Subsequent Thoracic Surgery Research Articles

Lung Nodule Marking With ICG Dye–Soaked Coil Facilitates Localization and Delayed Surgical Resection

BackgroundWhereas diagnosis and treatment of pulmonary nodules may be combined during a surgical resection, this approach may lead to excision of benign lesions and excessive healthy lung tissue if the lesion is difficult to localize. Bronchoscopy-guided marking of pulmonary nodules before surgery may facilitate this process, but it is limited by current technologies and often challenging as dye marking may dissipate if surgery is performed days later. We present a novel method to address this problem that allows surgery multiple days after lesion marking with accurate localization. MethodsFour patients with newly identified lung nodules underwent robot-assisted navigation bronchoscopy with lesion marking with a fiducial coil saturated for 10 minutes with indocyanine green (ICG) dye and subsequent thoracic surgery. ResultsThe novel approach to soaking the fiducial in ICG allowed the lesions to be seen multiple days (0-9 days) later at the time of da Vinci robotic surgery with the Firefly fluorescence imaging system. No evidence of dye dispersion was visualized, and all surgeries were completed without complications. ConclusionsMethods to improve peripheral pulmonary nodule marking to facilitate surgical resection are imperative as more asymptomatic, smaller lesions continue to be identified. In our initial experience, placement of ICG dye–soaked fiducial coils for lung nodule marking multiple days before thoracic surgery appears to be a viable option to facilitate surgical resection.

Chemical pleurodesis for first presentation of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) most commonly occurs in young, tall, lean males. The PSP recurrence rate varies between 16 and 52 % after the first episode. This high recurrence rate has stimulated the development of different therapeutic approaches, ranging from simple aspiration to invasive therapies, including chemical pleurodesis or surgery. Chemical pleurodesis is a procedure which uses sclerosing agents to cause adhesion between the two layers of the pleura. Traditionally, chemical pleurodesis for PSP has been recommended only if the patient is unwilling or unable to undergo surgery. However, several prospective, randomized trials have shown that additional chemical pleurodesis following simple aspiration or chest tube drainage is a safe and more effective initial treatment for PSP than simple aspiration and drainage alone and significantly reduces pneumothorax recurrence and subsequent thoracic surgery. In this article, the role of chemical pleurodesis in the first presentation of PSP is reviewed.

Lung Penetration by Thoracostomy Tubes

We have analyzed the radiographic and computed tomographic (CT) appearance of thoracostomy (chest) tubes inadvertently placed into the lungs. We have studied the clinical sequela of such malpositioning and discussed treatment options. Cases were collected from chest CT log book reports between January 1998 and January 31, 2005 which indicated or suggested intrapulmonary thoracostomy tube placement. CT scans were reviewed by the authors. The chest radiographs and medical records--including thoracic surgical reports--of those patients whose scans demonstrated intrapulmonary tube placement or indeterminate tube location were reviewed. Fifty patients, in whom 51 thoracostomy tubes were placed into the lungs, are included in this series. None of these tubes were described as intrapulmonary on reports of chest radiographs done before CT scanning. In 13 patients (26%), thoracostomy tube placements produced immediate improvement in pleural abnormalities. Dramatic increase or development of chest wall emphysema or pneumothorax was noted in 4 (8%) patients after tube placement. Twenty-five patients (50%) demonstrated either abrupt or gradual increase in pulmonary or pleural opacity on postplacement chest radiographs. Twenty-one (42%) had no apparent clinical complications. Thirteen (26%) had either prolonged air leaks or recurrent pneumothorax. Ten (20%) developed pneumonia. Retained hemothorax or empyema occurred in 8 (16%). Twelve patients (24%) required subsequent thoracic surgery. Intrapulmonary placement of thoracostomy tubes is probably more common than previously reported. This possibility should be considered when radiographs and CT scans are evaluated.

Impact of EUS-guided FNA of enlarged mediastinal lymph nodes on subsequent thoracic surgery rates

Background A histopathologic diagnosis of metastasis in enlarged mediastinal lymph nodes usually results in non-surgical management. Cytologic specimens obtained by EUS-guided FNA can be used to detect malignancy in posterior mediastinal lymph nodes. The purpose of this study was to determine the rate of thoracic surgery after EUS-guided FNA of enlarged mediastinal lymph nodes. Methods A prospective observational study of patients with enlarged posterior mediastinal lymphadenopathy who were referred for EUS-guided FNA. All patients were candidates for mediastinoscopy. Patients were followed for 12 months to determine the subsequent rate of mediastinoscopy or thoracotomy and the diagnostic accuracy of EUS-guided FNA. Results Evaluation of cytologic specimens obtained by EUS-guided FNA revealed malignancy in 23 of 59 (39%) patients. The overall rate of surgery was 22% (13/59): 95% CI[0.12, 0.35]. The surgery rate for patients with a positive cytologic result was 4% (1/23) compared with 33% (12/36) for those with a negative result ( p = 0.009). Of patients with CT findings of a peripheral lung mass plus mediastinal lymphadenopathy, 22 of 26 (42%) underwent surgery after EUS-guided FNA, compared with two of 33 (6%) of those with mediastinal lymphadenopathy alone ( p = 0.0009). For cytologic evaluation of specimens obtained by EUS-guided FNA, the overall sensitivity, specificity, and accuracy for the diagnosis of malignant lymphadenopathy were 96%, 100%, and 98%, respectively. Conclusions Few patients who undergo EUS-guided FNA of enlarged posterior mediastinal lymph nodes require subsequent thoracic surgery.

4466 Effectiveness of eus/fna for diagnosing lung cancer in a managed care setting.

Background: Trans-esophageal endoscopic ultrasound-guided fine needle aspiration (EUS/FNA) is an accurate method to diagnose malignant posterior mediastinal lymph nodes. Previous studies have shown the efficacy of EUS/FNA for lung cancer nodes in tertiary referral centers. The purpose of this study was to assess the effectiveness of EUS/FNA for diagnosing patients with mediastinal adenopathy in a managed care setting. Methods: Patients who received care from a large staff-model HMO and had CT findings of enlarged posterior mediastinal lymph nodes (LN) located adjacent to the esophagus were referred by a pulmonologist and thoracic surgeon for EUS/FNA. All patients were candidates for surgical biopsy (mediastinoscopy, thoracotomy, etc) if EUS/FNA were negative. Patients with prior EUS/FNA or recent chemotherapy were excluded. Data was prospectively collected with follow-up at 3-month intervals. Results: 44 patients underwent EUS/FNA (25 male/19 female, mean age 64). 82% had prior bronchoscopy. FNA was performed in 54 sites (43 LN, 9 masses, 3 other). Malignancy was diagnosed in 28/54 (52%) of FNA sites. There were 23 nonsmall cell lung cancer (NSCLC), 3 small cell lung cancers, and 2 lymphomas diagnosed. EUS/FNA made a new cancer diagnosis in 25/44 (57%) (95% CI: 42%,71%) patients. Cancer was diagnosed in 11% of patients before EUS/FNA, and in 68% of patients after EUS/FNA. 15/25 (60%) (95% CI: 41%, 79%) of patients with a final diagnosis of NSCLC had stage N2 nodes diagnosed. A thoracic surgical procedure was subsequently performed in 9/44 (20%) (95% CI: 68%,91%) of patients during a median follow-up of 6.5 months (1-14 months). There was one false negative LN FNA which was later diagnosed by repeat EUS/FNA as small cell carcinoma. The sensitivity was 96%, specificity 100%, and accuracy 98% for diagnosing malignant LNs. There were no complications. Conclusion: 1) EUS/FNA made a new diagnosis of lung cancer in 57% of patients. 2) EUS/FNA diagnosed malignant lymph nodes in 60% of patients with NSCLC, making surgical benefit unlikely. 3) Only 20% of EUS/FNA patients underwent subsequent thoracic surgery, compared to an expected rate of 100% if EUS/FNA were not performed. 4) In this managed care setting, EUS/FNA of selected patients with mediastinal adenopathy was an accurate, safe, minimally invasive method of diagnosing and staging malignancy, and resulted in patients undergoing fewer thoracic surgical procedures. This work was supported by a grant from the ASGE/ADHF.

Management of experimental pneumothorax in weanling rabbits with the use of fibrin glue sclerosant.

Fibrin glue pleurodesis successfully sealed surgically created pneumothoraxes in 12 (92.3%) of 13 New Zealand white rabbits, an animal model chosen for its similarity to the thoracic configuration of the human neonate. All chest tubes were removed at 24 hours; there were no recurrences. Two rabbits, in whom human cryoprecipitate was used, died of an immunologically mediated pneumonitis. This reaction would not be expected in the human setting. Four months' follow-up revealed nearly total fibrin glue resorption. This "biodegradability" is well suited to the neonate, since alveolar barotrauma, not congenital emphysematous blebs, is the usual initiator of pneumothorax. Time-limited adhesions created by fibrin glue pleurodesis should be adequate for treatment of the acute event, while avoiding persistent pleural adhesions that could interfere with subsequent thoracic surgery or cause long-term deleterious effects on pulmonary function.

Myasthénie, thymome et tumeur hypophysaire associant une prolifération adénomateuse hétérogène et un ganglio-neurome de la selle turcique

The authors report a case of myasthenia gravis in which a tumour of the sella turcica, without clinical symptoms, was discovered on X-ray examination of the skull and was removed with success. Histological study showed endocrine and neural type cells with cells of intermediate type. Subsequent thoracic surgery was performed with removal of a thymoma which was not visible on X-ray examination of the chest. The first operation on the sella turcica had no effect on the myasthenia but after the second on the thymoma a definite improvement was noted. The association of myasthenia, thymoma and ganglioneuroma of the sella turcica is unknown. In order to explain this, the authors hypothesize a common origin in the neural crests of both tumours.