Parathyroid adenomas (PAs) are the main cause for primary hyperparathyroidism with almost a quart... more Parathyroid adenomas (PAs) are the main cause for primary hyperparathyroidism with almost a quarter of them being ectopic, most likely located in the superior mediastinum within the thymus. Besides the challenge of their prompt and correct diagnosis, utmost care should be taken during surgical resection as leaving behind parathyroid tissue may result in metastasis and recurrence of hyperparathyroidism. With tumor excision via median sternotomy or thoracotomy being the conventional approaches for a long period, video-assisted thoracoscopic surgery (VATS) is of gaining popularity. As the lateral thoracic approach lacks in clarity on the contralateral mediastinum, the newest evolution in VATS-the supxiphoid approachcloses the gap to the insufficient intraoperative visibility and hence optimizes postoperative outcome. We hereby present the practicality of the uniportal subxiphoid resection of an ectopic mediastinal PA.
Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-as... more Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-associated thymomas. Within the context of video-assisted thoracoscopic surgery (VATS) as a widely known minimally invasive option, the most recent achievement is uniportal subxiphoid VATS. In MG patients, it is mandatory (1) to minimize perioperative interference with administered anesthetics to avoid complications and (2) to achieve a complete surgical resection, as the prognosis essentially depends on radical tumor resection. In order to fulfill these criteria, we merged this surgical technique with its anesthesiologic counterpart: regional anesthesia with the maintenance of spontaneous ventilation via a laryngeal mask. Non-intubated uniportal subxiphoid VATS for extended thymectomy allowed radical thymectomy in all MG patients with both rapid symptom control and fast recovery.
boring structures to cause symptoms. They consist of heat-generating brown adipose tissue, wherea... more boring structures to cause symptoms. They consist of heat-generating brown adipose tissue, whereas lipomas originate from heat-insulating white adipose tissue [3, 10]. The skin overlying the tumor may be warm, probably due to the hypervascularity of hibernomas [11]. Although the likelihood of confusion with other tumors is minimal, the differential diagnosis when the tumor is subpleural includes lipoma, localized mesothelioma, neurofibroma, or solitary pleural fibrous tumor [6, 11]. Computed tomography, ultrasonography, and angiography have been used to investigate this tumor [11, 12]. Hibernomas and lipomas have similar signal characteristics on magnetic resonance imaging and computed tomography because of their fat content. However, hibernomas are more heterogeneous due to their different fibrovascular composition. Their computed tomographic density is low with no infiltration of surrounding structures [12]. Contrast enhanced-computed tomographic highlights areas of heterogeneity are helpful in distinguishing hibernomas form lipomas [13]. Angiography also differentiates the highly vascular hibernoma from hypovascular lesions, such as lipomas, fibromas, and neurofibromas; it also defines the vascular anatomy for surgical planning [11]. Due to the risk of hemorrhage, preoperative biopsy seems ill advised. Rather, complete marginal surgical resection with meticulous hemostasis and identification of the feeding vessels is the treatment of choice [14]. Intraoperative tumor fragmentation experienced in this case did not result in hemorrhage. Nonetheless, delicate dissection around the tumor should be attempted. Histologic variants of hibernoma include typical, myxoid, and lipoma-like. The typical variant is the most frequent and includes three subtypes (1) pale cell, (2) mixed, and (3) eosinophilic cell. The lesion observed here corresponds to the typical variant, mixed subtype. The histologic differential diagnosis includes (1) rhabdomyoma a muscle-derived tumor with glycogen rich, eosinophilic, striated cells; (2) granular cell tumor, distinguishable by a strong Periodic acid Schiff reagent reactivity and lack of cytoplasmic lipids; (3) lipomas, composed of uni-vacuolated cells and much less vascularized; and (4) liposarcoma that shows lipoblasts, high cellularity, cellular atypia, and mitotic activity [3, 10]. The oil red O stain is useful to demonstrate the lipid content of hibernomas. Immunohistochemically, hibernomas are usually reactive for S100 protein and usually show no or little reactivity for keratin, CD68, epithelial membrane antigen, and carcinoembryonic antigen [3, 4]. Electron transmission microscopy discloses multivacuolated cells, a high concentration of mitochondria, and paucity of organelles [15]. Despite one case report of a malignant hibernoma based on muscle infiltration, no histologic criteria have been established for malignancy in this soft-tissue tumor [16]. All intrathoracic hibernomas reported in the literature are benign, solitary, and encapsulated tumors. Most are found on incidental routine chest x-ray films. Because it does not recur, and complete surgical excision is the treatment of choice, we consider videothoracoscopic re-section the ideal approach as it allows excellent visualization and reliable resection with minimal invasiveness. The rarity and unusual histologic features of hibernoma can make the diagnosis difficult.
In a retrospective analysis, we studied 24 cases of malignant small bowel tumors. Apart from 9 ca... more In a retrospective analysis, we studied 24 cases of malignant small bowel tumors. Apart from 9 cases of a carcinoid tumor, there occurred 6 cases of leiomyosarcoma and another 7 cases of adenocarcinoma. One case of malignant schwannoma and another case of lymphoma were also seen. Sonography and contrast-study of the GI-tract were the decisive diagnostic tools. Nevertheless, months and even years elapsed before diagnosis was established. Only in 13 patients curative resection could be accomplished. In the remainder of patients, hepatic metastases were found or the tumor could not be resected any more owing to its size. In 6 patients with synchronous and in 7 patients with metachronous liver metastases we carried out palliative regional intraarterial chemotherapy of the liver. The mean survival time of the whole patient group was 19 months. Patients, having submitted themselves to a complete resection of the tumor, had a significantly longer period of survival (mean survival time 25 months) in contrast to patients, having undergone a mere palliative operative procedure (mean survival time 14 months). Mean survival time for leiomyosarcoma was 38 months, for adenocarcinoma 14 months, and for carcinoid tumors 22 months. Owing to difficulties in establishing diagnosis, a tumor of the small intestine should be considered in any patient complaining of abdominal pain.
Following an empyema of the shoulder joint the patient had to undergo twelve operations in 14 mon... more Following an empyema of the shoulder joint the patient had to undergo twelve operations in 14 months to treat vast subcutaneous abscesses. An epidermoid cyst was extirpated in the end, whatafter no more abscess occurred.
Interactive Cardiovascular and Thoracic Surgery, Jul 1, 2013
Objectives: Segmentectomy is indicated for peripheral small lung carcinoma up to 2 cm diameter co... more Objectives: Segmentectomy is indicated for peripheral small lung carcinoma up to 2 cm diameter confined to one segment, and/or in patients unable to tolerate a lobectomy. The left upper lobe can be divided easily into an upper (segments 1-3) and lingular (segments 4 and 5) segmental group, facillitating sublobar resections that are probably appropriate for tumours of larger diameters and unfavourable localisation. Methods: This study compares 22 consecutive split-lobe resections to 44 pair-matched left upper lobectomy controls with regard to clinical and oncolgical outcome. Results: Split-lobe and lobectomy groups had equal tumour diameters (22.5 (11-63) mm vs 25 (7-68) mm) and identical pN stages (pN0 77.3%, pN1 9.1%, pN2 9.1%, ypN0 4.5%), a similar clinical course despite lower pre-OP FEV1 and higher comorbidity in the split-lobe group, and similar long-term overall (0.904 vs 0.821 at 5 years) and disease-free survival (0.854 vs 0.609 at 5 years). Conclusions: Left upper lobectomy might be an overtreatment for lung carcinoma resectable by split-lobe procedures. Larger confirmatory studies are neccessary.
This survey addressed common methods of video-assisted thoracoscopic pleurodesis for spontaneous ... more This survey addressed common methods of video-assisted thoracoscopic pleurodesis for spontaneous pneumothorax. A questionnaire asking for frequency, recurrence rate and complications of the different methods of pleurodesis was sent to all hospitals that belong to the German Society for Thoracic Surgery. 19 hospitals reported on a total of 1365 operations. 88 recurrences (6.5%), 26 severe bleeding complications (1.9%), 39 persisting air leaks (2.9%) and two hospital deaths (0.1%) had been observed. Pleurectomy and pleural abrasion were the most common procedures but induced significant (p = 0.01) more bleeding complications (3.1% and 2.6%) than all other methods of pleurodesis (0.4%). Overall recurrence rates depended significantly on the chosen procedure (p = 0.0013). Pleurectomy (4.4%) and coagulation of the pleura (2.7%) showed better results than the average. Due to smaller numbers of operations and the widely differing results this significance cannot be shown for the individual recurrence rates of the different clinics. This survey demonstrated a trend towards lower rates of recurrence and complications after coagulation of the pleura parietalis. The retrospective character of the investigation and extremely different recurrence rates for different hospitals demand cautious interpretation of these results.
Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, Jun 1, 2013
The aim of this study was to identify resorption, clinical performance, and safety of cotton-deri... more The aim of this study was to identify resorption, clinical performance, and safety of cotton-derived oxidized cellulose gauze applied as a hemostat in minimally invasive oncologic thoracic surgery. Methods: This is a pilot prospective noncomparative observational human in vivo study. A piece of cotton-derived oxidized cellulose gauze measuring 5 Â 20 cm was inserted into the subcarinal space of patients with potentially resectable lung carcinoma at the time of video-assisted mediastinoscopic lymphadenectomy and reexamined several days later for macroscopic and histologic evaluation at the time of subsequent lung resection. The primary endpoint was the local situation at the implantation site described by cellulose remnants, fluid collections, and adhesions. The secondary endpoint was safety, described by the number of adverse events and surgical reinterventions. Results: Twenty-five consecutive eligible patients with potentially resectable lung carcinoma were included. The desired hemostatic effect was achieved in all cases. No adverse events were observed. At re-exploration 10.5 (5Y28) days later, the cellulose gauze was found to lose its solid structure from the fifth day on. Remnants were last detected 14 days after insertion. The implantation site exhibited no inflammatory changes and a remarkable small amount of fluid collections and adhesions. Conclusions: Mediastinal application of cotton-derived oxidized cellulose is safe and effective. A piece of gauze measuring 5 Â 20 cm seems to be absorbed completely within 15 days, thus precluding any interference with oncologic restaging and follow-up. The absence of relevant adhesions facilitates further surgical procedures. Larger comparative confirmatory studies are required. For large-scale resorption studies, our clinical model should be translated into a porcine model.
Background: Based on the algorithm on preoperative mediastinal staging in patients with non-small... more Background: Based on the algorithm on preoperative mediastinal staging in patients with non-small cell lung cancer (NSCLC), endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is indicated in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. It represents both a safe minimal invasive procedure with complication rates of less than 1.5% and a valid tool with a high sensitivity defining mediastinal nodal disease. However, infectious complications like mediastinitis or pyopericardium are most feared. Case Description: A 54-year-old woman was admitted to our hospital for further investigation of a suspected NSCLC of the right upper lobe. EBUS-TBNA was performed to receive both diagnosis and samples of the mediastinal lymph nodes. Two weeks after EBUS-TBNA, the patient presented with symptoms of cardiogenic/septic shock: hypotension, tachycardia, chest pain and fever. Prompt diagnosis of concomitant infectious mediastinitis and extensive pyopericardium in consequence of EBUS-TBNA was obvious. Besides systemic antibiotics, bilateral thoracoscopic interventions finally made the breakthrough. The patient could be discharged roughly three weeks after emergent re-admittance. As being finally diagnosed with NSCLC (stage IIIA squamous cell carcinoma), the patient underwent-subsequent to induction chemotherapy-a definitive sequential chemoradiotherapy. Twelve-month follow-up confirmed stable disease. Conclusions: It is to be expected that with increasing application of EBUS-TBNA as mediastinal staging tool, the number of serious infection-related complications will rise accordingly. The efficacy of antibiotic prophylaxis after EBUS-TBNA has not yet been proved and is therefore not included in any guideline. Our case gives an impression on the severity of delayed infectious complications after EBUS-TBNA and outlines up-front surgery as primary objective to broadly debride all contagious abscess-/empyema sites. With increased use of EBUS-TBNA as mediastinal staging tool, clinicians should be aware of this rare but highly critical peri-interventional complication in order to closely monitor endangered patients.
European Journal of Cardio-Thoracic Surgery, Jun 1, 2008
Objective: To determine the impact of endoesophageal ultrasound-guided fine-needle aspiration (EU... more Objective: To determine the impact of endoesophageal ultrasound-guided fine-needle aspiration (EUS-FNA) on management of thoracic malignancies. Methods: One hundred and twenty patients referred for invasive diagnostic and resection of thoracic malignancies were studied prospectively. Negative and inconclusive EUS-FNA findings were assessed by video-assisted mediastinoscopic lymphadenectomy (VAMLA) or open lymphadenectomy. Results: One hundred and twenty patients, aged 64.1 years (range 38-85) underwent 120 EUS-FNA, 53 video-assisted mediastinoscopic and 48 open lymphadenectomies for diagnosis and treatment of 99 lung carcinoma, six lung metastases, five mesothelioma, three lymphoma, and eight other conditions. EUS-FNA showed T4 in 15/120 and adrenal or hepatic metastases in 9/120 cases. Prevalence of mediastinal lymph node metastases was 51.7%. EUS-FNA false-negative rate was 25.3%. EUS-FNA sensitivity was 91.7%, 78.1% and 43.8% for bulky disease, enlarged mediastinal nodes or normal nodes on CT scan, 50% and 96.6% for right-and left-sided tumours, and 80.6%, 78.9%, 23.8% and 25.0% for the lymph node stations 7, 5/6, 4R, and 4L. A 38.3% respectively 100% cut-down of mediastinoscopies leads in 7.5% respectively 20.8% to incorrect treatment decisions. Conclusions: EUS-FNA sensitivity depends on the localisation of the primary tumour, and extent and location of mediastinal disease. For left-sided tumours, EUS-FNA improves mediastinal staging by assessing stations 5 and 6 inaccessible to conventional mediastinoscopy. For extended mediastinal disease, mediastinoscopy can be avoided or spared for restaging after neoadjuvant therapy. Exclusion of mediastinal involvement requires mediastinoscopy or open lymphadenectomy. Beyond mediastinal nodal staging, EUS-FNA may detect T4 and M1 situations. Thus, EUS-FNA is a useful supplement to and not the replacement of mediastinoscopy.
Parathyroid adenomas (PAs) are the main cause for primary hyperparathyroidism with almost a quart... more Parathyroid adenomas (PAs) are the main cause for primary hyperparathyroidism with almost a quarter of them being ectopic, most likely located in the superior mediastinum within the thymus. Besides the challenge of their prompt and correct diagnosis, utmost care should be taken during surgical resection as leaving behind parathyroid tissue may result in metastasis and recurrence of hyperparathyroidism. With tumor excision via median sternotomy or thoracotomy being the conventional approaches for a long period, video-assisted thoracoscopic surgery (VATS) is of gaining popularity. As the lateral thoracic approach lacks in clarity on the contralateral mediastinum, the newest evolution in VATS-the supxiphoid approachcloses the gap to the insufficient intraoperative visibility and hence optimizes postoperative outcome. We hereby present the practicality of the uniportal subxiphoid resection of an ectopic mediastinal PA.
Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-as... more Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-associated thymomas. Within the context of video-assisted thoracoscopic surgery (VATS) as a widely known minimally invasive option, the most recent achievement is uniportal subxiphoid VATS. In MG patients, it is mandatory (1) to minimize perioperative interference with administered anesthetics to avoid complications and (2) to achieve a complete surgical resection, as the prognosis essentially depends on radical tumor resection. In order to fulfill these criteria, we merged this surgical technique with its anesthesiologic counterpart: regional anesthesia with the maintenance of spontaneous ventilation via a laryngeal mask. Non-intubated uniportal subxiphoid VATS for extended thymectomy allowed radical thymectomy in all MG patients with both rapid symptom control and fast recovery.
boring structures to cause symptoms. They consist of heat-generating brown adipose tissue, wherea... more boring structures to cause symptoms. They consist of heat-generating brown adipose tissue, whereas lipomas originate from heat-insulating white adipose tissue [3, 10]. The skin overlying the tumor may be warm, probably due to the hypervascularity of hibernomas [11]. Although the likelihood of confusion with other tumors is minimal, the differential diagnosis when the tumor is subpleural includes lipoma, localized mesothelioma, neurofibroma, or solitary pleural fibrous tumor [6, 11]. Computed tomography, ultrasonography, and angiography have been used to investigate this tumor [11, 12]. Hibernomas and lipomas have similar signal characteristics on magnetic resonance imaging and computed tomography because of their fat content. However, hibernomas are more heterogeneous due to their different fibrovascular composition. Their computed tomographic density is low with no infiltration of surrounding structures [12]. Contrast enhanced-computed tomographic highlights areas of heterogeneity are helpful in distinguishing hibernomas form lipomas [13]. Angiography also differentiates the highly vascular hibernoma from hypovascular lesions, such as lipomas, fibromas, and neurofibromas; it also defines the vascular anatomy for surgical planning [11]. Due to the risk of hemorrhage, preoperative biopsy seems ill advised. Rather, complete marginal surgical resection with meticulous hemostasis and identification of the feeding vessels is the treatment of choice [14]. Intraoperative tumor fragmentation experienced in this case did not result in hemorrhage. Nonetheless, delicate dissection around the tumor should be attempted. Histologic variants of hibernoma include typical, myxoid, and lipoma-like. The typical variant is the most frequent and includes three subtypes (1) pale cell, (2) mixed, and (3) eosinophilic cell. The lesion observed here corresponds to the typical variant, mixed subtype. The histologic differential diagnosis includes (1) rhabdomyoma a muscle-derived tumor with glycogen rich, eosinophilic, striated cells; (2) granular cell tumor, distinguishable by a strong Periodic acid Schiff reagent reactivity and lack of cytoplasmic lipids; (3) lipomas, composed of uni-vacuolated cells and much less vascularized; and (4) liposarcoma that shows lipoblasts, high cellularity, cellular atypia, and mitotic activity [3, 10]. The oil red O stain is useful to demonstrate the lipid content of hibernomas. Immunohistochemically, hibernomas are usually reactive for S100 protein and usually show no or little reactivity for keratin, CD68, epithelial membrane antigen, and carcinoembryonic antigen [3, 4]. Electron transmission microscopy discloses multivacuolated cells, a high concentration of mitochondria, and paucity of organelles [15]. Despite one case report of a malignant hibernoma based on muscle infiltration, no histologic criteria have been established for malignancy in this soft-tissue tumor [16]. All intrathoracic hibernomas reported in the literature are benign, solitary, and encapsulated tumors. Most are found on incidental routine chest x-ray films. Because it does not recur, and complete surgical excision is the treatment of choice, we consider videothoracoscopic re-section the ideal approach as it allows excellent visualization and reliable resection with minimal invasiveness. The rarity and unusual histologic features of hibernoma can make the diagnosis difficult.
In a retrospective analysis, we studied 24 cases of malignant small bowel tumors. Apart from 9 ca... more In a retrospective analysis, we studied 24 cases of malignant small bowel tumors. Apart from 9 cases of a carcinoid tumor, there occurred 6 cases of leiomyosarcoma and another 7 cases of adenocarcinoma. One case of malignant schwannoma and another case of lymphoma were also seen. Sonography and contrast-study of the GI-tract were the decisive diagnostic tools. Nevertheless, months and even years elapsed before diagnosis was established. Only in 13 patients curative resection could be accomplished. In the remainder of patients, hepatic metastases were found or the tumor could not be resected any more owing to its size. In 6 patients with synchronous and in 7 patients with metachronous liver metastases we carried out palliative regional intraarterial chemotherapy of the liver. The mean survival time of the whole patient group was 19 months. Patients, having submitted themselves to a complete resection of the tumor, had a significantly longer period of survival (mean survival time 25 months) in contrast to patients, having undergone a mere palliative operative procedure (mean survival time 14 months). Mean survival time for leiomyosarcoma was 38 months, for adenocarcinoma 14 months, and for carcinoid tumors 22 months. Owing to difficulties in establishing diagnosis, a tumor of the small intestine should be considered in any patient complaining of abdominal pain.
Following an empyema of the shoulder joint the patient had to undergo twelve operations in 14 mon... more Following an empyema of the shoulder joint the patient had to undergo twelve operations in 14 months to treat vast subcutaneous abscesses. An epidermoid cyst was extirpated in the end, whatafter no more abscess occurred.
Interactive Cardiovascular and Thoracic Surgery, Jul 1, 2013
Objectives: Segmentectomy is indicated for peripheral small lung carcinoma up to 2 cm diameter co... more Objectives: Segmentectomy is indicated for peripheral small lung carcinoma up to 2 cm diameter confined to one segment, and/or in patients unable to tolerate a lobectomy. The left upper lobe can be divided easily into an upper (segments 1-3) and lingular (segments 4 and 5) segmental group, facillitating sublobar resections that are probably appropriate for tumours of larger diameters and unfavourable localisation. Methods: This study compares 22 consecutive split-lobe resections to 44 pair-matched left upper lobectomy controls with regard to clinical and oncolgical outcome. Results: Split-lobe and lobectomy groups had equal tumour diameters (22.5 (11-63) mm vs 25 (7-68) mm) and identical pN stages (pN0 77.3%, pN1 9.1%, pN2 9.1%, ypN0 4.5%), a similar clinical course despite lower pre-OP FEV1 and higher comorbidity in the split-lobe group, and similar long-term overall (0.904 vs 0.821 at 5 years) and disease-free survival (0.854 vs 0.609 at 5 years). Conclusions: Left upper lobectomy might be an overtreatment for lung carcinoma resectable by split-lobe procedures. Larger confirmatory studies are neccessary.
This survey addressed common methods of video-assisted thoracoscopic pleurodesis for spontaneous ... more This survey addressed common methods of video-assisted thoracoscopic pleurodesis for spontaneous pneumothorax. A questionnaire asking for frequency, recurrence rate and complications of the different methods of pleurodesis was sent to all hospitals that belong to the German Society for Thoracic Surgery. 19 hospitals reported on a total of 1365 operations. 88 recurrences (6.5%), 26 severe bleeding complications (1.9%), 39 persisting air leaks (2.9%) and two hospital deaths (0.1%) had been observed. Pleurectomy and pleural abrasion were the most common procedures but induced significant (p = 0.01) more bleeding complications (3.1% and 2.6%) than all other methods of pleurodesis (0.4%). Overall recurrence rates depended significantly on the chosen procedure (p = 0.0013). Pleurectomy (4.4%) and coagulation of the pleura (2.7%) showed better results than the average. Due to smaller numbers of operations and the widely differing results this significance cannot be shown for the individual recurrence rates of the different clinics. This survey demonstrated a trend towards lower rates of recurrence and complications after coagulation of the pleura parietalis. The retrospective character of the investigation and extremely different recurrence rates for different hospitals demand cautious interpretation of these results.
Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, Jun 1, 2013
The aim of this study was to identify resorption, clinical performance, and safety of cotton-deri... more The aim of this study was to identify resorption, clinical performance, and safety of cotton-derived oxidized cellulose gauze applied as a hemostat in minimally invasive oncologic thoracic surgery. Methods: This is a pilot prospective noncomparative observational human in vivo study. A piece of cotton-derived oxidized cellulose gauze measuring 5 Â 20 cm was inserted into the subcarinal space of patients with potentially resectable lung carcinoma at the time of video-assisted mediastinoscopic lymphadenectomy and reexamined several days later for macroscopic and histologic evaluation at the time of subsequent lung resection. The primary endpoint was the local situation at the implantation site described by cellulose remnants, fluid collections, and adhesions. The secondary endpoint was safety, described by the number of adverse events and surgical reinterventions. Results: Twenty-five consecutive eligible patients with potentially resectable lung carcinoma were included. The desired hemostatic effect was achieved in all cases. No adverse events were observed. At re-exploration 10.5 (5Y28) days later, the cellulose gauze was found to lose its solid structure from the fifth day on. Remnants were last detected 14 days after insertion. The implantation site exhibited no inflammatory changes and a remarkable small amount of fluid collections and adhesions. Conclusions: Mediastinal application of cotton-derived oxidized cellulose is safe and effective. A piece of gauze measuring 5 Â 20 cm seems to be absorbed completely within 15 days, thus precluding any interference with oncologic restaging and follow-up. The absence of relevant adhesions facilitates further surgical procedures. Larger comparative confirmatory studies are required. For large-scale resorption studies, our clinical model should be translated into a porcine model.
Background: Based on the algorithm on preoperative mediastinal staging in patients with non-small... more Background: Based on the algorithm on preoperative mediastinal staging in patients with non-small cell lung cancer (NSCLC), endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is indicated in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. It represents both a safe minimal invasive procedure with complication rates of less than 1.5% and a valid tool with a high sensitivity defining mediastinal nodal disease. However, infectious complications like mediastinitis or pyopericardium are most feared. Case Description: A 54-year-old woman was admitted to our hospital for further investigation of a suspected NSCLC of the right upper lobe. EBUS-TBNA was performed to receive both diagnosis and samples of the mediastinal lymph nodes. Two weeks after EBUS-TBNA, the patient presented with symptoms of cardiogenic/septic shock: hypotension, tachycardia, chest pain and fever. Prompt diagnosis of concomitant infectious mediastinitis and extensive pyopericardium in consequence of EBUS-TBNA was obvious. Besides systemic antibiotics, bilateral thoracoscopic interventions finally made the breakthrough. The patient could be discharged roughly three weeks after emergent re-admittance. As being finally diagnosed with NSCLC (stage IIIA squamous cell carcinoma), the patient underwent-subsequent to induction chemotherapy-a definitive sequential chemoradiotherapy. Twelve-month follow-up confirmed stable disease. Conclusions: It is to be expected that with increasing application of EBUS-TBNA as mediastinal staging tool, the number of serious infection-related complications will rise accordingly. The efficacy of antibiotic prophylaxis after EBUS-TBNA has not yet been proved and is therefore not included in any guideline. Our case gives an impression on the severity of delayed infectious complications after EBUS-TBNA and outlines up-front surgery as primary objective to broadly debride all contagious abscess-/empyema sites. With increased use of EBUS-TBNA as mediastinal staging tool, clinicians should be aware of this rare but highly critical peri-interventional complication in order to closely monitor endangered patients.
European Journal of Cardio-Thoracic Surgery, Jun 1, 2008
Objective: To determine the impact of endoesophageal ultrasound-guided fine-needle aspiration (EU... more Objective: To determine the impact of endoesophageal ultrasound-guided fine-needle aspiration (EUS-FNA) on management of thoracic malignancies. Methods: One hundred and twenty patients referred for invasive diagnostic and resection of thoracic malignancies were studied prospectively. Negative and inconclusive EUS-FNA findings were assessed by video-assisted mediastinoscopic lymphadenectomy (VAMLA) or open lymphadenectomy. Results: One hundred and twenty patients, aged 64.1 years (range 38-85) underwent 120 EUS-FNA, 53 video-assisted mediastinoscopic and 48 open lymphadenectomies for diagnosis and treatment of 99 lung carcinoma, six lung metastases, five mesothelioma, three lymphoma, and eight other conditions. EUS-FNA showed T4 in 15/120 and adrenal or hepatic metastases in 9/120 cases. Prevalence of mediastinal lymph node metastases was 51.7%. EUS-FNA false-negative rate was 25.3%. EUS-FNA sensitivity was 91.7%, 78.1% and 43.8% for bulky disease, enlarged mediastinal nodes or normal nodes on CT scan, 50% and 96.6% for right-and left-sided tumours, and 80.6%, 78.9%, 23.8% and 25.0% for the lymph node stations 7, 5/6, 4R, and 4L. A 38.3% respectively 100% cut-down of mediastinoscopies leads in 7.5% respectively 20.8% to incorrect treatment decisions. Conclusions: EUS-FNA sensitivity depends on the localisation of the primary tumour, and extent and location of mediastinal disease. For left-sided tumours, EUS-FNA improves mediastinal staging by assessing stations 5 and 6 inaccessible to conventional mediastinoscopy. For extended mediastinal disease, mediastinoscopy can be avoided or spared for restaging after neoadjuvant therapy. Exclusion of mediastinal involvement requires mediastinoscopy or open lymphadenectomy. Beyond mediastinal nodal staging, EUS-FNA may detect T4 and M1 situations. Thus, EUS-FNA is a useful supplement to and not the replacement of mediastinoscopy.
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Papers by Martin Hürtgen