Slow-pull technique yields better quality smears: prospective comparison of slow-pull and standard suction techniques of endoscopic ultrasound-guided fine-needle aspiration.

BACKGROUND: Diagnostic accuracy and quality of smears obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are influenced by characteristics of suction and examined organ. AIMS AND METHODS: Efficiency of EUS-FNA and quality of smears obtained by slow-pull (SP) and standard suction (SS) techniques was prospectively compared in the sampling of pancreatic (N = 56) and extrapancreatic (N = 145) tumors. RESULTS: SS technique resulted in a higher number of smear pairs both in pancreatic (1.74 vs. 3.19; p < 0.001) and extrapancreatic tumors (1.62 vs. 3.28; p < 0.001); however, it decreased the proportion of diagnostic smears (46.69% vs. 36.52%; p = 0.002 and 49.17% vs. 30.67%; p < 0.001) and increased the bloodiness (1.51 vs. 2.07; p < 0.001 and 1.48 vs. 2.05; p < 0.001). In pancreatic cancers, no difference was observed in terms of diagnostic accuracy (81.38% vs. 83.45%) and cellularity (1.44 vs. 1.27; p = 0.067); however, they were substantially higher in extrapancreatic tumors using SP technique (71.41% vs. 60.71% and 1.34 vs. 0.77; p < 0.001). Only SP technique resulted in a significant difference between examiners in terms of technical success rate and quality of smears without any decrease of diagnostic accuracy. CONCLUSIONS: SP technique yields better quality smears independently from tumors characteristics; however, it shows significant examiner-dependency. SS technique reduces the diagnostic accuracy of sampling in extrapancreatic tumors.

[Initial experiences with VATS lobectomy]. / VATS-lobectomiák kezdeti tapasztalatai.

OBJECTIVE: The authors analyse the experience of videothoracoscopic (VATS) lung lobectomies performed since December 2010 at the Thoracic Surgery Department of Markusovszky University Teaching Hospital. PATIENTS AND METHOD: 78 patients (44 men and 34 women) underwent VATS lobectomy. The average age was 61.2 years ranging from 30 to 80. The indications were peripheral malignancy (35 cases) or the suspicion of that (43 cases), presence of curable distant metastasis was not considered as contraindication. RESULTS: In the initial period the operation time was quite long, but shortly after the duration of surgery became almost similar to lobectomies via thoracotomy. Late reoperation was performed in two cases, one for chronic pneumothorax and one for port-site metastasis. 10 vessel and two bronchial injuries occurred, eight of them needed conversion into axillary thoracotomy (conversion rate 10.26%). The postoperative pain was significantly less than after thoracotomy. CONCLUSION: VATS lobectomy is a safe procedure with less surgical stress and without oncological compromise.

[Long-term survival after lung-sparing central bronchoplastic procedures [CBPs] for malignant tumors]. / Hosszú túléléssel járó malignus tumor miatti tüdomegtartó centrális fohörgoplasztikáink.

BACKGROUND: Bronchial malignancies are leading tumour-related cause of death. Prolonged survival can only be expected after radical resections. Central bronchoplastic procedures, which save the whole lung parenchyma, however, may play a role. AIM: These bronchoplastic procedures can be good alternatives for pulmonectomies. The value of these operations can be evaluated by postoperative mortality complication, and the survival rate. MATERIAL AND METHODS: In the period of 1985-2012 we operated 7130 bronchial carcinomas. Of these, 7 cases of 80 central broncoplastics we preserved the whole lung (in one case as an alternative for inoperability, in 6 patients as an option instead of pulmonectomy). The indications were carcinoid in four cases, epidermoid carcinoma, mucoepidermoid carcinoma and main carina SCLC after induction chemo-radiotherapy. The average age of the 4 male and of the 3 female patients were 28.5 (14-58) years. In 5 cases the right main bronchus, while in one case the left main bronchus was resected and the bronchial tree was reconstructed. In one case (SCLC patient) we made a complete carina resection and end-to-end anastomosis between the trachea and the rebuilt neocarina to preserve both lungs. The anastomosis was made with 3-4/0 PDS interrupted sutures above a sterile tube (6 cases) and in one case due to a jet catheter which were positioned through the operation field into the distal part of the main healthy bronchus. RESULTS: There was no operative mortality nor bronchopleural fistula. In the early postoperative period we applied repeated bronchoscopic suctions. In the patient with carina SCLC anastomosis stenosis developed. The main bronchi were temporarily stented. This patient is fit 174 months after the intervention, the Karnofsky index mesures to 90%. Other 5 patients are alive without any consequences of recurrence nor metastasis. The patient with epidermoid carcinoma died 83 months later because of distant metastases of a SCLC, originating from the contralateral lung. The mean survival is 118 (7-233) months. CONCLUSION: In case of some properly selected localised mainstem bronchial malignancies, such as young age and low grade malignancy, radical surgical interventions can be performed with long term survival preserving the whole lung due to special CBPs. Some such successful series and case reports (under 200 cases) can be found in the literature but the long-term survival data was not demonstrated in most publications. In Hungary there has not been any publications yet on such a successful series with long term survival. These results are remarkable within international standards.

[Isolated pulmonary arteriovenous malformation (PAVM)--report of three cases]. / Izolált pulmonalis arteriovenosus malformatio (PAVM) - 3 eset kapcsán.

Isolated PAVM is rare condition and only a few cases of VATS (Video-Assisted Thoracoscopic Surgery) resection have been reported so far. Since the clinical course of PAVM is not entirely benign due to its possible progression and serious complications (paradoxical emboli, stroke, brain abscess, etc.), the most radical least invasive treatment should be chosen in all cases nowadays. Embolization may be incomplete and carries a risk of accidental systemic embolization, therefore surgical excision is the preferred method of choice. In cases of surgical resections, pulmonary parenchyma sparing techniques such as wedge resection and local excision by VATS is desirable, if possible. We present three patients who were admitted with asymptomatic pulmonary round shadow (umbra rotunda) for further investigation and treatment. We have performed two wedge resections by VATS and one segmentectomy via axillary thoracotomy. We wish to emphasize the importance of this disease to consider in differential diagnosis to avoid complications.

[Videothoracoscopic removal of ectopic liver]. / Ectopiás máj videothoracoscopos eltávolítása.

Authors present a case of an ectopic liver in the chest of a 14 year-old female patient. The lesion was discovered by screening chest X-ray and was consequently removed by videothoracoscopic surgery. A brief literature review was carried out, too.

[Role of surgical lung volume reduction in the treatment of patients with severe emphysema]. / A tüdovolumen-redukciós mutét helye a súlyos emphysemás betegek gyógykezelésében.

OBJECTIVE: Based on literature data and own experience (unique in Hungary) we like to present the indications, contraindications, risks as well as medium and long term follow ups of the lung volume reduction surgery (LVRS) applicable in cases of therapeutic resistant end-stage emphysema (COPD). MATERIAL: In Szombathely between 1997 and 2003, 69 LVRS--by multiple wedge resections of most functionless parts of the lungs--were made on 56 patients (44 males and 12 females with a mean age of 52.5 years) via median sternotomy for both sides (12 pts), axillary thoracotomy on one (30 pts) or both sides in two sessions (13 pts) and VATS (one side, 1 pt). Selection criteria based on radiographic, spirometric and cardiac function tests. Indications were: diffuse homogenous emphysema: 17 pts, heterogenous emphysema 39 pts. Combined surgery for severe COPD and pulmonary malignancy was applied too (7/56 pts - 12.5%). RESULTS: Thirty-day operative mortality was 4.3% (3/69) similar to international results. We noticed high incidence of early complications: air leak (37.6%), serious arrhythmia (13%), respiratory insufficiency (8.7%), longer drainage time (5.7 days). Reoperations were 2/69 interventions (2.9%) because of air leak and bleeding. Late recurrent pneumothorax was observed in 1 case (1.3%). The mean follow up time was: 31.8 months. FEV1, RV, paO2, paCO2 and the quality of life improve as seen in follow-up, and patients regain apart of the former activity. There were no differences in the outcome in patients undergoing unilateral or bilateral LVRS. On the basis of literature and own data the long-term significant positive improvements last about 12-24 months. Thereafter one can observe a slow decrease of the cardiopulmonary functions, however, the quality of life remains adequate for longer. SUMMARY: The LVRS has a certain risk, but perioperative mortality is acceptable. LVRS is a realistic alternative of lung transplantation in case of severe COPD first of all in patients presenting with heterogenous emphysema (particularly upper lobe) and low exercise capacity. The expense of LVRS is maximum 10% of lung transplantation. Patients having undergone an LVRS and patients unacceptable for LVRS can be suitable for lung transplantation.