Detailed Morphological Analysis of Cryoinjury in Human Ovarian Tissue Following Vitrification or Slow Freezing

Cryopreservation of human ovarian tissue represents a key procedure for fertility preservation. The two most widely used cryopreservation methods for human ovarian cortex samples are slow freezing\thawing (SF\T) and vitrification\warming (V\W). The aim of the present study was to analyze the effects of SF\T and V\W using a metal chamber, on specific follicle and oocyte structures and on the stromal organization post-cryopreservation. We did histology analysis of SF\T and V\W ovarian fragments from nine healthy subjects. Overall results showed that cryopreserved tissues presented significant rates of damage in primordial and primary follicles. Altered nuclear structure of primordial follicles and cell detachment from primordial and primary follicles were the main injuries observed after V/W and SF/T. The stromal components were similarly well preserved after cryopreservation. We conclude that both cryopreservation methods may be used for fertility preservation purposes with similar outcomes in terms of follicular and stromal integrity. Detachment of follicle cells from basal membrane represents an important cryoinjury that deserves further investigation.

Applicability of logistic regression (LR) risk modelling to decision making in lung cancer resection

The objective of this study was to evaluate the performance of a locally derived risk-adjusted model to predict cardiorespiratory morbidity after major lung resection for bronchogenic carcinoma. A logistic regression risk model has been developed using a database of 515 patients undergoing major lung resection between 1994 and 2001. Independent studied variables were: age of the patient, body mass index, predicted postoperative forced expiratory volume in the first second (ppoFEV1%), cardiovascular co-morbidity, diabetes mellitus, induction chemotherapy, tumour staging, extent of resection, chest wall resection, and perioperative blood transfusion. The analyzed outcome was the occurrence of postoperative cardiorespiratory complications prospectively recorded and codified. Variables with an influence on the outcome on univariate analysis were entered in the risk model. The calculated probabilities of complication were compared to its actual occurrence in 53 consecutive cases operated on between January and June 2002 and a receiver operating characteristic (ROC) curve was constructed. On logistic regression analysis, age (P < 0.001) and ppoFEV1 (P = 0.003) independently correlated with the outcome. The accuracy for morbidity prediction (area under the ROC curve) was 0.55 (95% CI: 0.31-0.78). These data show that this locally derived lung resection risk-adjusted model fails to predict postoperative cardiorespiratory morbidity in individual patients.

Sleeve Lobectomy Compared to Pneumonectomy for the Treatment of N0-N1 Non-Small Cell Lung Cancer

OBJECTIVE

To compare survival, morbidity, and mortality rates for a series of patients who underwent either bronchoplastic sleeve lobectomy or pneumonectomy to treat non-small cell lung cancer (NSCLC).

PATIENTS AND METHOD

We reviewed the clinical records for patients who underwent sleeve lobectomy or pneumonectomy for NSCLC from January 1994 through December 2003.

RESULTS

From January 1994 through December 2003, 35 sleeve lobectomies and 220 pneumonectomies were performed at our department on patients with NSCLC. The perioperative mortality rate was 2.8% for the lobectomy group and 9.1% for the pneumonectomy group. The mean survival time for the pneumonectomy group was 45 months (95% confidence interval [CI], 37-53), with a 5-year survival rate of 32% (SE, 5.1%). The mean survival time for the sleeve lobectomy group was 72 months (95% CI, 56-87) (P< or =.0041), with a 5-year survival rate of 56% (SE, 9.6%). If we stratify the groups according to node involvement, patients classified as N0-N1 had a mean survival time of 52 months (95% CI, 43-61), with a 5-year survival rate of 39% (SE, 6.2%) for the pneumonectomy group. The mean survival time for patients undergoing sleeve lobectomy was 75 months (95% CI, 59-92) (P< or =.018), with a 5-year survival rate of 60% (SE, 10.4%). Survival for patients with N2 disease was similar to that of patients with N0-N1 disease.

CONCLUSION

For patients with N0-N1 non-small cell lung cancer, sleeve lobectomy offers better survival than pneumonectomy.

[Agreement between type of lung resection planned and resection subsequently performed on lung cancer patients]

OBJECTIVE

To assess agreement between planned lung resections and the type subsequently performed on a series of patients, to assess whether tumor location (central or peripheral) affected the degree of discrepancy, and, in the case of unscheduled pneumonectomies, to examine why the planned resection had to be extended.

METHOD

Prospective, observational clinical study of 199 patients scheduled for lung cancer surgery. Tumors were preoperatively classified as central or peripheral, and the type of operation planned--lobectomy (or bilobectomy) or pneumonectomy--was compared with the operation finally performed. Rates of agreement and Wilks' lambda statistic were calculated.

RESULTS

Twenty unscheduled pneumonectomies were performed. Agreement between planned and performed operations was found in 86.9% of cases (76.9% in central tumors and 95.4% in peripheral tumors). Wilks' lambda statistic was 0.38 (0.42 for central tumors and 0.17 for peripheral tumors). Seven unscheduled pneumonectomies were performed due to hilar node involvement.

CONCLUSIONS

The resections performed differed from the resections initially planned in 13% of the bronchial carcinoma operations, in most cases because the planned lobectomy had to be converted to pneumonectomy, a situation which occurred more often with central tumors and was more often due to direct invasion of anatomic structures rather than hilar spread.

Subendometrial power Doppler quantification: a new classification proposal

Fifty-two women with regular menses were enrolled in the study. The patients were not allowed to use non-steroidal anti-inflammatory drugs within 24 h of any examination. All patients were examined during the mid-luteal phase (6-9 days after ovulation, according to previous ultrasound record). Power Doppler energy levels were classified into five categories according to the per cent area of sub-endometrial signal: I (<10%), II (10-25%), III (25-50%), IV (50-75%) and V (>75%). The colour Doppler signal was considered positive when it reached at least the endometrial basal layer. The picture of the endometrium was analysed and the regions of interest were identified and marked for further analysis. Each recorded image was then independently evaluated and classified by three blinded observers. According to the power Doppler classification, age, body mass index (BMI) and endometrial thickness were analysed, and no significant differences were observed among them. The Kappa test (0.70) demonstrated an excellent agreement among examiners (P = 0.0001). This study has validated a very simple and cost-effective classification for sub-endometrial vascularization. This method of quantification may potentially be of use, and its relevance to clinical practice should be explored.

[A descriptive analysis of a series of patients diagnosed with acute mediastinitis]

Acute mediastinitis is one of the most aggressive chest diseases. The mortality rate ranges between 14% and 42%. We present a retrospective analysis of a series of 26 cases (20 men and 6 women) treated between January 1994 and March 2002 and review the literature. Mediastinitis originated in the esophagus in 17 patients (8 postoperative, 4 due to iatrogenic perforation, 4 due to noniatrogenic perforation, and 1 due to a foreign body) and in the oropharynx in 6 patients; mediastinitis was secondary to median sternotomy in 3. Twenty-five patients were treated surgically. In addition to radical debridement and drainage, which were carried out on all the patients, 10 also underwent esophagectomy or resection of the esophago-gastric reconstruction, 5 received primary sutures of the esophagus, 1 received reconstructive surgery with a pectoral muscle flap, and 1 underwent sternectomy plus intrathoracic omental transposition. Four patients died within 30 days of surgery (15.4%). The mortality rate in our practice is similar to that described in the literature. The results argue for early, aggressive treatment.

[A model to predict death after lung cancer resection: applicability to individual cases]

OBJECTIVE

To evaluate the reliability of a logistic regression model to predict individual risk of death related to lung cancer resection.

METHOD

A study of 515 consecutive patients undergoing anatomical pulmonary resection (lobectomy or pulmonectomy) for lung cancer between January 1994 and December 2001. Dependent variable: death in or out of hospital within 30 days of surgery. Continuous independent variables: age, body mass index, and percent of predicted postoperative FEV1. Binary independent variables: ischemic heart disease, diabetes mellitus, preoperative arrhythmia, induction chemotherapy, type of resection (lobectomy or pneumonectomy), chest wall resection, tumor extension (localized or extended tumor) and perioperative blood transfusion. All data were gathered prospectively. A univariate analysis was performed using contingency tables for binary variables and analysis of variance for continuous ones; stepwise logistic regression analysis was then performed and the likelihood of death for each individual was calculated. A receiver operating characteristic (ROC) curve was constructed with the data, using surgical death as the state variable.

RESULTS

The following variables were found to be independently related to death in the univariate analysis: age (p < 0.001, odds ratio 1.11); tumor extension (p = 0.002; OR 3.47) and perioperative transfusion (p = 0.004; OR 3.87). The area under the ROC curve was 0.77, attributable to high specificity given that none of the complications could have been predicted.

CONCLUSION

Although some variables are related to surgical death, the described model is not able to give a prediction. Therefore, the model is of little use for application in making decisions about individual cases.

Morbidity after surgery for non-small cell lung carcinoma is not related to neoadjuvant chemotherapy

OBJECTIVES

To compare postoperative morbidity and mortality rates in two groups of operated non-small cell lung carcinoma patients (NSCLC) with or without induction chemotherapy.

METHODS

This is a case-control study on 42 cases and 42 controls. Cases (Group A) underwent induction chemotherapy. Chemotherapy indications and regimens were variable. Control cases (Group B) were randomly selected among 494 NSCLC comparable patients operated on in the same period of time. The selection criteria for operation were the same in both groups. Dependent outcomes were operative death and complications. Independent selected variables were: age, co-morbidity, predicted postoperative FEV1% (1 s forced expiratory volume in percentage), type of surgery and clinical and pathological staging. All postoperative events and independent variables were prospectively registered. Chi-square and risk calculations on contingence tables and one-way ANOVA have been tested.

RESULTS

Both series are comparable in demographics, preoperative variables and type of surgery. No mortality has been registered. In Group A, the overall morbidity was 26.2% (11 out of 42 cases), and in Group B, this was 42.9% (18 out of 42 cases; P=0.084). Morbidity was not related to the type of surgery (pneumonectomy vs. other; P=0.205 in Group A and P=0.08 in Group B). Pathological staging did not influence the postoperative outcome, either in Group A (P=0.72; odds ratio, 1.515; 95% confidence interval (CI), 0.375-6.122) or Group B (P=0.299; odds ratio, 0.4; 95% CI, 0.089-1.797).

CONCLUSIONS

Induction chemotherapy in NSCLC has no influence on postoperative morbidity.

Prospective study on video-assisted thoracoscopic surgery in the resection of pulmonary nodules: 209 cases from the Spanish Video-Assisted Thoracic Surgery Study Group

OBJECTIVE

The diagnosis of pulmonary nodules has become one of the main indications of video-assisted thoracoscopic surgery (VATS), especially for small nodules not accessible by bronchoscopy or by percutaneous transthoracic needle aspiration. In this study we evaluate the indications, diagnostic safety, complications, and technical difficulty of VATS in the diagnosis of pulmonary nodules in Spain.

MATERIALS AND METHODS

We conducted a prospective study of 209 patients with one or more pulmonary nodules from a group of Spanish thoracic surgery divisions (The Spanish Video-assisted Thoracic Surgery Study Group). Data was collected and evaluated on variables contained on a questionnaire including demographic information, characteristics of the nodules, identification methods, surgical technique, morbidity and mortality rates, and diagnostic yield.

RESULTS

The mean size of the nodules was 1.9 cm (range 0.3-5 cm). A total of 93.3% were peripheral. A diagnosis was established in 100% of the cases. In this study, 51.1% of lesions were benign and 48.8% were malignant. In 16.3% of cases, a conversion to thoracotomy was needed. The morbidity was 9.6% and the mortality 0.5%. We found a relationship between the size of a nodule and a diagnosis of malignancy (P=0.019) and between a central location and a need to convert to thoracotomy (P=0.002). Patients with nodules >2 cm had a greater risk of complications (P=0.0001).

CONCLUSIONS

In the diagnosis of pulmonary nodules, VATS has a specificity of 100% and a low mortality rate. The probability of developing complications is higher when the nodule is >2 cm.

Utility of standardized exercise oximetry to predict cardiopulmonary morbidity after lung resection

OBJECTIVES

To evaluate if desaturation, measured by finger oximetry on standardized exercise, accurately predicts cardiopulmonary morbidity after pulmonary resection.

METHODS

A prospective observational clinical study was carried out on 81 consecutive lung carcinoma patients scheduled for pulmonary resection from February 1998 to March 1999. Finger oximetry was monitored during an incremental to exhaustion cycle exercise test. The presence or absence of desaturation (cut-off value 90%) during exercise was recorded. Other independent analyzed variables were: age of the patient (over 75th percentile), body-mass index (BMI) (over 75th percentile), presence of major cardiovascular co-morbidity, and calculated postoperative FEV1% (under 25th percentile) according to the number of resected segments (ppoFEV1%). Postoperative cardiopulmonary morbidity was the evaluated dependent outcome. Fisher's exact test and risk calculation on contingency tables were used for statistical analysis.

RESULTS

A lobectomy was performed in 62 cases, a pneumonectomy was performed in 16 cases, and a segmentectomy was performed in three cases. The mean age of the patients was 63.6 years (SD 10.3, range 34-79 years, 75th percentile 72 years), the mean BMI was 25.9 (SD 4.9, range 16.9-38.1, 75th percentile 29.3), and the mean ppoFEV1% was 64.1 (SD 2016.1, range 29.5-98.6, 25th percentile 50.5). In 14 patients exercise desaturation was registered. Postoperative cardiopulmonary morbidity was presented in 32 cases (five deaths). No correlation was found between postoperative morbidity and any of the following variables: age of the patient, BMI, and co-morbidity. On univariate analysis only low ppoFEV1% (P<0.001) was associated with the outcome, so no multivariate analysis has been carried out.

CONCLUSIONS

We have shown that desaturation during standardized exercise in this series adds no relevant information to predict postoperative cardiorespiratory morbidity after lung resection.

Influence of age and predicted forced expiratory volume in 1 s on prognosis following complete resection for non-small cell lung carcinoma

OBJECTIVE

To evaluate age of the patient at the time of surgery and estimated postoperative forced expiratory volume in 1 s (FEV1%) as predictors of long-term survival following complete resection of non-small cell lung carcinoma (NSCLC).

METHODS

Retrospective, observational study. Records of patients operated on for NSCLC between January 1994 and December 1997 were reviewed. One hundred and ninety three patients who underwent complete pathological resection and survived surgery were included for study. Patients were divided in groups depending on age at the time of surgery and predicted postoperative FEV1% calculated according to the number of resected segments. Values of the 75th percentile of age (70.29 years) and 50th percentile of predicted FEV1% (52.9) were the cut-points selected for group division. To increase the power of the analysis pathological staging was also converted in a binary variable and resumed to localized (stage I) or extended (stage II-IIIB). Univariate analysis of the effect of each variable on survival was assessed by Kaplan-Meier method and log-rank test. Relationship between variables was investigated using 2x2 tables and Fisher's exact test. Unrelated variables (extension, age and low estimated postoperative FEV1%) entered in a Cox-regression model to predict long-term survival following resection.

RESULTS

Pathological stage (P<0.0001), age (P=0.01) and low estimated postoperative FEV1% (P=0.0007) showed independent value to predict the outcome.

CONCLUSION

Advanced age and low predicted postoperative FEV1% play an adverse effect on survival of completely resected NSCLC.

[Descriptive study of complications caused by mediastinoscopy]

To analyze the surgical and non surgical complications of mediastinoscopy in a series of 200 consecutive patients. Retrospective study of all surgical patients between 1 January 1994 and 1 May 1997. Any complication presenting between time of surgery and patient release is analyzed. Complications were seen in 8 out of 200 cases (4%). In three cases, there were lesions in neighboring structures (recurrent nerve, bronchial artery and innominate artery). The rest were non surgical complications (3 cases of arrhythmia, 2 of prolonged mechanical ventilation). One male patient (0.5%) died from cerebral infarction, probably as a result of arterial occlusion needed to suture damage to the innominate artery. Superior win cava syndrome affected 20% (1 in 5) and morbidity was 60% (3 in 5). Morbidity involving both medical and surgical complications in this series is higher than that reported elsewhere in the literature, in series for which non surgical complications go unreported.

[Perfusion of donor tissue improves the preservation of graft in heterotopic tracheal transplantation]

To assess the effect on tracheal graft preservation of perfusion of donor tissue with a Collins solution before extraction and immunosuppression of the recipient. An experimental study was performed in 36 albino rabbits with revascularized heterotopic cervical reconstruction of the trachea with omentum. The animals were distributed in four groups. Groups I (n = 9) and III (n = 9) were transplanted with non perfused donor tissue. Animals in groups II (n = 9) and IV (n = 9) received grafts perfused with Collins solution. Immunosuppression with steroids and cyclosporin was continued for 21 days in groups III and IV. In a mid portion of the trachea viewed under optical microscope, the degree of inflammation or circumferential necrosis was assessed on a scale of 0 to 9 by adding the scores for mucosa, submucosa and cartilage. The mean score for tracheal lesion was lower in group IV, with a likelihood of random difference of less than 5%. Perfusion of peritracheal tissues with Collins solution in the donor, in addition to immunosuppression decreases the extent of tissue damage in the tracheal graft.

Subarachnoid-pleural fistula as a complication of the lateral-extracavitary approach to thoracic intraspinal neurinoma

STUDY DESIGN

This report describes an infrequent but major complication resulting from a lateral extracavitary approach to the spinal cord. The diagnosis was made via myelography-computed tomography.

OBJECTIVES

The authors emphasize the importance of a proper approach in diagnosing a subarachnoid-pleural fistula and treating this clinical condition correctly.

SUMMARY OF BACKGROUND DATA

Myelography-computed tomography was used to diagnose the subarachnoid-pleural fistula. It was necessary to re-open the thoracotomy to seal the dura mater because the pleuroperitoneal shunting was not effective.

METHODS

The patient presented with an intradural and extramedullary thoracic neurinoma located on the anterior part of the spinal canal that was causing anterior spinal cord compression. A lateral extracavitary approach was taken with a thoracotomy, with the tumor being completely removed. During the postoperative period, the patient had a persistent pleural effusion. The diagnosis of a cerebrospinal fluid fistula was made via myelography-computed tomography. Implantation of a pleuroperitoneal shunt was unsuccessful, and it was necessary to re-open the thoracotomy to seal the dura mater.

RESULTS

Myelography-computed tomography successfully helped diagnose the subarachnoid-pleural fistula and identify the precise anatomic location of the leakage. Pleuroperitoneal shunting was not effective in dealing with the pleural effusion.

CONCLUSIONS

This complication should be taken into account when this kind of surgical approach is performed. Myelography-computed tomography is the most reliable test for diagnosing this clinical condition and pinpointing the exact location of the leakage.