Efficacy and Safety of Pleurodesis Using Platelet-Rich Plasma and Fibrin Glue in Management of Postoperative Chylothorax After Esophagectomy.

INTRODUCTION: Chylothorax is by definition a collection of lymphatic fluids in the pleural cavity because of leakage from main thoracic duct or its tributaries. It is an uncommon but serious postoperative complication in esophageal cancer patients. There is no standard therapeutic algorithm for chylothorax because no prospective or randomized trials have yet been performed to evaluate the available treatment options. The aim of this study was to evaluate the efficacy of pleurodesis with a combination of platelet-rich plasma (PRP) and fibrin glue to the treatment of chylothorax after trans-hiatal esophagectomy. MATERIALS AND METHODS: We randomly allocated 52 consecutive esophageal cancer patients with postoperative chylothorax who did not respond to conservative management to either PRP fibrin glue pleurodesis or surgical thoracic duct ligation. 26 patients in each group were treated with PRP fibrin glue pleurodesis or surgical thoracic duct ligation in order to control chylothorax. Perioperative data, including success rate and complications of both interventions, were analyzed. RESULTS: Two groups were similar in terms of patients' demographics and tumor characteristics. All 26 patients in pleurodesis group (100%) and 20 patients in surgery group (76.9%) were successfully treated (p = 0.009). Seven patients (26.92%) in pleurodesis group required a second application of PRP fibrin glue after a week. The mean length of hospital stay was 53.50 ± 16.662 days in surgery group and 36.04 ± 8.224 days in pleurodesis group (p < 0.001). Although mortality rate in surgery group was higher than pleurodesis group, it was not statistically significant (p = 0.1621). There was no significant difference in complications between two groups either. No serious side effect occurred with PRP fibrin glue application. CONCLUSION: In conclusion, pleurodesis using PRP and fibrin glue for chylothorax after trans-hiatal esophagectomy was associated with significantly increased success rate, decreased ICU stay, decreased overall hospital stay, and decreased mortality compared with surgical thoracic duct ligation. No patient after PRFG required additional intervention including surgery. Thus, given the improved outcomes with PRFG pleurodesis, this technique may be considered in all patients with postoperative chylothorax after or during conservative management and before proceeding to more invasive interventions.

Feasibility and safety of minimally invasive radioguided parathyroidectomy using very low intraoperative dose of Tc-99m MIBI.

BACKGROUND: Surgical resection of the abnormal parathyroid glands is the only curative treatment for primary hyperparathyroidism (PHPT). Radioguided parathyroidectomy with technetium-99m (TC-99m) sestamibi has been successfully used in patients with PHPT. This study was designed to evaluate the results of a series of patients with PHPT who underwent minimally invasive radioguided parathyroidectomy (MIRP) using very low dose (1 mCi) of TC-99m sestamibi (MIBI) without application of intraoperative parathyroid hormone (PTH) assay or frozen section analysis. METHODS: Eighty-seven patients with PHPT were prospectively studied from November 2012 to January 2015. Following neck ultrasound (US) and MIBI scan concordant for single gland disease, patients underwent MIRP using a handheld gamma probe. The technique involved injecting of 1 mCi MIBI in the operative room before the beginning of the intervention. All patients were followed up for a minimum of 6 months postoperatively. RESULTS: MIRP was successfully performed in 86 out of 87 patients (98.85%). The Gamma probe was particularly useful in detection of ectopic parathyroid adenomas in upper mediastinum. Mean operative time was 23.95 ± 7.982 min and mean hospital stay was 1.44 ± 0.604 days. No major surgical complications were recorded. CONCLUSIONS: The MIRP technique using very low dose (1 mCi) of Tc-99m MIBI without intraoperative PTH assay and frozen section analysis resulted in excellent cure rate for PHPT. This technique involves a radiation exposure to patients and surgical staffs 20 times lower than conventional MIRP using 20 mCi Tc-99m MIBI. Besides, patients with PHPT due to ectopic parathyroid adenoma may especially benefit from MIRP.

Sentinel node mapping in papillary thyroid carcinoma using combined radiotracer and blue dye methods.

INTRODUCTION: In the current study, we evaluated the accuracy of sentinel node mapping in thyroid cancer patients using both radiotracer and blue dye. MATERIAL AND METHODS: 30 patients with a diagnosis of papillary thyroid carcinoma (PTC) were included in the study; 2-3 hours before surgery, 0.5 mCi 99m-Tc-Antimony Sulfide Colloid was injected intra-tumourally. 15 minutes post-injection, lymphoscintigraphy images of the neck were obtained. Immediately after anaesthesia induction, 0.5 mL patent blue V was also injected in the same fashion. Sentinel lymph nodes were detected intraoperatively using gamma probe and blue dye. Total thyroidectomy was performed for all patients with dissection of central neck lymph nodes as well as sampling of the lateral neck lymph nodes. RESULTS: At least one sentinel node could be identified during surgery in 19 patients (63.3%). The median number of sentinel nodes per patient was 1. Sentinel nodes in 12 patients were pathologically involved. No false negative case was noted. Upstaging occurred in six patients (20%). CONCLUSIONS: Sentinel node mapping in papillary thyroid carcinoma is a feasible technique with high accuracy for the detection of lymph node involvement. This technique can guide surgeons to perform central lymph node dissection only in patients with pathologically involved sentinel nodes. Although SLN detection in the lateral neck lymph nodes increases the extension of lymphadenectomy, SLN mapping can result in upstaging in older patients (> 45 years of age) or treatment plan change in younger patients (< 45 years of age) by the detection of lateral lymph node involvement.

The effect of excisional biopsy on the accuracy of sentinel lymph node mapping in early stage breast cancer: comparison with core needle biopsy.

Despite the successful application of sentinel node mapping in breast cancer patients, its use in patients with a history of previous excisional biopsy of the breast tumors is a matter of controversy. In the present study we evaluated the accuracy of sentinel node biopsy in this group of patients and compared the results with those in whom the diagnosis of breast cancer was established by core needle biopsy. Eighty patients with early stage breast carcinoma were included into our study. Forty patients had a history of previous excisional biopsy and the remainder 40 had undergone core needle biopsy. Intradermal injections of 99mTc-antimony sulfide colloid as well as patent blue were both used for sentinel node mapping. Sentinel nodes were harvested during surgery with the aid of surgical gamma probe. All patients underwent standard axillary lymph node dissection subsequently. Detection rate was 97.5 per cent for both groups of the study. Number of detected sentinel node during surgery was not significantly different between groups. False negative rate was 0 per cent for both groups of the study. In conclusion sentinel node biopsy is reliable in patients with previous history of excisional biopsy of the breast tumors and has a low false negative rate.

Comparison of early and delayed lymphoscintigraphy images of early breast cancer patients undergoing sentinel node mapping.

OBJECTIVE: We compared early and delayed lymphoscintigraphy images using intradermal injection of (99m)Tc-antimony sulfide colloid, which has small particles. METHODS: Eighty patients with early-stage breast cancer were included into the study. Intradermal injection of (99m)Tc-antimony sulfide colloid was used for sentinel node mapping. After radiotracer injection, 30 min and 20 h later, lymphoscitigraphy images were obtained in lateral and anterior views. After the completion of each image sets, the location of the visible nodes in the axilla was marked on the skin. Two nuclear medicine specialists reviewed the images independently and the number and location of detected nodes were recorded. RESULTS: At least one hotspot was detected in the axillary region in 78 (97.5%) and 79 (98.75%) patients on the early and delayed images, respectively. No extra-axillary drainage was noted in the patients. The number and location of detected hot spots were the same in 77 patients on both image sets. In one patient the early image did not show any axillary hot spot despite its visualization on the delayed image set and in one patient no hot spot was noted on either images. In one patient an additional axillary hot spot was noted on the delayed image, which was not apparent on the early image. CONCLUSION: Our study showed that a delay of up to 20 h in sentinel lymph node biopsy using intradermal injection of (99m)Tc-antimony sulfide colloid does not result in washout of the tracer from the true sentinel node or migration of the radiotracer into second-echelon nodes.