (0mm) although he was not immunocompromised (HIV negative). All cultures were negative, and 3 sputum samples and his pleural fluid sample tested negative for acid-fast bacilli. A computed tomography (CT) scan of his chest revealed features suggestive of an early empyema. There was no evidence suggestive of a malignant effusion. In an effort to attain a diagnosis, he underwent a video-assisted thoracoscopy (VATS) procedure with pleural drainage and biopsies. Anti-tuberculosis therapy (ATT) was commenced due to a high level of suspicion after failure of empirical therapy. Although the Ziehl-Neelsen stain for acid fast bacilli was negative, pleural biopsies demonstrated active chronic granulomatous pleuritis with many Langerhans type giant cells highly suggestive of tuberculosis. He was responsive to treatment and completed 6 months of ATT with complete clinical resolution. In young, immunocompetent patients with an exudative, culture-negative effusion, the diagnosis of pleural tuberculosis must be considered. Pleural biopsy is the gold standard for diagnosing pleural TB but demonstration of acid-fast bacilli or necrotizing granulomas in the specimen are not absolutely necessary to make the diagnosis.

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