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Current Issue Volume 1, Issue2 2016

 

Review Article

 1. Endobronchial Tuberculosis

Authors: Pyng Lee, Associate Professor, National University of Singapore Director of Interventional Pulmonology, Senior Consultant, Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore

Endobronchial tuberculosis refers to tuberculous infection of the tracheobronchial tree. Diagnosis requires a high index of suspicion since symptoms are attributed to co-existing pulmonary tuberculosis and airway lesions are not detectable on chest radiograph. While computed tomography and bronchoscopy are useful for the evaluation of tracheobronchial stenosis or obstruction, goals of treatment remain in the eradication of tubercle bacilli and prevention of airway stenosis. Corticosteroids may halt progression of active disease to fibro-stenotic stage, however if tracheobronchial stenosis causing post-obstructive pneumonia, atelectasis and dyspnea has occurred, airway patency must be restored mechanically by surgery or bronchoscopic techniques.
 
Keywords: pulmonary tuberculosis, endobronchial tuberculosis, bronchoscopy, surgery, airway stricture
 
(Thoracic Endoscopy 2016; 1: 87-95)
 

Corresponding Author: Pyng Lee, Associate Professor, National University of Singapore, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Email: pyng_lee@nuhs.edu.sg

 
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Original Article

 1. Role of Conventional TBNA in Mediastinal Adenopathy

Authors: 1Mahavir Modi, 2K Sai Kiran, 3Shwetang Jani, 3Dipak Dhangar, 3Nikhil Chillal, 1Consultant Pulmonologist, 2Third year resident, 3Second year resident, Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra.

Background:

Mediastinal adenopathy remains one of the most common challenging cases to a pulmonologist. TBNA is a safe and minimally invasive flexible bronchoscopic technique. In set-ups, where EBUS is not available, TBNA still remains the ultimate modality in the diagnosis of mediastinal adenopathy.

 
Objective:
The aim of this study is to assess the diagnostic yield of conventional TBNA in mediastinal adenopathy.
 
Material and Methods:
It is a retrospective study performed in Ruby Hall Clinic, Pune from November 2014 to March 2016. Fifty cases of mediastinal adenopathy were assessed as per history, clinical examination, CT findings, location of nodes and risk assessments. TBNA was performed in all the patients. ROSE technique was not utilized. The slides were fixed and sent for cytological examination.
 
Results:
Of the 50 cases, sample was adequate in 45 patients (90% yield). In 40 out of 50 cases a definite diagnosis could be made (80% diagnostic rate) and the rest 10 cases were undiagnosed (20%). Most common lymph node station accessed was subcarinal in 40 patients (80 %) followed by paratracheal in 7 patients (14 %) and hilar in 3(6%). Out of the 40 patients in whom TBNA was diagnostic, 20 patients (50%) were sarcoidosis, 17 patients (42.5%) were TB and remaining 3 patients (7.5%) were metastasis from adenocarcinoma.
 
Conclusions:
Sarcoidosis is becoming as common as TB in our developing world and we are westernizing in a true sense. Conventional TBNA still remains a safe modality for the diagnosis of mediastinal adenopathy especially where EBUS is not available.
 
Keywords:
Cytology, Endobronchial Ultrasound (EBUS), Mediastinal Adenopathy, Rapid onsite evaluation (ROSE), Transbronchial needle aspiration (TBNA)
 
(Thoracic Endoscopy 2016; 1: 97-100)
 

Corresponding Author: Dr. K Sai Kiran Goud, P.No: 27, H.No: 21-155, Ramachandriah Colony, West Venkatapuram, Alwal, Secunderabad, Telangana – 500015, India. Email: ksaikirangoud@hotmail.com

 

 

Background:

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 2. Diagnostic utility of thoracoscopic pleural biopsy in histopathological confirmation of undiagnosed pleural effusions cases

Authors: 1K C Agarwal, 2Madhu Gupta*, 3J Mohan, 4Ramakant Dixit, 1Senior Professor, 2Professor, 3Resident, Department of Respiratory Medicine & Pathology*, S N Medical College, Jodhpur, 4Professor, Department of Respiratory Medicine, J L N Medical College, Ajmer

Background:
Pleural diseases affect over 3000 people per million populations each year worldwide and present a significant contribution to the workload in clinical settings. About 20% to 25% of pleural effusions remain undiagnosed despite repeated thoracocentesis and closed needle biopsy.
 
Objective:
To analyze the outcome of medical thoracoscopy in undiagnosed pleural effusions and evaluate complications with this procedure.
 
Material and Methods:
The present study was conducted with an aim to study the diagnostic yield of medical thoracoscopy in cases of undiagnosed pleural effusion. This was a cross sectional descriptive study in 25 patients of undiagnosed pleural effusion. The pleural effusion cases which remained undiagnosed after routine pleural fluid analysis were subjected for the medical thoracoscopy using semi-rigid thoracoscope.
 
Results:
Medical thoracoscopy using semi-rigid thoracoscope in undiagnosed pleural effusion cases has diagnostic yield of 88% in our study. Diagnostic yield of the medical thoracoscopy in malignant suspect cases was 88.88% and in tubercular suspect cases was 85.71%. Medical thorcaoscopy with nodular lesions and sago grain lesions has got good diagnostic yield. Medical thoracoscopy is a minimally invasive procedure with very low complication rates.
 
Conclusions:
Medical thoracoscopy is a relatively simple and safe procedure for a definite and histopathological confirmation of pleural effusion of unknown etiology. This should be considered in patients with lymphocytic predominant, exudative, effusions where tuberculosis and malignant pleural effusion are clinical possibilities with inconclusive initial pleural fluid analysis, so that wrong treatment can be avoided.
 
Keywords: Pleural effusion, thoracoscopy, pleural biopsy
 
(Thoracic Endoscopy 2016; 1: 101-105)
 

Corresponding Author: Dr. K. C. Agarwal, Principal & Controller, J L N Medical College, Ajmer. Email: kailashagarwal42@yahoo.com

 
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 3. Role of bronchial washing in the pathological diagnosis of bronchoscopically visible lung mass

Authors: 1Nimit Khara, 2Anand Patel, 3Purvi Buch, 4Firoj Ghanchi 1Associate Professor, Department of Pulmonary Medicine, P.S. Medical College, Karamsad, Gujarat, 2Associate Professor, Department of Pulmonary Medicine, GMERS Medical College, Gotri, Vadodara, Gujarat, 3Intern, GMERS Medical College, Gotri, Vadodara, Gujarat, 4Professor and Head, Department of Pulmonary Medicine, Shree M.P. Shah Medical College, Jamnagar, Gujarat

Background:
There is still disagreement as to the value and reliability of bronchial wash in comparison with histology, for the diagnosis of malignancy by flexible bronchoscopy. Objective: To evaluate the usefulness of bronchial washings in addition to endobronchial biopsies
for the pathological diagnosis of bronchoscopically visible lung mass (tumour).
 
Material and Methods:

In this study, patients were included if they had 1) bronchoscopically visible mass (outgrown, necrotic, infiltrative, nodular, ulcerative) and 2) bronchial washings (BW) performed along with endobronchial biopsies (EBB).

 
Results:

Forty five patients were included in the present study. Endobronchial biopsy and bronchial wash cytology both were positive for malignancy in 38 (84.45%) patients. Exclusive endobronchial biopsy was positive for malignancy in 6 (13.33%) patients while exclusive bronchial wash cytology was positive for malignancy in only 1 (2.22%) patient.

 
Conclusions:

The addition of BW to EBB is beneficial, but it may not be cost-effective. This procedure may be useful in patients with a bronchoscopically visible outgrown tumour with necrosis. Processing of bronchial washing specimen only when the histocytologic results of EBB is negative; is the best diagnostic approach because combining BW with EBB improves the diagnostic yield only marginally.

 
Keywords:

bronchial wash, cytology, bronchoscopically visible mass, endobroncial biopsy

 

(Thoracic Endoscopy 2016; 1: 107-110)

 
Corresponding Author: Dr. Nimit Khara, Department of Pulmonary Medicine, P. S. Medical College, Karamsad, Gujarat, India. Email: drkhara@gmail.com
 
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 4. Conventional TBNA with 19 G TBNA needle – Is 19 G needle useful?

Authors: 1Umang Shah, 2Ajay Lall, 3Andleeb Abrari, 4Nitin Dayal, 5Palak Shah, 1Fellow in Interventional Pulmonology, Department of Respiratory Medicine, 2Senior Consultant & Director, Department of Respiratory Medicine, 3Senior Consultant & Histopathologist, Department of Pathology, 4Senior Consultant & Cytopathologist, Department of Pathology, 5Cardio Respiratory Therapist & Research Assistant, Department of Respiratory Medicine, Max Super Speciality Hospital, Saket, New Delhi.

Background: 

As the practice of TBNA becomes more widely accepted, it has also revived a longstanding question on the optimum size of needle and whether larger needle with core biopsy is of any additional benefit.

Objective:

In routine practice 19G needle is rarely used even in large nodes as it is perceived to be   technically difficult and likely to give a poor yield of representative tissue. We report our experience with yield and safety using 19G needle for Conventional TBNA.

Material and Methods:

Eighteen patients with large mediastinal nodes (short axis > 25 mm) underwent 19G Conventional TBNA and station 4R and/or stations 7 were punctured respectively.

Results:

Out of Eighteen patients, core biopsy material was inadequate or unrepresentative in 4 / 18 cases and cytology material was unrepresentative in 2 patients. A diagnosis was reached in 16 of 18 patients by smear cytology and in 14 cases by histology. Out of eighteen patients, 12 patients had granulomatous etiology, two had poorly differentiated adenocarcinoma, one had malignant round cell tumor, and one patient had reactive lymphadenitis

Conclusions:
The 19G TBNA procedure is effective and safe, and can be a cost-saving alternative to surgical mediastinal exploration. It should be performed after careful case selection during initial diagnostic bronchoscopy and familiarization with the technique should not be neglected in training programmes and workshops.
 
Keywords:
Conventional TBNA, 19 G needle, mediatinal nodes, histopathology, cytopathology
 
(Thoracic Endoscopy 2016; 1: 111-114)
 
Corresponding Author: Dr. Umang C. Shah, Fellow in Interventional Respiratory Medicine, Max Super Speciality Hospital, 1,2 Press Enclave Road, Saket, New Delhi - 110017, Email: dr_umangshah@yahoo.co.in
 
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 5. Bronchogenic carcinoma: multifaced endoscopic encounter

Authors: 1Firoj Ghanchi, 2 Iva Chatterjee, 3Anand Patel, 4Arun Joy, 4Kinjal Rami, 4Divyesh Patel 1Professor & Head, 2Associate Professor, 4Resident, Department of Pulmonary Medicine, Shree M. P. Shah Medical College, Jamnagar, Gujarat, 3Associate Professor, Department of Pulmonary Medicine, GMERS Medical College, Gotri, Vadodara, Gujarat.

Background:
Bronchogenic carcinoma with stray causal relationship with tobacco smoking still has significant impact on healthcare services in developing countries like India. In view of variable and inconsistently proved susceptibility of selected smokers, diverse clinical scenario, multiplicity of histopathological typing, the need of comprehensive and confirmatory diagnostic strategy is a significant medical challenge, especially when resources are limited.
 
Objective:
This study is being undertaken to learn more on the bronchoscopic presentation of bronchogenic carcinoma and the diagnostic utility of different bronchoscopic sampling procedures in relation to different histopathological types.
 
Material and Methods:
In this retrospective study, analysis of endoscopic morphology and type of bronchogenic carcinoma was carried out. A total of 90 diagnosed cases of bronchogenic carcinoma by bronchoscopy were included in the study.
 
Results:
36.67% of the cases had proximal lesions while 63.33% cases had distal lesions. Wall confined distorting lesions, Intraluminal projectile lesions and extraluminal lesions with external compression were present in 51.1%, 30%and 18.8% of the cases respectively. A positive report of malignancy was obtained by bronchial wash in 69.3% cases, by bronchial brush in 70% cases and by bronchial punch biopsy in 89.18% cases.
 
Conclusions:
Intramural wall distorting lesion is the most common presentation of squamous cell carcinoma while extraluminal compressing lesion is that of adenocarcinoma. Bronchial biopsy and bronchial wash has almost similar diagnostic yield for intraluminal and intramural wall distorting lesions. Bronchial biopsy, wash and brush has very low yield in extraluminal compression.
 
Keywords:
Bronchoscopy, Bronchogenic carcinoma, Endoscopic morphology, Histopathological type
 
(Thoracic Endoscopy 2016; 1: 115-118)
 
Corresponding Author: Dr. F. D. Ghanchi, Professor – Department of Respiratory Medicine, Shree M. P. Shah Medical College, Jamnagar, Gujarat - 361008, Email: afin62@yahoo.co.in
 
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Case Series

 1. Stent and stay suture

Authors: 1A M Khoja, 2C S Patel, 2A Yannawar, 2D Jain, 2S Garde, 2O Kajale, 1Professor & Head, 2Post Graduate Resident, Department of Pulmonary Medicine, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India.

Silicone stents are effective; however, one of its known complications is migration. To prevent migration of stent we used a different practical approach, of securing the stent in the trachea with non-absorbable proly-propylene suture material through trachea and silicone stent after skeletonizing trachea to prevent infection and better cosmetic result.
 
Keywords: Central airway obsturection, Stenosis, stent, stay suture
 
(Thoracic Endoscopy 2016; 1: 119-122)
 

Corresponding Author: Dr. Chintan S. Patel, Part 3/402 Asopalav Complex, Brahmakumari Marg, Vapi, Valsad, Gujarat - 396191. Email: drchintanspatel@gmail.com

 
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Case Report

 1. Tracheal Stenosis: Multimodality Management – A Case Report

Authors: 1Aditya Chawla, 2Arun Madan, 3Rakesh Chawla, 4Kiran Chawla, 1Senior Resident, Department of Pulmmonary Medicine, Saroj Super Speciality Hospital, 2Professor & Head, Department of Respiratory Medicine, Sharda Medical College, Noida 3Senior Consultant, Department of Respiratory Medicine, Jaipur Golden Hospital, Rohini, Delhi, 4Ph.D. Scholar, Department of Hospital Management, Singhania University, Rajasthan

A case of post-corrosive tracheal stenosis was successfully managed with a multi-disciplinary approach involving Endo Bronchial Electro-Surgery (EBES), Intrabronchial Ballooning, local administration of inj. Bleomycin followed by Tracheal Stenting. Patient was successfully discharged on the same day.
 

Keywords: Tracheal Stenosis, EBES, Intrabronchial Ballooning, Tracheal Stenting

 
(Thoracic Endoscopy 2016; 1: 123-126)
 

Corresponding Author: Dr. Rakesh K, Chawla, Chawla Respiratory Care, Allergy, Sleep Disorders and Research Centre, 58-59/C-12/Sector-3, Rohini, Delhi-110085. Email: chawla.rakesh@rediffmail.com

 
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 2. Endobronchial leiomyoma successfully treated with flexible bronchoscopic cryotherapy: A case report

Authors: 1Nepal SK, 1Cirino M, 2Grider D, 1Rubio E, 1Department of Pulmonary and Critical Care Medicine, Virginia Tech Carilion School of Medicine, 2Department of Pathology, Virginia Tech Carilion School of Medicine

Benign tumors of the tracheobronchial tree are rare. Leiomyoma is one such tumor that, though benign, may lead to complete bronchial obstruction. Secondary symptoms are dependent upon the location and extent of airway involvement. The mainstay to manage these tumors has been surgical resection. With the advance in interventional bronchoscopic techniques, non-surgical options are being more commonly explored, including a few reports of successful resection of leiomyomas with laser therapy. We report the first case of complete resection of bronchial leiomyoma with endobronchial cryotherapy.
 
Keywords: Endobronchial leiomyoma, Cryotherapy, Flexible bronchoscopy
 
(Thoracic Endoscopy 2016; 1: 127-130)
 

Corresponding Author: Nepal SK, Department of Pulmonary and Critical Care Medicine, Virginia Tech Carilion School of Medicine. Email: santoshnpl@gmail.com

 
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 3. Bronchoscopic findings in lung sequestration – Case Report

Authors: 1Jayalakshmi TK, 2Sindhu Kamath, 3Aparna Iyer, 4Bhumika Madhav, 1Professor & Head, 2Ex-resident 3Assistant Professor, 4Third year resident, Department of Pulmonary Medicine, D. Y. Patil Hospital and Research Centre, Mumbai, Maharashtra

25 year old man came with chest x-ray showing a lesion in left lower zone detected on a  pre-employment check-up .CT thorax showed intralobar sequestration. Bronchoscopy showed abnormally narrowed segmental openings in the left lower lobe.
 
Keywords: Bronchoscopy, Congenital Malformation, Sequestration
 
(Thoracic Endoscopy 2016; 1: 131-133)
 

Corresponding Author: Dr. Jayalakshmi T. K., B 405, Jasmine, Neelkanth Garden, S P Jain Marg, Deonar, Govandi (E) – 400088, Maharashtra. Email: jaiclinic@gmail.com

 
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 4. Case of lung aplasia

Authors: 1Darshit Shah, 2Alisha Ghanchi, 3Harshad Shah, 4Ashutosh Dave, 4Nirmala Chudasama, 5Rashesh Vyas, 1Second year resident, 2Third year resident, 3Professor & Head, 4Professor, 5Associate Professor, Department of Radiodiagnosis, C. U. Shah Medical College & Hospital, Surendranagar, Gujarat

Pulmonary aplasia is a rare congenital pathology in which there is unilateral or bilateral absence of lung tissue. Here we report a case of a case of lung aplasia who came with repeated respiratory tract infection with difficulty in breathing.
 

Keywords: Absent pulmonary artery, VACTERL ,White out hemithorax

 
(Thoracic Endoscopy 2016; 1: 135-137)
 

Corresponding Author: Darshit Shah, Second year resident, Department of Radiodiagnosis, C. U. Shah Medical College & Hospital, Surendranagar, Gujarat. Email: sdds.shah@gmail.com

 
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 5. Retroperitoneal mass lesion leading to massive chylothorax and chylous ascites. An extrathoracic pathology

Authors: 1Umang C Shah, 2Nevin Kishore, 3Sitendu Kumar, 4Vivek Raj, 1Fellow in Interventional Pulmonology, 2Senior Consultant & Head, Department of Respiratory Medicine, 3DNB resident, 4Senior consultant & Director, Department of Gastroenterology, Max Super Speciality Hospital, Saket, New Delhi

Most common causes for chylous ascites include trauma, malignancy and infections. Amongst pediatric age group congenital lymphatic anomalies such as lymphangectasia are most common described cause for chylous ascites. We are presenting a case of retroperitoneal mass lesion leading to massive chylothorax and chylous ascites.
 

Keywords: Retroperitoneal mass, Chylothorax, Chylous ascites, Extrathoracic pathology

 
(Thoracic Endoscopy 2016; 1: 139-143)
 
Corresponding Author: Dr. Umang C. Shah, Fellow in Interventional Respiratory Medicine, Max Super Speciality Hospital, 1,2 Press Enclave Road, Saket, New Delhi - 110017, Email: dr_umangshah@yahoo.co.in
 
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