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Endobronchial Ultrasound (EBUS) Biopsy of Mediastinal Lymph Nodes


Mediastinoscopy is the ‘gold standard’ method for determining the presence of nodal metastases in the mediastinum. Generally performed as an outpatient surgical procedure, it is associated with a low rate of serious adverse effects (<1%) and the procedure is highly accurate, with false negative rates reported to be between 6% and 9%. Endobronchial ultrasound (EBUS) guided fine needle aspiration biopsy of mediastinal nodes offers a less invasive alternative for histologic sampling of the mediastinal nodes. The procedure has been widely adopted by pulmonologists and is poised to replace mediastinoscopy in the future. For thoracic surgeons, the technique can be easily learned and it may be important to do so if our specialty is to maintain its traditional and important role in the diagnosis and staging of thoracic malignancies.

The EBUS bronchoscope (BF-UC160F-OL8; Olympus America Inc., Center Valley, PA) is similar in dimensions to a standard adult fiber optic bronchoscope. The 6 mm diameter scope has a curvilinear ultrasound (US) probe at its distal end which provides a 50 degrees linear continuous B-mode ultrasound image, with color Doppler capability to aid identification of vascular structures . Proximal to the US probe, and at 30 degrees to the long axis of the bronchoscope, are a fiber optic lens and a biopsy channel, through which a 22-G biopsy needle can be passed (NA-201SX-4022; Olympus America Inc., Center Valley, PA) . A disposable latex balloon is placed over the US probe, which is inflated with sterile water to provide a fluid interface between the probe and the tracheal wall.

Operative Steps


The biopsy needle consists of a 22-guage needle with inner stylet housed in a flexible sheath, both of which may move independently of one another relative to the bronchoscope. The biopsy needle is passed through the biopsy channel and the housing secured to the bronchoscope by a flange. There are two main techniques to perform transbronchial puncture. The ‘quick jab’ technique is easiest and most useful for the subcarinal nodes or nodes along the main stem bronchi where the cartilage is thinner (Figures 8 and 9). With the node visualized by US, the sheath is advanced out of the end of the scope until the top right corner of the ultrasound image becomes slightly indented. This indicates that the end of the sheath is in contact with the wall of the bronchus and it is therefore safe to advance the needle. The guard for the needle is then released and using a quick jab the needle is plunged into the lymph node. If the needle is more slowly advanced there is a tendency for it to push the wall of the bronchus away from the scope, thus losing contact with the balloon and resulting in image loss. Once the needle is visualized within the lymph node, the stylet is moved in an out a few times to dislodge any bronchial epithelium that may have entered the needle, and then withdrawn. Suction is applied to the biopsy needle (typically negative 20 cc of air using a Vac-Loc syringe) and the needle passed in and out of the node approximately 10 times under US visualization. Suction is then released and the entire biopsy needle withdrawn. Smears are prepared by advancing the needle out of the sheath, reinserting the stylet and applying a drop of the aspirate to frosted glass slides. Air is used to ‘flush’ remaining aspirate material either onto additional slides or into RPMI medium for cell block analysis.

Specificity is as high as 90%.


EBUS being performed under general intravenous anesthesia with use of laryngeal mask airway. The CV-180 video processor enables picture-in-picture display, which allows easy correlation between visualized anatomy and the ultrasonic image.




Reference:
http://www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-40.html

WHY I LIKE EBUS ?


1. This reduces the reliance on pulmonologists on radiology oncologists

2. The specificity in locating tumorous nodules ! We can excise nodules as small as 2 mm.

3. Speed ! The procedure takes less than 5 minutes to do !

4. We can screen, identify, stage, and make diagnosis and plan for treatment in such rapid manner

5. This technology, once it is imported to emerging markets abroad ,can make effective change for their respective health systems.

The DOWN SIDE of EBUS:


1. Cost. A single tube costs $ 1200 + additional costs of customization

2. The machines are expensive, starting at $100,000.

3. The emerging markets EX-US cannot afford this technology , with the exception of Europe.

With this new technology, there will be interoperability between radiology oncologists and pulmonologists; between thoracic oncologists with thoracic surgeons and cardiothoracic surgeons. Kuyaw kaayo oy. Even a General Surgeon can use this simple procedure with ease and be qualified to do thoracic bronchioectomy if needed be and the total procedure would take less than 10 minutes.

Some 30 years ago, this was unheard of. There is no more need for unnecessary exploratory surgery anymore.

I attended morning Mass at 9:30 AM at St. Mary of the Lake Roman Catholic Parish. The occasion was beautiful because we had three new members being inducted into the Roman Catholic Faith Community , these were RCIA adults. In addition to these three, a little baby named Nathan was being baptized into the Church. The celebrants included Fr. Paul and Deacon Paul. It really was a beautiful Mass !

The color was blue today, signifying the first Sunday of Advent. During the observation of mass today, Deacon Paul said something that really inspired me and touched me -- and I thought I should share it with all of you here. He said this:

"In your life, you meet all kinds of people. People who you agree with and people who you don't agree with. In this advent season, I want you to think of all the blessings that God has given you , has showered you. However, I want you to think about the enemies you have -- those who are alive and those who are already dead. Think of them and pray for them."



So yes, dear Brothers and Sisters in Christ, ponder on this statement as you all proceed into the Season of Advent. May God Bless all of Us!



Yours In Christ,
Lorenz

Seek Ye First The Kingdom of God - Canon in D by Pachelbel



http://www.youtube.com/watch?v=zeWewPtD_ag#

God, Truly, Is Good. I just had dinner with an old friend of mine who I had a fight with some 3 months ago. At the urging of today's mass, I invited my friend over to my apartment for dinner. We apologized to each other and I reiterated to her how important she is in my life. She cried in front of me. And I also  could not hold back the tears from my eyes, cried also. I am so blessed right now, and am joyous at the revival of our friendship. Thank you, Deacon Paul, for today's message. Lipay ko. Thank you so much Lord for this blessing... ! 

Quote from: Lorenzo on December 03, 2012, 03:18:02 PM
God, Truly, Is Good. I just had dinner with an old friend of mine who I had a fight with some 3 months ago. At the urging of today's mass, I invited my friend over to my apartment for dinner. We apologized to each other and I reiterated to her how important she is in my life. She cried in front of me. And I also  could not hold back the tears from my eyes, cried also. I am so blessed right now, and am joyous at the revival of our friendship. Thank you, Deacon Paul, for today's message. Lipay ko. Thank you so much Lord for this blessing... ! 

malipayon ko para ninyong duha...

Quote from: roots on December 03, 2012, 03:21:48 PM
malipayon ko para ninyong duha...

I told her today, "Do you know how much I have missed you?" She responded, with tears overflowing her face and falling, "I thought you didn't even want to talk to me ever again."

As I used my right hand to wipe the tears off her face, I felt the Holy Spirit within me. I apologized to her for the wrongs I did to her, and her forgiveness was the reward. How sweet it is, truly my friends, the forgiveness of a friend. How sweet is the Love of the Holy Spirit.....!

 

done with today's work... ugma na pod... kadali ra sa oras...

play

gotom gid way na gid soknod para aboham. 

just me in the office... asa kaha akong boss hehehe

office mski gabagyo diri sa davao....

Quote from: roots on December 04, 2012, 08:35:58 AM
office mski gabagyo diri sa davao....

aw pareha ra pod dire sa Digos..

mao lagi oi...
lami unta sa balay lang basta ingon aning panahon...

Quote from: roots on December 04, 2012, 08:52:28 AM
mao lagi oi...
lami unta sa balay lang basta ingon aning panahon...

mao heheheh.. hapit ko ma late ganina kay nagluko luko pa ko sa higdaanan hahah lami gyud itulog pa...

marag one man army pa jud ko karon diri sa office...

hahahah same here... wala akong boss pod.. ambot asa heheh

makalingaw pud maski ako ra ug ang guard ug driver naa... atleast ako ang boss nila karon, hahahahaha

kadaghan sa urgent reports nangabot kung kanus-a nagbagyo.... podpod na akong kuko ug encode... wala pa gyud akong boss.. i.for na lang nako ning signature dapat before 5pm human na ni..

humana ang trabaho watchin UFC & replay Boxing pang patay sa oras.. wew!

Quote from: Pikoy on December 04, 2012, 04:30:09 PM
humana ang trabaho watchin UFC & replay Boxing pang patay sa oras.. wew!

Agoi, makagaba ra ba nang mopatay og oras, Bay Piks...

Quote from: roots on December 04, 2012, 09:27:39 AM
makalingaw pud maski ako ra ug ang guard ug driver naa... atleast ako ang boss nila karon, hahahahaha

kuyawa lagi si Bossing Roots.  

half day lang sa work.. i don't feel well.. subawan ko... T_T

oh my.  karon pang grabe ang workload.  get well soon, lolla.  the last time gisubawan ko, wa koy nahimo ug usa ka semana.  mora kog tuyom nga nanglisik ug sapot kay bug-at kaayo ang ulo.  hinaot you fare better than i did.

Quote from: Lollapalooza on December 05, 2012, 01:15:53 PM
half day lang sa work.. i don't feel well.. subawan ko... T_T

tungod seguro na sa dark nga imong gikaon...

he he he ! gi decorated ang room lagi oh...

Katawa ko ganina kai when i came inside my office, i overheard one of the instructors say, "Oh, did you see Dr. Lorenzo's cute ginger bread house on his desk?"

hahaha! Awwwwwww. Christmas theme man gud uy.

Quote from: islander on December 05, 2012, 02:32:45 PM
oh my.  karon pang grabe ang workload.  get well soon, lolla.  the last time gisubawan ko, wa koy nahimo ug usa ka semana.  mora kog tuyom nga nanglisik ug sapot kay bug-at kaayo ang ulo.  hinaot you fare better than i did.

Thanks Chief Justice Isles... I still feel sick pero gikaya lang nako.. dili pwedeng moabsent karon kay need ko motambong aning conference sa data gathering together with school planning officers...

I watched the news TV Patrol, 24-Oras, Aksyon (TV5)...all about the devastation of Typhoon Pablo, nakahilak ko nagtan-aw.. looy kaayo ang mga bata, animals, mga namatyan... hayy.. nagsakit akong dughan, kahunahuna ko, dili na lang ko magtan-aw ug news..

Just came back from a conference meeting on non-profit grant writing, health care fundraising etc, which was held in Northbrook, Illinois. It was a good 30 minute drive. I attended it with the President of Northwestern.

I learned a lot. Nag network network pod gamay.

Attended a funeral of a brother priest at St. Louis Cathedral in New Orleans

Quote from: chicogon on December 07, 2012, 06:04:25 AM
Attended a funeral of a brother priest at St. Louis Cathedral in New Orleans

Da, Domine, propitius pacem in diebus nostis, ut, ope misericordiae tuae adiuti, et a peccato simus semper liberi et ab omni perturbatione securi. Per Christum Dominum nostrum. Amen.

Réquiem æternam dona ei,
Dómine.

Et lux perpétua lúceat ei.
Requiéscat in pace.
Amen.

Anima ejus, et ánimæ ómnium fidélium defunctórum, per misericórdiam Dei requiéscant in pace.

Amen.

Sanctus, Sanctus, Sanctus, Dominus Deus exercituum: Plena es terra gloria tua: Gloria Patri, Gloria Filio, Gloria Spiritui Sancto.

Isla Reta here we come ^__^

simba

samot d ko katulog kay nangabot na among gipaabot.. hastang saba.a after 7 years nga wala magkita sa akng mga friends..

Et benedictio Dei omnipotentis, Patris et Filii et Spiritus Sancti descendat super vos et maneat semper.

AMEN.

SALVE REGINA, Mater misericordiae. Vita, dulcedo, et spes nostra, salve. Ad te clamamus exsules filii Hevae. Ad te Suspiramus, gementes et flentes in hac lacrimarum valle. Eia ergo, Advocata nostra, illos tuos misericordes oculos ad nos converte. Et Iesum, benedictum fructum ventris tui, nobis post hoc exsilium ostende. O clemens, o pia, o dulcis Virgo Maria.

A Most Blessed Feast of the Immaculate Conception to all of you, my Brothers and Sisters in Christ. May the Lord Our God pour forth abundant Graces and Blessings for you all , from the crown of your heads to the soles of your feet, to your entire family, your friends, and to you. This I ask in Jesus Christ Our Lord.

Amen.

Mother Mary, Conceived without sin, Pray for Us who have recourse to you.

Amen.

Right now, I am thinking of my loved ones in the Philippines, and my family here in the United States. I am asking for continued abundant Graces and Blessings to pour down onto my loved ones, my family and my friends, those who are also at qualms with me, I pray for continued abundant Graces and Blessings for them. May God always bless them.

As the days come closer to Christmas, I am reminded of the significance of this day. The reverence we must have at each passing day towards the Day of Salvation. May we all take the time to discern and spend time in prayer -- as we look at the Blessings and Spiritual Graces that God has given us in our individual lives.

May God Bless all of you. May God continue to have mercy on you. Amen.

Right now I'm preparing a concoction for tonight's reception para sa akong 28th anniversary to the priesthood adto sa among parish hall, courtesy of my parishioners.

Ingridients to my tusloanan: trinidad scorpion pepper (hottest in the world), kolikot pepper (hottest pod kung bol-anon pasultion), tupelo lemon, bellpepper, red onion, green shallot, green tomato, soy sauce garlic and datu puti vinegar.

Also said Mass early today as it is the Solemnity of the Immaculate Conception, patroness of the United States. Pyesta baya pod sa amo sa Catigbian, also Baclayon , Duero ug Sierra Bullones.

Right now, huwat2 lang ko for confession at 3:30pm and Saturday Vigil Mass at 4pm. Human misa duna daw mi reception for my 28th Sacerdotal Anniversary, potluck style.

God bless you both... still cant sleep.. waaaa...

Quote from: chicogon on December 09, 2012, 03:00:01 AM
Also said Mass early today as it is the Solemnity of the Immaculate Conception, patroness of the United States. Pyesta baya pod sa amo sa Catigbian, also Baclayon , Duero ug Sierra Bullones.

Right now, huwat2 lang ko for confession at 3:30pm and Saturday Vigil Mass at 4pm. Human misa duna daw mi reception for my 28th Sacerdotal Anniversary, potluck style.

How is everything with you, Fr. Roel? Okay ka lang dyan sa Slidell? Okay ra pod diri sa Chicago, Fr. Roel, tugnawtugnaw na pod lagi. What are you doing for Christmas?

Quote from: Lollapalooza on December 09, 2012, 03:27:29 AM
God bless you both... still cant sleep.. waaaa...

May God Bless You, sweetheart !

Last night, I attended Mrs. Isabella's birthday party, which was in downtown Chicago. I saw everyone from the hospital there, the medical director, other docs, and nurses and the executive staff. Mrs. Isabella is the Director of Nursing. I was pleased to make the acquaintance of her husband, Terry, and other family and friends there. Very warm family, very beautiful home as well.


he he he, it was American themed with a sprinkle of Pinoy.


Mrs. Isabella, the birthday celebrant.

I am getting ready for Christmas. Christmas shopping ko this week. I'm planning to drive home to New Jersey with my sister on December 20, 2012. God Willing, I will see my mother, father, my brothers and our dogs. I have missed them so much. I can't wait to be with them again.

Here is a beautiful, beautiful song "Angels We Have Heard on High" by David Archuleta. Enjoy!

http://www.youtube.com/watch?v=sb0Jg96bWMo#

Quote from: Lorenzo on December 09, 2012, 11:06:45 PM
How is everything with you, Fr. Roel? Okay ka lang dyan sa Slidell? Okay ra pod diri sa Chicago, Fr. Roel, tugnawtugnaw na pod lagi. What are you doing for Christmas?

Everything is fine here in Slidell, as usual... medyo mo busy sometimes, usahay pod very quiet. Weather-wise usahay cool, usahay humid pero tugnaw early in the morniing, moinit inig ka hapon... autumn weather more than winter. Gahapon zero visibility gesapot ang jamog...

Quote from: Lollapalooza on December 06, 2012, 07:12:29 PM
I watched the news TV Patrol, 24-Oras, Aksyon (TV5)...all about the devastation of Typhoon Pablo, nakahilak ko nagtan-aw.. looy kaayo ang mga bata, animals, mga namatyan... hayy.. nagsakit akong dughan, kahunahuna ko, dili na lang ko magtan-aw ug news..

i've decided on this a long time ago.  our media coverage is sometimes thoughtless, that's why. 

at my friend's house...doing what we used to do... drinking and listening to yANO!!!!!

karon pa ko kamata... gaki-at lang ning agi nako, sige lang, dugay na man sad pod mi magtapok sa akong mga friends...preparing myself for work... kumbati na sad ni.. daghan pod ko namiss dire sa dokdok da..

nag install sa bag-ong PC nga naabot... unsa'y nindot nga anti-virus?

kaspersky anti virus

Quote from: Chongki on December 12, 2012, 12:20:21 PM
kaspersky anti virus

okay pud pero dali lang man ma block iyang keys gud..blacklisted dayon heheheh

Getting ready for work.

Most Holy and Adorable Trinity, one God in three Persons, I firmly believe that You are here present; I adore You with the most profound humility; I praise You and give You thanks with all my heart for the favors You have bestowed on me. Your Goodness has brought me safely to the beginning of this day. Behold, O Lord, I offer You my whole being and in particular all my thoughts, words and actions, together with such crosses and contradictions as I may meet with in the course of this day. Give them, O Lord, Your blessing; may Your divine Love animate them and may they tend to the greater honor and glory of Your Sovereign Majesty. Amen.

super laay...going back to bed.. or watch movie until i fall asleep...

sleep

did all the reading i could about the connecticut school shooting and wondering why the u.s. is enamored with guns.  strangest of all, what has a household got to do with an assault rifle?

early this morning, nawala ko sa akong pangisip... ganahan ka ug sa plato nako gitimpla ang kape?!? blanko man kaayo akong utok oi...hahahahaha

Sunday: Wala na lang ko muadto sa 2 ka party - one Christmas and one birthday - kay gasunod2x na parties and can't even eat. Friday Christmas party sa among Men' Club unya Saturday night sa Fil-Am. So nitan-aw na lang kog football sa tv unya ga pritog sanga. Lami pa unya ka handay2 pas sofa hehehe

I spent the entire weekend writing a paper with babycakes.On Saturday evening, tho, I attended a Filipino Christmas Party held in Highland Park, Illinois.

kayod

Clinical paper work.

toxic kaayo today.

report, report, report..... salamat sa Ginoo

tiwas sa year-end report

andam ug tagana for an upcoming trip.  nahadlok lang ko kay medyo nagkiang ko gamay, something's wrong with my left leg.  i hope to have a meaningful christmas anyway.

sige pa kog basa about the connecticut tragedy.  i avoid philippine news because of the rh bill...

Quote from: islander on December 18, 2012, 03:31:33 PM
sige pa kog basa about the connecticut tragedy.  i avoid philippine news because of the rh bill...

same here Madam CJ...reading news about the school shooting.. nagtulo intawn akong luha..

di ko matagbaw.  the more i read, the more i cannot imagine why a civilized country like the u.s. with its civilized multiracial citizens can be so enamored with guns.  sure, it's enshrined in the constitution.  but when was that constitution written?  that was even before the wild, wild west era of dueling with guns at high noon.     

what i'm doing tonight...

staying awake until 2 a.m. to make sure that the banana republic wakes up at such time.  he has to go somewhere for a job-related function.

Quote from: islander on December 18, 2012, 11:37:23 PM
what i'm doing tonight...

staying awake until 2 a.m. to make sure that the banana republic wakes up at such time.  he has to go somewhere for a job-related function.

hmmm..alarm clock?..

the time is 9:56 am. i am getting ready for my lecture at 10 am. i'm doing a medical review lecture.

my day begins. wishing you all a wonderful and productive day.

have a great lecture!

i finished it at 2:00 pm. the time is now 2:58.

it was a 4 hour lecture. took 10 minute breaks in between each hour. i spent my breaks posting here on tb. haha.

YES!!!!!! humana gyud akong report... ugma relax na... sa Friday, team building at Sea Grass Resort Samal Island...

relaksing .... watching pba

Human nag panihapon , nag TB na.

Ali ilpolt takay plano

pa relax lang... mingaw ang office..

ngita ko ug site na pwede magdownload ug songlist para sa karavision.
pakyas man... basin naa moy ikatabang:'(

I'm getting ready for my drive home tonight. Working today then, as soon as i clock out at 9 pm, deretso mo drive back to New Jersey.

Getting ready now. Going to gas up my Mitsubishi Montero and then load up and heading out. Mo larga kami around 9 pm, hopefully, maluuy ang Ginoo, we will arrive home tomorrow afternoon.

Sending my love to all of my family and friends. To everyone here in Tubag Bohol Dot Com, wishing you all a very Merry Christmas ! God Bless !


Sincerely,
I remain,
Dr. Lorenzo

nanglimpyo ug kwarto... karon laay keu...

Naghinoktok... naghina-huna unsay buhaton; moadto bag tindahan mag tan-aw2x o magluto o magpainit sa tub labon tugnaw hehehe

nagpondo sa balay...first time nga magChristmas ko na may fever..

Quote from: Lollapalooza on December 24, 2012, 07:38:44 PM
nagpondo sa balay...first time nga magChristmas ko na may fever..

get well soon lolla..merry xmas..!

Quote from: Pikoy on December 24, 2012, 10:28:28 PM
get well soon lolla..merry xmas..!

tenk kyuw Engr..

back to work and nag attend ug 2-day YEAR END EVALUATION sa SIP/AIP/SBM  ... still sick pero makaya ra.... sige lang, naa man additional bonus heheheheh

Quote from: Lollapalooza on December 26, 2012, 02:23:02 PM
back to work and nag attend ug 2-day YEAR END EVALUATION sa SIP/AIP/SBM  ... still sick pero makaya ra.... sige lang, naa man additional bonus heheheheh

barato ha

I am writing this entry at home in New Jersey. No words can describe the feeling of being home with family. Am so very happy.

Finally, nahuman ra gyud ang seminar ug nanguli ang tanan nga basa kay bundak gyud ang ulan..

Quote from: Lorenzo on December 27, 2012, 10:23:17 AM
I am writing this entry at home in New Jersey. No words can describe the feeling of being home with family. Am so very happy.

Bran, belated Merry Christmas and Happy New Year to you and your family ^__^

First day of work this 2013 pero ugma pa ko duty...luya pa ko karon.. ehehhehe HAPPY NEW YEAR sa tanan ^__^

karon, nag work na intawn ko.... mingaw pa ang office, wala pa ni work akong crush... ganahan nako mopauli...

Quote from: Votives on January 02, 2013, 01:57:01 PM
karon, nag work na intawn ko.... mingaw pa ang office, wala pa ni work akong crush... ganahan nako mopauli...

luya pag way inspirasyon sa work Engr. Votives? hehehe