Sezai Çubuk

Quantative computerized tomography assessment of lung density as a predictor of postoperative pulmonary morbidity in patients with lung cancer

BACKGROUND The aim of this study was to evaluate the pulmonary reserve of the patients via preoperative quantitative computerized tomography (CT) and to determine if these preoperative quantitative measurements could predict the postoperative pulmonary morbidity. METHODS Fifty patients with lung cancer who underwent lobectomy/segmentectomy were included in the study. Preoperative quantitative CT scans and pulmonary function tests data were evaluated retrospectively. We compare these measurements with postoperative morbidity. RESULTS There were 32 males and 18 females with a mean age of 54.4±13.9 years. Mean total density was -790.6±73.4 HU. The volume of emphysematous lung was (<-900 HU) 885.2±1,378.4 cm(3). Forced expiratory volume in one second (FEV1) (r=-0.494, P=0.02) and diffusion capacity of carbon monoxide (DLCO) (r=-0.643, P<0.001) were found to be correlate with the volume of emphysematous lung. Furthermore FEV1 (r=0.59, P<0.001) and DLCO (r=0.48, P<0.001) were also found to be correlate with mean lung density. Postoperative pulmonary morbidity was significantly higher in patients with lower lung density (P<0.001), larger volume of emphysema (P<0.001) and lower DLCO (P=0.039). A cut-off point of -787.5 HU for lung density showed 86.96% sensitivity and 81.48% specificity for predicting the pulmonary morbidity (kappa =-0.68, P<0.001). Additionally a cut-off point of 5.41% for emphysematous volume showed 84.00% sensitivity and 80.00% specificity for predicting the pulmonary morbidity (kappa =0.64, P<0.001). According to logistic regression analyses emphysematous volume >5.41% (P=0.014) and lung density <-787.5 HU (P=0.009) were independent prognostic factors associated with postoperative pulmonary morbidity. CONCLUSIONS In this study, the patients with a lower lung density than -787.5 HU and a higher volume of emphysema than 5.41% were found to be at increased risk for developing postoperative pulmonary morbidity. More stringent precautions should be taken in those patients that were found to be at high risk to avoid pulmonary complications.

Could the grade of the tumour be related to nodal involvement

We read the article of Hattori et al. [1] with great interest. We thank the authors for this well-designed study. Tumour node metastasis (TNM) staging is important for predicting the recurrence of the tumour and for survival. The authors mentioned that sub-centimetric pure solid nodules with high SUVmax values have a tendency toward lymph node metastasis. Also, the invasiveness of the tumour is declared to be an important determinant of recurrence and survival [2]. In this context, we think that the differentiation degree of the tumour may be a prognostic factor in lung cancer. As a result, we recommend lobectomy for high-grade sub-centimetric nodules. Evaluation of the sub-centimetric nodules with PET scans may be misleading [3]. Too many centres do not perform a PET scan for nodules smaller than 1 cm because of high ratio of false-negative results. So, we think that the invasiveness and the grade of the tumour may be directive for whether to perform limited resection or lobectomy in these nodules. In this context, a histopathological decision is thought to be more reliable than PET scan results. As a final comment, we think that grade of the tumour will be a component in the staging system of lung cancer over time, that is, in oesophageal cancer staging.

Postintubation Mediastinal Tracheal Stenosis

Uzun süreli entübasyonda bazen trakea darlıklarına yol açmaktadır. Trakea darlıklarında cerrahi dışı seçenekler çoğu zaman yetersiz kalmaktadır. Stenozlu alanın rezeksiyonu takiben rekonstriksiyon en önemli tedavi seçeneklerindendir. Biz bu çalışmada trakea cerrahisinde eğitici olacağına inandığımız bir olgumuzu sunmayı amaçladık. Polikliniğimize travma sonrası uzun süreli entübe kalmış ve endotrakeal tüpe bağlı trakea stenozu olan bir olgu müracaat etti. Yapılan rijit bronkoskopta karinadan 24 mm uzaklıkta, 12 mm uzunluğunda darlık gözlendi (Resim1). Parsiyel sternetomi sonrası trakeanın darlık bölgesine ulaşıldı. Trakeadan 15 mm rezeksiyon sonrası rekonstriksiyon yapıldı (Resim 2-4). Postoperatif komplikasyon gelişmeyen hasta şifa ile taburcu edildi. Mediastinal trakea darlıklarında darlık bölgesi teknik olarak ulaşılması zor alanlardır. Parsiyel sternotomi bu alana ulaşmada son derece faydalı olmakta ve trakea ya güvenli anastomoz yapmaya imkân vermektedir.

VATS Pneumonectomy After Induction Chemotherapy

Santral yerleşimli primer bronş tümörlerinde pnömenektomi ameliyatı gerekebilmektedir. Biz bu çalışmamızda down-stage sonrası VATS ile pnömenektomi ameliyatı uyguladığımız yassı hücreli karsinomalı bir olguyu uzmanlık eğitimine katkısı olması için sunduk (Resim 1, 2). Olgu bize ilk müracaat ettiğinde Evresi 3A’idi. Down-stage için kemoterapi planlandı. İndiksiyon kemoterapi sonrası evresi 2A’ya kadar geriledi. Kitlede %50’nin üzerinde küçülme oldu ve VATS yardımıyla sol pnömenektomi ameliyatı uygulandı (Resim 3). Postoperatif komlikasyon gelişmeyen hasta şifa ile taburcu edildi (Resim 4). Primer bronş tümörlerinde VATS yardımıyla pnömenektomi ameliyatı bir çok merkezde başarıyla uygulandığı gibi kemoterapi sonrası down stage yapılan olgularda da güvenli şekilde uygulanabilmektedir.

eComment. The ways to increase the effectivity of pleurodesis

lower recurrence rate in comparison with TT talc pleurodesis. Aihara et al. [3] studied the efficacy and safety of blood and TT talc pleurodesis for SSP in 34 patients with interstitial lung disease. Air leakage ceased in 16 of 22 (72.7%) episodes after blood pleurodesis and in 11 of 14 (78.6%) episodes after talc pleurodesis. No harmful events were associated with either procedures, but the median survival after an attack of pneumothorax was 9 months; hence, no long-term follow-up period was available. Ng et al. [4] conducted a retrospective analysis on SSP patients who underwent minocycline pleurodesis (n = 121) versus talc slurry (n = 64). Both groups had a comparable sclerosing efficacy in SSP, with immediate success rates of 71.9 and 78.1%, respectively (P = 0.31). Pain was experienced in 44.6 and 37.5%, respectively, with more common in patients receiving high doses of talc (≥5 g; P = 0.03). Respiratory distress was found in 1.7 and 1.6%, respectively. There was no long-term follow-up recorded. The authors concluded that both agents appeared to be effective and safe for chemical pleurodesis in SSP, but were associated with a slightly high failure rate. Adewole et al. [5] treated 20 SSP out of 41 spontaneous pneumothorax patients by VATS talc pleurodesis over a 2-year period. Immediate success was observed in 18 of 20 patients (90%). The mean postoperative hospital stay was 3 ± 3.2 days. There was no associated significant morbidity or in-hospital mortality. Follow-up period was 24 months. Pneumothorax recurred in 3/20 (15%) of patients during the follow-up period and all were treated successfully by repeated VATS talcage. The authors concluded that the study confirms the short-term andmedium-term effectiveness of VATS talc pleurodesis. Pletinckx et al. [6] reported 5 SSP patients out of 20 pneumothorax patients who underwent VATS talc pleurodesis over a 5-year period. Immediate success of talcage was 100%. There were no major complications or in-hospital mortality. The mean follow-up period was 22.7 months. No cases of recurrence were recorded during this follow-up period. The authors concluded that thoracoscopic talc pleurodesis was safe and efficient in their experience. Noppen et al. [7] studied 20 patients with SSP who had a VATS talc pleurodesis over a 25-month period. Prolonged air leak was observed in 26% of patients, but all air leaks ceased during the hospital stay period. The median hospital stay was 4.7 (±2) days. No major postoperative complications or in-hospital mortality was recorded. The recurrence rate was 8.7% during a mean follow-up period of 18 months. The authors concluded that thoracoscopic talcage is efficient and safe in achieving pleurodesis in persistent spontaneous pneumothorax. The BTS guidelines in 2010 [8] for the management of spontaneous pneumothorax suggest that chemical pleurodesis via TT for recurrent spontaneous pneumothorax should be reserved for frail patients as it is associated with a higher recurrence rate when compared with VATS pleurodesis although there are no available comparative studies.

A Comment on the Pulmonary Contusion Model

We read the article of Boybeyi et al.1 The authors studied the effect of dimethyl sulfoxide and dexamethasone on a contused lung with a rat model. They declared using 0.5 kg weight and 0.4 m height for pulmonary contusion. We think that falling 500 g weight from 40 cm is too much for the rats. We also have a model for blunt thoracic trauma identical to theirs.2 In our model, we used a 90-cm pipe and three types of weights: 40, 70, 100 g. With these weights, we gained light, moderate, and severe thoracic blunt trauma. In their model, Raghavendran et al3 used 0.3 kg weight and height combinations (1.80–2.70 J) to gain bilateral lung contusion. They positioned the rat in supine position and used a platform above the rat. Therefore, higher trauma intensities can be used with a platform to the anterior chest wall. As we understand from the text, this study has two parts: the first part is the trauma part and the second part is the evaluation of the substances. To gain reliable results, the first part must be established well. We think that a control group for the trauma should have been established. If a preliminary study was performed, it should be mentioned. As a result, we think that the first part of the article should have been detailed.

Is Single Level Paravertebral Analgesia Enough for Controlling Postoperative Pain in VATS

I read the article by Cioffi et al with great interest.1 I want to express my comments on the article and paravertebral analgesia procedure. In the article it is mentioned that the catheter is placed only into the intercostal space of the camera port level. In VATS procedures, generally three ports are used, and if a major lung resection is planned, a utility thoracotomy is added, which is approximately 5 cm long. Applying the paravertebral catheter only to the intercostal space of the camera port may be effective in thoracoscopy, but I think that a paravertebral catheter applied to only one intercostal space is not enough for controlling the postoperative pain in VATS procedures. It is understood from the text that the catheter is placed into a subpleural space that is generated by hydrodissection. Some authors have also mentioned the usage of a pocket in the subpleural area.2 I think that when a tent is made in the subpleural area, there is a possibility for subpleural hematoma. This hematoma may lead to localized pleural thickening. In this context, this thickening may be misdiagnosed as pleural metastasis in a malignancy patient in follow-up or this localized thickening may be investigated for suspicion of a disease in future. As a result, the procedure of the authors may be suitable for thoracoscopy, but I think that it is not suitable for VATS procedures. In my opinion, performing a procedure that has a potential for misdiagnosis in the future should not be used for postoperative pain control.

eComment. Muscle sparing thoracotomy for the apical posterior mediastinal lesions

We thank Yang et al. for their study about the resection of the posterior mediastinal lesions [1]. We want to add a comment on the approach for the posterior mediastinal tumours. We agree that thoracoscopic resection of posterior mediastinal tumours can be performed successfully with decreased operation time, hospital stay and patient discomfort. But we think that those that are located to the apex of the hemithorax should not be resected thoracoscopically. Authors wrote that thoracoscopic surgery was associated with reduced operation time, blood loss and hospital stay. These were good results but there was one complication (brachial plexus lesion) that was higher in the video-assisted thoracoscopic surgery (VATS) group. We think that this complication is much more important than the benefits mentioned above. Most posterior mediastinal tumours have a benign character [2]. No surgeon wants such a complication after performing surgery for a benign lesion. Also, the thoraco-scopic approach near to the great vessels carries the risk of massive haemorrhage because of the limited manoeuvrability. At our institution, we used muscle sparing thoracotomy on a patient who had a lesion at the apex of the right hemithorax. More than half of the operation was performed with blunt finger dissection. We did not spend too much time for the exposure, as is so in VATS procedures, and for the dis-section. Closure of the hemitorax was also not time-consuming because there was not a lot of muscle tissue to be cut through. Authors declared that they used two chest tubes after the operation. We think that placing two chest tubes for these kind of surgeries adds to the discomfort of the patient. Chest tubes can be the only annoying thing after thoracic procedures for the patients. In general, we use single chest tubes for all procedures performed, other than lung surgery. We place the chest tube to the apex of the hemithorax and open a hole on the lower part of it to drain any effusions. Also, cutting the specimen before taking it out of the thorax is a better approach than to enlarge the utility thoracotomy [3]. A comparative study of video-assisted thoracoscopic resection versus thoracotomy for neurogenic tumours arising at the thoracic apex.

Importance of tube position after tube thoracostomy.

depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care 2013;17:330–8. [11] Studnek JR, Crawford JM, Wilkins III JR, Pennell ML. Back problems among emergency medical services professionals: the LEADS health and wellness followup study. Am J Ind Med 2010;53:12–22. [12] Myers JB, Slovis CM, Eckstein M, Goodloe JM, Isaacs SM, Loflin JR, et al. Evidencebased performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care 2008;12:141–51.

Some tricks in iatrogenic pneumothorax.

We read the article of Vinson et al [1] titled “Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs.” We thank the authors about their well-designed study. Iatrogenic pneumothorax that occurred during central vein catheterization is generally related to the experience of the practitioner. When it becomes a routine for thepractitioner, thenumber of iatrogenic pneumothorax decreases. However, we think that, in a teaching hospital, the incidence of this complication cannot be decreased because of the continuity of the education. Insertion of a needle to the lung does not always cause pneumothorax. It is declared that pneumothorax incidence after transthoracic needle biopsy is approximately 20% in general [2]. The occurrence of emphysema and/or bullous formation of the lung, the diameter of the needle, the extent of the needle passing the pleura, and the pleural adhesionsdetermine the occurrence of pneumothorax in all kinds of interventional procedures to the lung including central venous catheterization. During the awake procedures of central venous catheterization, some incompatible patients may mimic symptoms of pneumothorax such as pain and shortness of breath. If the patient is stable and physical examination does not clearly reveal a pneumothorax, we should not perform an evacuation procedure, which may be unnecessary, before performing a radiological study. In some centers, central venous catheterization is performedwith the help of an ultrasound, as mentioned in the text. Ultrasound can also be used for detection of pneumothorax [3]. We think that, with the help of ultrasound, overlooked occult pneumothorax cases can be detected. Radiological studies are performed after the catheterization procedure to verify the position of the catheter and to determine any complication. This approach is suitable for unilateral attempts. However, if an attempt from the contralateral side is needed, we recommend radiological studies “before” a contralateral attempt in order not to strugglewith the complication of bilateral pneumothorax. We sometimes face bilateral pneumothorax after central vein catheterizations that require emergency evacuation.