术前超声内镜引导下细针穿刺对可切除胰腺癌诊断之安全性和准确性的探讨*

目的探讨术前超声内镜引导下细针穿刺(EUS-FNA)对可切除胰腺癌患者诊断之安全性及准确性。方法回顾性分析该院2010年1月-2014年12月256例胰腺癌患者的临床资料,其中82例有手术切除的指征:54例术前行EUS-FNA术(FNA+组)和28例无术前EUS-FNA(FNA-组),观察EUS-FNA的诊断情况及两组患者的生存时间。结果 FNA+组54患者EUS均见肿瘤病灶,所有患者FNA均成功。根据细胞学和组织学,EUS-FNA诊断的准确性分别为94.44%(51/54)和88.89%(48/54),总准确率为94.44%(51/54)。2例EUS-FNA后出现轻度胰腺炎,2例并发出血,经保守治疗后痊愈,无其他严重并发症。在FNA+和FNA-组的中位无复发存活时间分别为282和265 d(P0.05),平均总生存时间分别为568和557 d(P0.05)。FNA+组的RFS和OS并不逊色于FNA-组。这些数据表明,EUS-FNA并不影响中位无复发存活期或总生存期,也没有增加其他并发症的风险。结论术前EUS-FNA对可切除胰腺癌患者是一种安全、准确的诊断方法。     

Incidence and Risk Factors for Infectious Complications of EBUS-TBNA: Prospective Multicenter Study

The aim of our study was to describe the incidence of infectious complications of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) and to analyze the potential risk factors in a prospective cohort of patients.MethodsWe conducted a prospective multicenter study, with all consecutive patients referred for an EBUS-TBNA with patients at risk of developing an infectious complication (considering > 10 nodal samplings, known immunosuppression, bronchial colonization and cavitated or necrotic lesions) and a second group without any risk factor.ResultsThree hundred seventy patients were included: 245 with risk factors and 125 without risk factors (as the control group). Overall, 15 patients (4.05%) presented an acute infectious complication: fourteen in cases (5.7%) and 1 in controls (0.8%). Of these, 4 patients presented pneumonia, 1 mediastinitis, 4 obstructive pneumonitis and 6 mild complications (respiratory tract infection that resolved with antibiotic). Also 7 (1.9%) patients had self-limited fever. One-month follow-up showed 1 mediastinitis at sixteenth day post-EBUS, which required surgical treatment, and 3 pneumonias and 3 respiratory tract infections at nineteenth day (1.9%). All patients had a good evolution and there were no deaths related with infectious complication. We observed an increased risk of complication in patients with risk factors and in patients with necrosis (p = 0.018).ConclusionsThe incidence of infectious complications in a subgroup of patients with risk factors was higher than in patients without risk factors. Nevertheless, it remains low, and no fatal complication occurred, which reinforces the idea that EBUS-TBNA is a safe technique for the assessment of the mediastinum. Necrotic lesions are a risk factor of post-EBUS infection, and their puncture should be avoided.     

Discordance between clinical and pathologic staging and the timeliness of care of non-small cell lung cancer patients diagnosed with operable tumors

Aim

This study was performed to evaluate concordance between clinical and pathologic staging of non-small cell lung cancer (NSCLC) in our hospital network.

Methods

We retrospectively reviewed records of 417 patients with NSCLC who received curative surgery and whose pathology was evaluated in our hospital between 2016 and 2021. Cytology, tissue pathology, and associated clinical, surgical, and imaging information were retrieved from hospital digital records.

Results

The cohort included 214 female and 203 male patients aged 20.6–85.8 years. Median times among staging computed tomography and surgery (105 days [interquartile range (IQR) 77.0–143.0]), positron emission tomography and surgery (78.5 days [IQR 56.0–109.0]), and endobronchial ultrasound-guided transbronchial needle aspiration and surgery (59 days [IQR 42–94]) indicated that Australian guidelines of <42 days between original referral and commencement of treatment were not being met in the majority of cases. Discordance between clinical TNM (cTNM) and pathologic TNM staging was 25.9%, including 18.4% cases that were clinically understaged and two patients with undetected stage IVA disease. cTNM understaging was significantly associated with time between the final staging investigation and surgery (p = .023), pleural (p < .05) and vessel (p < .05) invasion, and diagnosis of high-grade adenocarcinoma (p = .001).

Conclusion

Discordance between clinical and pathologic staging of NSCLC is associated with tumor histopathologic characteristics and treatment delays. Although tumor factors that lead to discordant staging cannot be controlled, reduced time to surgery may have resulted in better outcomes for some patients in this potentially curable lung cancer cohort.     

Percutaneous Neuromodulation of the Brachial Plexus and Sciatic Nerve for the Treatment of Acute Pain Following Surgery: Secondary Outcomes From a Multicenter,Randomized, Controlled Pilot Study

ObjectivesWe recently reported that percutaneous peripheral nerve stimulation (PNS or “neuromodulation”) decreased pain and opioid consumption within the first two weeks following ambulatory surgery. However, the anatomic lead locations were combined for the analysis, and benefits for each location remain unknown. We therefore now report the effects of percutaneous PNS for brachial plexus and sciatic nerve leads separately.Materials and MethodsBefore surgery, leads were implanted percutaneously to target the brachial plexus (N = 21) for rotator cuff repair or sciatic nerve (N = 40) for foot/ankle surgery, followed by a single injection of local anesthetic. Postoperatively, subjects were randomized in a double masked fashion to 14 days of electrical stimulation (N = 30) or sham/placebo (N = 31) using an external pulse generator. The primary outcome of interest was opioid consumption and pain scores evaluated jointly. Thus, stimulation was deemed effective if superior on either outcome and at least noninferior on the other.ResultsFor brachial plexus leads, during the first seven postoperative days pain measured with the numeric rating scale in participants given active stimulation was a median [interquartile range] of 0.8 [0.5, 1.6] versus 3.2 [2.7, 3.5] in patients given sham (p < 0.001). For this same group, opioid consumption in participants given active stimulation was 10 mg [5, 20] versus 71 mg [35, 125] in patients given sham (p = 0.043). For sciatic nerve leads, pain scores for the active treatment group were 0.7 [0, 1.4] versus 2.8 [1.6, 4.6] in patients given sham (p < 0.001). During this same period, participants given active stimulation consumed 5 mg [0, 30] of opioids versus 40 mg [20, 105] in patients given sham (p = 0.004). Treatment effects did not differ statistically between the two locations.ConclusionsAmbulatory percutaneous PNS of both the brachial plexus and sciatic nerve is an effective treatment for acute pain free of systemic side effects following painful orthopedic surgery.     

Lateral Subdermic Venous Plexus Insufficiency: The Association of Varicose Veins with Restless Legs Syndrome and Nocturnal Leg Cramps

PurposeTo determine whether nocturnal symptoms of restless legs syndrome (RLS) and muscle cramps in the legs are associated specifically with lateral subdermic venous plexus (LSVP) insufficiency and whether treatment can provide symptomatic relief.Materials and MethodsA retrospective cross-sectional observational study of 506 patients at a single site analyzed whether RLS or nighttime leg cramping symptoms were associated with venous reflux in the LSVP using comprehensive venous ultrasound. The treatment outcomes of ultrasound-guided foam sclerotherapy (USGFS) were followed up for 1 year.ResultsOf 209 patients who reported restless legs symptoms, 179 (85%) demonstrated an abnormal LSVP. A total of 214 patients reported nighttime muscle cramping, of whom 197 (92%) demonstrated an abnormal LSVP. Among 124 patients presenting with both the symptoms, 113 (91%) demonstrated an abnormal LSVP. Conversely, of 83 patients who presented with neither RLS nor nocturnal cramping, 2 (2%) had an abnormal LSVP. Among 242 symptomatic patients with an abnormal LSVP who underwent treatment, the technical success rate was 100%. At 90-day follow-up, 224 patients (93%) reported continued relief, which was maintained at 93% (224/242) at follow-up at 1 year. When substratified, 90 patients presented primarily with RLS or cramping and showed only LSVP reflux, and when treated, all 90 (100%) had significant or complete relief of the symptoms.ConclusionsLSVP insufficiency demonstrates an association with symptoms of RLS and nocturnal leg cramps. LSVP treatment using USGFS demonstrated high technical and clinical success rates, with symptomatic relief up to 1 year, most pronounced when the LSVP was the only treated vein.     

Ultrasound guidance for femoral venous access in patients undergoing pulmonary vein isolation: A quasi-randomized study

Introduction

Routine ultrasound (US) guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized-trial data.

Methods

Consecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi-random allocation to either US-guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with a US machine including a vascular transducer. The same four novice operators in rotation, with no relevant previous experience in US-guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation).

Results

Of the 457 patients 199 were allocated to the US-guided puncture group, while the conventional, palpation-based approach was performed in 258 cases. Compared with the conventional technique, US guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p < .0001), including both major (4.26% vs. 1.01%, p = .038) and minor (7.36% vs. 1.01%, p = .001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US-guided puncture group (5.04% vs. 1.01%, p = .032).

Conclusion

The use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi-randomized comparison strongly supports adapting routine use of US for AF ablation procedures.     

Usefulness of Routine Bronchial Aspirate of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

IntroductionEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used for the study of intrathoracic lymphadenopathy and centrally tumours but no report has discussed the contribution of routine cytological and microbiological BA during the procedure. The aim of the study was to analyse the diagnostic yield of BA during EBUS, and to determine the potential cost reduction.MethodsA prospective study of cytological and microbiological BA collected during EBUS-TBNA was conducted between January 2021 and June 2022. Demographic data, indication, previous BA bronchoscopy or EBUS diagnosis were recorded. The main variable tested was the number of patients in which the result of the BA obtained through EBUS-TBNA determined a change in the diagnosis.ResultsA total of 450 (70.9% male) patients were included. BA cytology showed abnormal cells in 33 (7.3%) of patients, and only 1 case (0.2%) provided a previously unknown diagnosis. All these cases were patients with suspected malignancy. BA microbiological samples found germens in 30 (6.7%) patients but only in 5 cases (1.1%) found microbiological specimens not detected in previous bronchoscopy. None of them received antibiotics and evolved correctly. The potential total cost reduction during the study period at our centre if routine BA was deleted would be 21,937.50€ for routinely combined study.ConclusionsThe low diagnostic yield of cytological and microbiological bronchial aspirate in EBUS-TBNA supports the idea of not performing routine BA. Although the potential for cost savings in caring for an individual patient is modest, many centres routinely perform BA, so the potential savings could be significant.