The efficacy of computed tomography (CT) and mediastinoscopy as staging modalities to assess mediastinal lymph node status was evaluated in 569 patients with a presumed resectable non-small cell lung cancer (NSCLC). Computed tomography scan was performed in every patient and followed by mediastinoscopy in 331 and by thoracotomy in 477 patients. Mediastinal lymph nodes on CT larger than 1.5 cm were considered pathological. Overall, CT had a sensitivity of 69%, a specificity of 71% and an accuracy of 71% in identifying mediastinal lymph node metastases. For mediastinoscopy these figures were 72%, 100% and 89%, respectively. Computed tomography accuracy was distinctly lower in squamous cell carcinomas and in central tumors, as CT sensitivity was significantly lower in left-sided tumors. The positive predictive value (PPV) of CT in T1 lesions (29%) and PPV and negative predictive value (NPV) of CT in T2 squamous cell carcinomas (30% and 83%, respectively) were low, so questioning its use in those instances. We perform a mediastinoscopy in every situation except for squamous cell carcinomas or small (less than 3 cm) peripheral tumors in the absence of enlarged mediastinal lymph nodes. This selective attitude is rewarding since a) the number of pN2 in the straight thoracotomy group was only 16% versus 41% in the mediastinoscopy group, b) the exploratory thoracotomy rate in the straight thoracotomy group was low (4.6%).

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In contrast to their widespread use, %EBL and %EWL are not suited for comparing different patients or nonrandomized groups. They cause variation by initial BMI, which disappears using %TWL. In general, absolute terms should be preferred for bariatric outcome and goals. The power of bariatric procedures is best represented by their mean %TWL value.

BackgroundThe effects of the patient’s body position on the intraabdominal workspace in laparoscopic surgery were analyzed.MethodsThe inflated volume of carbon dioxide was measured after insufflation to a preset pressure of 15 mmHg for 20 patients with a body mass index (BMI) greater than 35 kg/m2. The patients were anesthetized with full muscle relaxation. The five positions were (1) table horizontal with the legs flat (supine position), (2) table in 20° reverse Trendelenburg with the legs flat, (3) table in 20° reverse Trendelenburg with the legs flexed 45° upward at the hips (beach chair position), (4) table horizontal with the legs flexed 45° upward at the hips, and (5) table in 20° Trendelenburg with the legs flat. The positions were performed in a random order, and the first position was repeated after the last measurement. Repeated measure analysis of variance was used to compare inflated volumes among the five positions.ResultsA significant difference in inflated volume was found between the five body positions (P = 0.042). Compared with the mean inflated volume for the supine position (3.22 ± 0.78 l), the mean inflated volume increased by 900 ml for the Trendelenburg position or when the legs were flexed at the hips, and decreased by 230 ml for the reverse Trendelenburg position.ConclusionsThe Trendelenburg position for lower abdominal surgery and reverse Trendelenburg with flexing of the legs at the hips for upper abdominal surgery effectively improved the workspace in obese patients, even with full muscle relaxation.