EBUS ROSE-guided cytological evaluations of intrathoracic lesions. Assessments of the pathological material adequacy and the diagnostic efficacy

BACKGROUND

Several clinical groups consider cytological assessment under EBUS (Endobronchial Ultrasonography)-ROSE (Rapid Onsite Evaluation) as the golden standard for diagnosis and staging of intrathoracic lesions. On the other hand, some investigators proposed that EBUS-TBNA (Transbronchial Needle Aspiration) has considerably high false-negative rates for diagnosis. In this study, we analyzed our patient cohort (n = 152) with intrathoracic lesions and suspected malignancies evaluated by EBUS-ROSE. Our specific aims were: (i) to determine whether EBUS-ROSE could provide sufficient pathologic material for diagnosis and staging; (ii) to determine the fidelity of EBUS-ROSE-guided initial diagnoses in comparison to paraffin block diagnoses; (iii) to evaluate whether anatomical localization of sampled lymph nodes associate with material adequacy and final diagnoses.

METHODS

NCSS (Number Cruncher Statistical System) 2020 Statistical Software (Utah, USA) was used for statistical analysis.

RESULTS

In EBUS-ROSE cytological assessment, material adequacy was determined in 50,7% (n = 77) of the cases. Considering the paraffin block pathology as the golden standart, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy rates of EBUS-ROSE were 90,2%, 93,1%, 94,8%, 87,1%, and 91,4%, respectively. There was no statistically significant difference between the final pathology and EBUS cytology results (p > .05) with a non-random Kappa agreement rate as 82.9%. There were differences in material adequacy and diagnoses according to the localization of sampled lymph node stations.

CONCLUSIONS

EBUS-ROSE is efficient to decide for the adequacy of the pathological specimen and provides diagnoses with reliable fidelity.

Could cytology supplant frozen section for intraoperative evaluation of thoracic lesions? A single institutional experience in a developing country

BACKGROUND

The diagnostic performance of cytology was compared with the frozen results and its usability was evaluated as a rapid diagnosis method in intraoperative thoracic surgery in a single institution (Istanbul, Turkey).

METHODS

All 197 subsequent patient specimens (cases) from 158 patients who were sent to our department from the thoracic surgery clinic for an intraoperative diagnosis request between the years 2016 and 2021 were evaluated. Obtained results from frozen and cytology were compared with final paraffin section diagnoses. Lesions were grouped into three different groups as nonneoplastic, benign, and malignant neoplasms.

RESULTS

Diagnostic accuracy values of cytology and frozen sections in intraoperative consultation were 98.8% and 99.4%, respectively. Sensitivity values of cytology and frozen sections in intraoperative consultation were 96.3% and 98.7%, respectively. Specificity values of cytology and frozen sections in intraoperative consultation were 100% and 100%, respectively. Negative predictive values of cytology and frozen sections in intraoperative consultation were 96.7% and 98.9%, respectively. Positive predictive values of cytology and frozen sections in intraoperative consultation were 100% and 100%, respectively. Kappa statistics between cytology and frozen revealed a very high interrater reliability (Cohen's Kappa value: 0.911; p = .001; p < .01). The difficulty in distinguishing primary and metastatic carcinoma, which is mostly undecided in frozen sections and the definitive diagnosis is left to paraffin sections, seems also be a problem in the cytological examination.

CONCLUSIONS

Cytological diagnosis can be used in the evaluation of small biopsy specimens that require tissue preservation in intraoperative consultation, especially for immunohistochemical and advanced genetic studies.

Midkine levels and its relationship with atherosclerotic risk factors in essential hypertensive patients

Background and Objectives

Hypertension (HT) is one of the risk factors associated with atherosclerosis. Midkine (MK) plays a role as a growth factor in various biologic and pathologic events. In some reports, MK expression has been shown to be linked with vascular smooth muscle proliferation and neo-angiogenesis in atherosclerotic vessels. The aim was to research relationship of MK serum levels with some atherosclerotic risk factors in hypertensive patients.

Methodology

This study examined 60 patients with essential HT and 30 healthy controls. Serum biochemistry, including lipid profile, MK, Vitamin B₁₂, C-reactive protein, zinc and copper levels were obtained.

Results

MK levels of the HT patients were significantly higher than the control group (24.8 ± 6.8 ng/mL vs. 18.39 ± 5.6 ng/mL, respectively, P < 0.01). Lipid profile parameters such as total cholesterol, triglyceride, low-density lipoprotein (LDL) were also significantly higher in HT patients (P < 0.021, P < 0.01, and P < 0.01, respectively). Zinc levels were 179.13 ± 34.06 μg/dL and 172.55 ± 45.47μg/dL in the HT and control group, respectively. Serum MK levels were positively correlated with diastolic (r = 0.288, P < 0.05) and systolic blood pressures (r = 0.390, P < 0.002), and also with serum total cholesterol (r = 0.406, P < 0.002) and LDL cholesterol (r = 0.318, P < 0.015) levels. Furthermore MK was also negatively correlated with zinc and Vitamin B₁₂levels (r = -0.298, P < 0.023, r = -0.334, P < 0.027, respectively).

Conclusion

This study has demonstrated an important association between increased serum MK levels and risk factors of atherosclerosis such as HT, increased total and LDL cholesterol.

Thoracic Traumas: A Single-Center Experience

OBJECTIVES

Trauma is currently among the most important health problems resulting in mortality. Approximately 25% of trauma-related deaths are associated with thoracic trauma. In the present study, morbidity and mortality rates and interventions performed in patients who had been treated as inpatients in Dr. Siyami Ersek Thoracic and Cardiovascular Surgery hospital after trauma were aimed to be evaluated.

MATERIAL AND METHODS

In our study, 404 patients who were treated as inpatients because of thoracic trauma between January 2005 and December 2008 were retrospectively evaluated.

RESULTS

The rates of blunt and penetrating trauma were 39.6% and 60.4%, respectively. In the study, 115 (28.4%) patients were noted to have pneumothorax, 99 (24.5%) had hemothorax, and 57 (14.1%) had hemopneumothorax. While tube thoracostomy was sufficient for treatment in approximately 80% of the patients, major surgical interventions were performed in 12.6% of the patients. Mortality rate was found to be 2.2%.

CONCLUSION

In patients with chest trauma, necessary interventions should be started at the time of the event, and the time from trauma to arriving at the emergency department should be made the best of. Mortality and morbidity rates in thoracic trauma cases may be reduced by timely interventions and effective intensive care monitoring.

Sympathectomy versus Sympathicotomy in Palmar Hyperhidrosis Comparing T3 Ablation

OBJECTIVE

The objective of this study was to evaluate and compare thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction.

MATERIALS AND METHODS

Two groups of patient underwent T3 thoracoscopic sympathectomy and thoracoscopic sympathicotomy under general anesthesia using single-lung ventilation via a double-lumen endotracheal tube by the same surgical team for the treatment of severe primary palmar hyperhidrosis or a combination of levels for multiarea between 2008 and 2013. The groups were homogeneous for relevant demographic, physiological, and clinical data. All patients were examined preoperatively and were followed up at 6 months postoperatively. In both groups, patient's satisfaction was evaluated 6 months after surgery by a detailed interview and scored into three grades (1 = very satisfied, 2 = satisfied, and 3 = dissatisfied).

RESULTS

No operative mortality, major intraoperative complication, infections, and Horner syndrome were recorded. There was no treatment failure. The average time of operation was 50 minutes for Group A (sympathectomy) and 36 minutes for Group B (sympathicotomy). Compensatory sweating occurred in 40 patients (89% for Group A and 85.11% for Group B) with a different accumulation of the severity degree. The satisfaction rate was 91.11% for Group A and 93.61% for Group B.

CONCLUSION

There was no significant difference between thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction. Neither surgical technique is better than the other one for palmar hyperhidrosis treatment. Development of severe compensatory sweating and postoperative pain are major determinant factors of patient dissatisfaction. Sympathicotomy should be preferred for palmar hyperhidrosis treatment, as it is much technically shorter, simpler to implement, and also easier to learn.

[Esophageal foreign bodies in children and adults: 20 years experience]

BACKGROUND

Esophageal foreign object ingestion is frequently seen in all ages. Failure to treat can cause serious complications such as esophageal perforation. The aims of this study were to characterize the clinical features related to foreign objects in the esophagus and to analyze the results of commonly used methods for their removal.

METHODS

We analyzed 20 years of records from Siyami Ersek Hospital, Istanbul and identified 512 cases of foreign objects enlodged in the esophagus.

RESULTS

In pediatric patients, the majority were aged between 2-5 years (34.4%), while in adult patients, the majority were above 55 years (38.7%). Coins were the most common foreign object detected in children (68.8%), whereas meat impaction was most common in adults (87.4%). The most common location of the foreign object was the cervical esophagus in children (78.2%), and the thoracic esophagus in adults (66.4%). In 30.8% of adults, there was esophageal or systemic disease. Objects were removed with a Magill clamp in 48.3% of children. Rigid endoscopy was the main treatment in adult patients. Perforation due to endoscopy developed in three patients. Surgical repair was performed on these patients but all died due to mediastinitis.

CONCLUSION

Underlying esophageal or systemic diseases may predispose adults to foreign object ingestion in the esophagus. Improved endoscopic experience and clinical management of thoracic surgeons led to reduced morbidity and mortality in recent years.

Echocardiographic assessment of right ventricular function before and after surgery in patients with pectus excavatum and right ventricular compression

BACKGROUND

We aimed to evaluate the effect of surgical repair on right ventricular (RV) function in patients with pectus excavatum (PE) and RV compression by Doppler echocardiography.

MATERIALS AND METHODS

Twenty-three patients who were admitted to our hospital for surgical correction of PE between 2009 and 2012 were included in the study. After transthoracic echocardiographic evaluation, 16 patients with RV compression were enrolled. All patients were males (100%) with a mean age of 20.5 ± 5.6 years. Transthoracic echocardiography was repeated 1 month after surgery. Echocardiographic evaluation included the assessment of RV diastolic diameter, tricuspid annular plane systolic excursion (TAPSE), pulsed tissue Doppler systolic velocity (S'), RV isovolumic acceleration (RV IVA), systolic pulmonary artery pressure, left ventricular (LV) ejection fraction, and myocardial performance indexes of both the right and the left ventricles (Tei index).

RESULTS

Following the surgery, the RV end-diastolic diameter, TAPSE, S', and RV IVA were found to be significantly increased in patients with PE. In addition, RV and LV Tei index significantly improved after surgical correction.

CONCLUSIONS

RV function significantly improved after corrective surgery. Quantitative echocardiographic examination provides accurate estimation when deciding for corrective surgery and also should be used in the assessment of postoperative improvement.

Intrathoracic giant solitary fibrous tumor

Background

Solitary fibrous tumor of the pleura is a rare, usually benign, and slow-growing neoplasm. Complete surgical resection for giant tumor of the pleura is challenging because of poor exposure and a large blood supply. We report the case of a giant hypervascular fibrous tumor that filled nearly the entire left hemithorax and anterior mediastinum, and its preoperative management.

Case Report:

A 59-year-old woman presented to us with exertional dyspnea and chest pain. A chest radiograph showed the right hemithorax completely opaque and a mediastinal shift to the left hemithorax. A tomography scan of the thorax showed a giant mass that almost completely filled the right hemithorax and compressed the mediastinum to the left. Because of excessive bleeding during dissection, the operation was terminated after a biopsy specimen was obtained. The biopsy was diagnosed as a benign fibrous tumour. A thoracic computed tomography angiogram showed that the mass was supplied by multiple intercostal arteries as well as an aberrant artery that branches off the celiac trunk in the subdiaphragmatic region. Due to the many arteries that needed to be embolized, the final decision was to control the bleeding following resection by inducing total circulatory arrest with the help of cardiopulmonary bypass. The bleeding could not be controlled under cardiopulmonary bypass and the patient’s death was confirmed.

Conclusions:

We report this case to emphasize the necessity of preoperative embolization; the use of cardiopulmonary bypass and total circulatory arrest is not a valid alternative method to control the bleeding.

Interlaboratory proficiency testing of tensile and flexural testing for cellulose based transformed board material

Optimum safety and reliability can be achieved by coordinating an interlaboratory proficiency testing among different laboratories. Testing laboratories need to verify their test procedures and testing capability for reliable results. In this study, equivalent samples are prepared by cellulose based transformed board material used in transformers as electrical isolation material. Randomly selected test samples having specified dimensions are sent to the participant laboratories. Then they are tested and results are analyzed according to previously defined parameters. Each laboratory applied tensile and flexural tests on the samples according to procedures given in IEC 60641-2, 2004 and IEC 60763-2, 2007 standards respectively. Test results are evaluated according to same procedures explained in related standards by the participant laboratories. TUBITAK UME Material Testing Laboratory being the pilot laboratory collected to the all evaluated results including associated measurement uncertainties. Then the collected results evaluated according to ISO 17043, 2010 are reported by each laboratory as a part of the proficiency test report. Z-scores of the participant laboratories are presented.

Calculation of measurement uncertainty for cellulose based transformed board material in tensile testing

Today’s global economy obliges manufacturers to produce their products in high quality with cheaper cost. Thus, manufacturers must develop their products applying tests to get better performance and higher quality before distributing them to the competitive market. In order to produce long working life of transformer reactors without losing their performance, different tests including axial and flexural testing are applied on the cellulose based laminated board material used in production. During development of laminated board material, test results should be known very well and the measurement uncertainty of tensile tests should be calculated taking into account all parameters. In this study, effective parameters on the quality of tensile testing causing an increase on the measurement uncertainty are investigated. Tensile strength and elongation test of laminated board material were carried out according to IEC 60641-2 and the uncertainty contributions based on experimental results were calculated. The results and impact of the uncertainty parameters are presented in detail.

[Tracheobronchial injuries]

BACKGROUND

We aimed in this study to investigate and compare the diagnostic and therapeutic methods in tracheobronchial injuries.

METHODS

Nine cases (7 male, 2 female) operated between 2003 and 2008 because of tracheobronchial injury were included in the study. The cause of tracheobronchial injury was trauma in 7 cases and postintubation laceration in 2 cases. The cases were evaluated in terms of age, sex, type of trauma, clinical findings, localization of injury, performed diagnostic and therapeutic methods, and results.

RESULTS

The causes of tracheobronchial laceration were blunt trauma in 6 cases, penetrating trauma in 1 case and iatrogenic (postintubation) in 2 cases. Lacerations were in the trachea in 5 cases and at the bronchial level in 4 cases. Operations included right upper bilobectomy in 1 case, tracheal resection and end to end anastomosis in 1 case, end to end anastomosis in 3 cases, and primary repair in 4 cases. One case died during the operation and 1 case died postoperatively.

CONCLUSION

In tracheobronchial injuries, early diagnosis and treatment are very important. The most useful method is bronchoscopy for determining the type and localization of the injury. In treatment, primary repair should be preferred over anatomical resections whenever possible.

Trace elements and toxic heavy metals play a role in Buerger disease and atherosclerotic peripheral arterial occlusive disease

AIM

The aim of the present study was to define the roles of trace elements and toxic heavy metals in Buerger disease and atherosclerotic peripheral arterial occlusive disease (PAOD).

METHODS

Seventy-five subjects who were identical in demographic charecteristics were selected for the study; 25 with Buerger disease, 25 with PAOD, 25 healthy volunteers. Serum selenium (Se), zinc (Zn), copper (Cu), iron (Fe),whole blood cadmium (Cd) and lead (Pb), erythrocyte glutathione (GSH), erythrocyte glutathione peroxidase (GSH-Px), erythrocyte and plasma malondialdehyde (MDA) levels were measured.

RESULTS

Serum Se and Zn levels were significantly low in patients with Buerger disease compared to patients with PAOD and controls (P<0.001 and P<0.001 respectively). Serum levels of Fe and Zn were also significantly low in patients with PAOD compared to controls (p<0.001 and p<0.05 respectively). In contrast, Cu and Pb levels in Buerger disease group were significantly high compared to PAOD and control groups (P<0.001 and P<0.001 respectively). Erythrocyte GSH and GSH-Px levels were significantly lower in patients with Buerger disease compared to patients with PAOD and controls (P<0.001 and P<0.001 respectively), while erythrocyte and plasma MDA levels were significantly higher (P<0.001 and P<0.001 respectively).

CONCLUSION

It can be concluded that the levels of trace elments and toxic heavy metals and oxidative stress influence the disease process in Buerger disease more than PAOD.

A new approach to pectus deformity in females

One of the most preferred procedures for correction of pectus deformities is the modified Ravitch procedure. The main aim is cosmetic for many patients, especially in females. Two types of skin incisions have been described for this operation in the literature: midsternal and transversal. Both incisions leave a skin scar on the sternum and result in unacceptable cosmetic results. As a way of concealing the ugly skin incision scar under the breasts after puberty, we describe and discuss the use of bilateral inframammarian separated skin incisions. We have used our method for correction of pectus deformity in 12 female cases in our clinic since 1991. Two 4-5 cm incisions were localized as 1/3 medially and 2/3 laterally below both breasts. With this incision we performed the modified Ravitch technique. In spite of technical difficulties of exposure, correction of the deformity was satisfactory in all patients. Only one patient had seroma and one had perioperative pneumothorax. The patients were followed up for from 3 months to 9 years. No recurrence was observed. Breast development and sensitivity was found to benormal at follow-up. The new approach was found to be effective and more cosmetically acceptable than the other approaches for correction of pectus excavatum in female patients.

Relationships between levels of estradiol and testosterone in seminal plasma and GSTM1 polymorphism in infertile men

Glutathione S-transferase M1 (GSTM1) enzyme serves as a steroid-binding protein by its ability to bind to testosterone and estradiol. The levels of total estradiol and testosterone were measured by using an electrochemiluminescence immunoassay in serum and seminal plasma from 103 subjects including 62 subfertile patients. GSTM1 polymorphism was examined using polymerase chain reaction. The estradiol and testosterone levels in seminal plasma were not different in control and subfertile subjects. No role for GSTM1 enzyme as a steroid-binding protein seemed likely as there was also no significant difference in seminal plasma estradiol and testosterone levels according to GSTM1 genotype. Significant positive correlations were found between seminal estradiol and serum estradiol in infertile males, and between seminal testosterone and serum testosterone in fertile males, independent of GSTM1 genotype. GSTM1 polymorphism is not a genetic risk factor of seminal estradiol and testosterone levels in infertile males although further studies are warranted.

PercuTwist: a new alternative to Griggs and Ciaglia's techniques

BACKGROUND AND OBJECTIVE

Tracheostomy is one of the most common procedures in intensive care units worldwide. In this study we aimed to compare three different tracheostomy techniques with respect to duration of procedure and complications.

METHODS

One hundred and thirty patients requiring endotracheal intubation for more than 10 days due to acute respiratory distress syndrome, infections or cerebrovascular events were consecutively selected to undergo the percutaneous dilatational tracheostomy technique (PDT n = 44), the guide-wire dilating forceps technique group (GWDF n = 41) or the PercuTwist technique (n = 45). The time taken to perform the procedure (skin incision to successful placement of tracheostomy tube) and complications were recorded.

RESULTS

The operating times were found to be 9.9 +/- 1.1, 6.2 +/-1.4 and 5.4 +/- 1.2 min in PDT, GWDF and PercuTwist groups, respectively. The duration of the procedure was significantly shorter in the PercuTwist group as compared to the percutaneous dilatational tracheostomy (P < 0.01) and guide-wire dilating forceps (P < 0.05) groups. During postoperative bronchoscopy, eight cases of longitudinal tracheal abrasion (four in the PDT group, two in the GWDF group and two in the PercuTwist group), two cases of posterior tracheal wall injury (one in PDT and one in GWDF) and one case of tracheal ring rupture in the PDT group were seen.

CONCLUSIONS

Percutaneous tracheostomy techniques have their own advantages and complications. PercuTwist, a new controlled rotating dilatation method, was associated with minimal complications, appears to be easy to perform and a practical alternative to percutaneous dilatational tracheostomy and guide-wire dilating forceps techniques.

Outcome of Renal Allograft in Turkish Patients With Pretransplantation Hepatitis C Virus Infection

BACKGROUND

The aim of the present study was to investigate the impact of hepatitis C virus (HCV) infection on the long-term survival of renal transplant recipients.

METHODS

Outcomes and survivals among 325 patients who received renal allografts from July 1991 to September 2005 were compared between those known to have pretransplantation HCV infection (Group I, HCV+ group, n = 33) versus a matched cohort of those without this infection (Group II, HCV- control group, n = 33). Allograft performance, liver function, cholesterol, and glucose levels were determined both at transplantation and at a mean of postgrafting year 8. A one-way analysis of variance (ANOVA) statistical method was used for multivariate analysis.

RESULTS

Thirty-three patients (10.15%, 19 women and 14 men) were positive for HCV antibody. The mean follow-up period was 8 years (range, 0.5-14 years). The mean survival rates were similar in Groups I and II (96.6% and, 100%, respectively). Although the allograft survival rate was lower in Group I (84.8% vs 90.9%), the rejection rate among the HCV- group was 6%; only 1 patient died of hepatic failure. In spite of a significant rise in both total and direct bilirubin values (P < .01) in both groups, we failed to observe an adverse effect on graft survival. A significant rise in the fasting glucose level was seen in both HCV+ and HCV- patients.

CONCLUSIONS

Chronic HCV infection before transplantation did not have a significant impact on graft survival or mortality compared with noninfected patients.

An Aspergilloma in an Echinococcal Cyst Cavity

Aspergilloma is a saprophytic infection which can colonize preexisting lung cavities. The most common underlying diseases are tuberculosis, sarcoidosis, cavitary lung cancer, etc. Although aspergilloma can also occur in operated hydatid cyst cavities, only a few cases have been reported in literature. A 32-year-old female patient underwent cystectomy for the diagnosis of perforated intraparenchymal giant hydatid cyst located in the right upper lobe, reaching down to the hilum. Capitonnage was not performed and it was observed that a residual cavity remained in the cystectomy area. The patient was discharged; however, during clinical and radiological follow-ups, it was found that the residual cyst cavity had expanded. As it was thought that one of the drainage bronchi in the cyst cavity could have opened, the patient was reoperated. During the operation, it was noted that purulent fluid and necrotic tissues were present in the cystic cavity. It was seen that the posterior upper lobe segment was consolidated and not ventilated. Contents of the cavity were removed and the posterior upper lobe segment was resected. Histopathological examination revealed that the tissue in the cavity was that of an aspergilloma, and that chronic organized pneumonia and diffuse interstitial fibrosis were present in the resected segment. Refraining from surgical obliteration (capitonnage) of cyst cavities in cases of giant hydatid cysts extending to the hilum can lead to opportunistic infections such as aspergilloma.