The Use of Polyvinyl Alcohol Sponge and Cyanoacrylate Glue in the Treatment of Large and Chronic Bronchopleural Fistulae following Lung Cancer Resection.

BACKGROUND: Bronchopleural fistulae represent a relatively rare complication of pulmonary resection. For inoperable patients, several endoscopic procedures have been described. In the presence of large and chronic bronchopleural fistulae, persistent air leaks require a surgical therapy, while endoscopic airway stent represents a useful palliative treatment. OBJECTIVE: We describe the successful closure of large and chronic bronchopleural fistulae using an expandable polyvinyl alcohol (PVA) sponge and cyanoacrylate glue. METHODS: In all patients, a rigid bronchoscope was used to insert a small cylinder of PVA sponge within the fistula. After releasing the patch, cyanoacrylate glue was applied directly on the PVA sponge using a channel catheter. This methodology induces an expansion of the clot and the closure of the air leak. The long-term outcome of treatment was checked by flexible bronchoscopy once every month for 3 months and every 6 months until 5 years. RESULTS: We performed endoscopic treatment in 7 consecutive patients with bronchopleural fistula ranging from 4 to 8 mm. In 6 of 7 patients, the bronchial stump was the site of the fistula. In 1 patient, the fistula was visualized on the right wall of the distal trachea. A temporary complete occlusion of the fistula was achieved in 7 of 7 patients and a definitive result in 5 of 7 patients. CONCLUSIONS: The use of an expandable PVA sponge and cyanoacrylate glue is an available strategy for endobronchial closure of bronchopleural fistulae.

Post-intubation tracheal lacerations: Risk-stratification and treatment protocol according to morphological classification.

Background: Post-intubation tracheal laceration (PITL) is a rare condition (0.005% of intubations). The treatment of choice has traditionally been surgical repair. Following our first report in 2010 of treatment protocol tailored to a risk-stratified morphological classification there is now clear evidence that conservative therapy represents the gold standard in the majority of patients. In this paper we aim to validate our risk-stratified treatment protocol through the largest ever reported series of patients. Methods: This retrospective analysis is based on a prospectively collected series (2003-2020) of 62 patients with PITL, staged and treated according to our revised morphological classification. Results: Fifty-five patients with Level I (#8), II (#36) and IIIA (#11) PITL were successfully treated conservatively. Six patients with Level IIIB injury and 1 patient with Level IV underwent a surgical repair of the trachea. No mortality was reported. Bronchoscopy confirmed complete healing in all patients by day 30. Statistical analysis showed age only to be a risk factor for PITL severity. Conclusions: Our previously proposed risk-stratified morphological classification has been validated as the major tool for defining the type of treatment in PITL.

Role of Transbronchial Needle Core Biopsy in the Diagnosis of Mediastinal Diseases: Experience With an Innovative Endoscopic Technique Using a Rigid Tru-Cut Needle.

BACKGROUND: Enlarged lymph nodes or mediastinal masses diagnosed by computed tomographic scan before the advent of bronchoscopic procedures (TBNA or EBUS) were usually investigated using a thoracic surgical approach. In this paper, we report the experience with the use of a modified rigid tru-cut needle in the bioptical approach to mediastinal masses; to determine whether it could be considered a valid alternative to surgery, we investigated the diagnostic accuracy of this new endoscopic technique. METHODS: A total of 156 selected patients with radiographic evidence of lymphadenopathy or mediastinal masses (subcarinal and paratracheal with a short-axis diameter >3 cm) were studied in our center by rigid bronchoscopy using a 18-G tru-cut needle to obtain a core biopsy of the lesion. RESULTS: In 140 of 156 cases (89.7%), a histologically correct diagnosis was reached without perioperative or postoperative complications. A total of 114 (81.4%) malignant and 26 (18.6%) benign lesions were diagnosed avoiding further invasive surgical approach. CONCLUSIONS: Our results confirm that, in selected cases, transbronchial rigid core biopsy could be considered a safe and valid alternative technique to more invasive surgical approach in the diagnosis of mediastinal diseases.

The technique of endoscopic airway tumor treatment.

More than half of primary lung cancers are not resectable at diagnosis and 40% of deaths may be secondary to loco-regional disease. Many of these patients suffer from symptoms related to airways obstruction. Indications for therapeutic endoscopic treatment are palliation of dyspnea and other obstructive symptoms in advanced cancerous lesions and cure of early lung cancer. Bronchoscopic management is also indicated for all those patients suffering from benign or minimally invasive neoplasm who are not suitable for surgery due to their clinical conditions. Clinicians should select cases, evaluating tumor features (size, location) and patient characteristics (age, lung function impairment) to choose the most appropriate endoscopic technique. Laser therapy, electrocautery, cryotherapy and stenting are well-described techniques for the palliation of symptoms due to airway involvement and local treatment of endobronchial lesions. Newer technologies, with an established role in clinical practice, are endobronchial ultrasound (EBUS), autofluorescence bronchoscopy (AFB), and narrow band imaging (NBI). Other techniques, such as endobronchial intra-tumoral chemotherapy (EITC), EBUS-guided-transbronchial needle injection or bronchoscopy-guided radiofrequency ablation (RFA), are in development for the use within the airways. These endobronchial interventions are important adjuncts in the multimodality management of lung cancer and should become standard considerations in the management of patients with advanced lung cancer, benign or otherwise not approachable central airway lesions. We aimed at revising several endobronchial treatment modalities that can augment standard antitumor therapies for advanced lung cancer, including rigid and flexible bronchoscopy, laser therapy, endobronchial prosthesis, and photodynamic therapy (PDT).

A new technique for treatment of tracheal stenosis.

We show the use of a new endoscopic drill for the management of web-like tracheal stenosis. Our device creates radial holes within stenosis that facilitate the use of scissors for cutting the scar tissue and the subsequent mechanical dilatation.

Endoscopic hand drill for management of tracheal stenosis.

We propose the use of a new endoscopic drill for management of web-like tracheal stenosis. Our device allows creating radial holes within stenosis that facilitates the use of the scissors for cutting the  scar and the subsequent mechanical dilatation.

The red blood cell as a biosensor for monitoring oxidative imbalance in chronic obstructive pulmonary disease: an ex vivo and in vitro study.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity in Western countries. The increased oxidative stress, caused by the release of reactive oxygen and nitrogen species (ROS/RNS) from inflammatory airways cells, contributes to the pathogenesis of the disease. The aim of the present study was to evaluate (a) whether the oxidative imbalance can lead to specific alterations of red blood cells (RBCs) from stable COPD patients; (b) whether treatment with N-acetyl-cysteine (NAC), in widespread use as mucolytic agent in clinical practice, can counteract these effects; and (c) whether an in vitro model represented by the exposure of RBC to ROS/RNS could mimic the in vivo situation. The results obtained clearly indicated that the RBC integrity and function are similarly altered in COPD patients and in ROS/RNS in vitro-treated samples and that NAC administration was capable of counteracting RBC oxidative modifications both in vivo, as detected by clinical and laboratory evaluations, and in vitro. Altogether these results point to RBC oxidative modifications as valuable bioindicators in the clinical management of COPD and indicate that in vitro RBC exposure to ROS/RNS as a useful tool in experimental studies aimed at the comprehension of the pathogenic mechanisms of the redox-associated diseases.

Mediastinal bronchogenic cyst's recurrence treated with EBUS-FNA with a long-term follow-up.

Bronchogenic cysts are congenital abnormalities generally mediastinal and are frequently detected incidentally. We report a case of a symptomatic mediastinal cyst treated previously by video-assisted thoracoscopy (VATS) but complicated by pericystic adhesions. The subsequent incomplete excision led, after 8 months, to a cyst's recurrence that was accurately drained by endobronchial ultrasonography-guided fine needle aspiration (EBUS-FNA), with no new regrowth after 18 months. We hypothesized that the support of a high-definition diagnostic tool (EBUS) improved the FNA ability to make a deep and complete aspiration of the cyst. The usefulness of FNA in bronchogenic cyst's treatment is underestimated. Our experience is an attempt to encourage the use of EBUS-FNA as a new therapeutic option in the management of bronchogenic cyst.

A new endoscopic hand drill for management of tracheal stenosis.

Tracheal resection and primary anastomosis is the treatment of choice for the management of benign tracheal stenoses. Rigid endoscopy with laser-assisted mechanical dilatation is an alternative to surgery and helps to improve symptoms and quality of life in patients unfit for surgery. Here, we describe the treatment of a simple web-like stenosis, using a new endoscopic hand drill that was assembled by sharpening the blunt tip of a standard endoscopic cotton applicator. The bronchoscopy was positioned proximally to the stenotic lesion and radial holes were made at 12, 3 and 9 o'clock. The tip of instrument touched the target area of the stenotic scar. The proximal end was handily rotated and the force, applied on the instrument's tip, and the hole was drilled. Next, endoscopic scissors was placed in the drill holes and the stenotic scar was cut. Mechanical dilatation with rigid bronchoscopes of increasing diameters completed the procedure. This procedure was successfully applied in 5 patients with simple benign tracheal stenosis and unfit for surgery. No intraoperative and/or postoperative complications occurred. No recurrence of stenosis was detected after a mean follow-up of 26 ± 2 months.

Endobronchial ultrasound-driven biopsy in the diagnosis of peripheral lung lesions.

STUDY OBJECTIVES: The aim of our study was to compare the diagnostic yield of two bronchoscopic procedures: endobronchial ultrasound-driven transbronchial biopsy (EBUS-TBB) and transbronchial biopsy (TBB) in peripheral pulmonary lesions. DESIGN: Prospective, randomized, blinded study. SETTING: University Hospital of Rome, Italy. PATIENTS AND METHODS: We examined 799 patients with peripheral lung lesions using bronchoscopy. Patients who could undergo a complete clinical diagnostic follow-up (n = 293) were enrolled in the study and randomly assigned to EBUS-TBB or TBB. We performed these two procedures on 221 patients (97 EBUS-TBB and 124 TBB). Patients in whom biopsies were not diagnostic underwent more invasive procedures to obtain a final diagnosis, and a complete follow-up was possible in 206 patients (87 EBUS-TBB and 119 TBB). RESULTS: Lung cancer was diagnosed in 61 patients in the EBUS-TBB group and in 83 patients in the TBB group. Pulmonary diseases other than cancer were diagnosed in 26 patients and 36 patients, respectively. For patients with lung cancer, sensitivity was 0.79 in the EBUS group and 0.55 in the TBB group (p = 0.004), and accuracy was 0.85 and 0.69, respectively (p = 0.007). The analysis of a subset of patients with lesions > 3 cm showed no significant difference in diagnostic ability between the two procedures. In lesions < 3 cm, we found a considerable decline in TBB sensitivity and accuracy (0.31 and 0.50) while EBUS-TBB maintained their diagnostic yield (0.75 and 0.83) [p = 0.0002 and p = 0.001, respectively]. A similar difference was observed when we compared the sensitivity of the two procedures in lesions < 2 cm (0.23 vs 0.71, p < 0.001). CONCLUSIONS: EBUS-TBB can be an important option in the early diagnosis of peripheral lung cancer, especially in small-sized lesions and in patients who are not eligible for surgery.

The lung cancer breath signature: a comparative analysis of exhaled breath and air sampled from inside the lungs.

Results collected in more than 20 years of studies suggest a relationship between the volatile organic compounds exhaled in breath and lung cancer. However, the origin of these compounds is still not completely elucidated. In spite of the simplistic vision that cancerous tissues in lungs directly emit the volatile metabolites into the airways, some papers point out that metabolites are collected by the blood and then exchanged at the air-blood interface in the lung. To shed light on this subject we performed an experiment collecting both the breath and the air inside both the lungs with a modified bronchoscopic probe. The samples were measured with a gas chromatography-mass spectrometer (GC-MS) and an electronic nose. We found that the diagnostic capability of the electronic nose does not depend on the presence of cancer in the sampled lung, reaching in both cases an above 90% correct classification rate between cancer and non-cancer samples. On the other hand, multivariate analysis of GC-MS achieved a correct classification rate between the two lungs of only 76%. GC-MS analysis of breath and air sampled from the lungs demonstrates a substantial preservation of the VOCs pattern from inside the lung to the exhaled breath.

The Rationale for Treatment of Postresectional Bronchopleural Fistula: Analysis of 52 Patients.

BACKGROUND: Bronchopleural fistulas are a major therapeutic challenge. We have reviewed our experience to establish the best choice of treatment. METHODS: From January 2001 to December 2013, the records of 3,832 patients who underwent pulmonary anatomic resections were retrospectively reviewed. RESULTS: The overall incidence of bronchopleural fistulas was 1.4% (52 of 3,832): 1.2% after lobectomy and 4.4% after pneumonectomy. Pneumonectomy vs lobectomy, right-sided vs left-sided resection, and hand-sewn closure of the stump vs stapling showed a statistically significant correlation with fistula formation. Primary bronchoscopic treatment was performed in 35 of 52 patients (67.3%) with a fistula of less than 1 cm and with a viable stump. The remaining 17 patients (32.7%) underwent primary operation. The fistula was cured with endoscopic treatment in 80% and with operative repair in 88.2%. Cure rates were 62.5% after pneumonectomy and 86.4% after lobectomy. The cure rate with endoscopic treatment was 92.3% in very small fistulas, 71.4% in small fistulas, and 80% in intermediate fistulas. The cure rate after surgical treatment was 100% in small fistulas, 75% in intermediate fistulas, and 100% in very large fistulas. Morbidity and mortality rates were 5.8% and 3.8%, respectively. CONCLUSIONS: The bronchoscopic approach shows very promising results in all but the largest bronchopleural fistulas. Very small, small, and intermediate fistulas with a viable bronchial stump can be managed endoscopically, using mechanical abrasion, polidocanol sclerosing agent, and cyanoacrylate glue. Bronchoscopic treatment can be repeated, and if it fails, does not preclude subsequent successful surgical treatment.

[Legionnaire's pneumonia with rhabdomyolysis and acute renal failure. A case report]. / Polmonite da Legionella pneumophila complicata da insufficienza renale acuta e rabdomiolisi.

Legionella pneumophyla is the agent responsible of Legionnaire's disease. It appears as a severe pneumonia and often requires admission in Intensive Care Unit. In literature, renal failure is reported to occur in 15 percent of Legionnaire disease and this event induce a mortality over 50% of these cases. The authors describe a case of Legionnaire's pneumonia with respiratory failure, rhabdomyolysis and acute renal failure. Patient was a female, 61 yrs old, admitted to our hospital because of fever (38 degrees-38.5 degrees C), severe respiratory failure (pH = 7.49, PaCO2 = 23.1 mmHg, PaO2 = 56.7 mmHg), oliguria (< 200 ml/24 h); chest x-rays and computed tomography (TC) showed a pneumonia at right lower lobe. Among other things, in blood analysis was noted the following values: BUN = 47 mg/dl, creatinine = 2.1 mg/dl, Na+ = 133 mmol/L, Cl- = 97 mmol/L, Ca+ = 7.2 mg/dl, K+ = 5.8 mmol/L, AST = 213 U/L, ALT = 45 U/L, LDH = 1817 U/L, CPK = 16738 U/L, CPK-MB = 229 U/L, myoglobin > 4300 ng/ml., leucocyte count = 17,500/mmc (N = 92%, L = 3%, M = 5%), positive anti Legionella IgG and IgM (IgG > 1:64, IgM > 1:96), evidence of Legionella soluble antigen in the urine analysis. Therapy with clarytromicyne (500 mg b.i.d i.v.) and rifampicin (600 mg/die i.v.) was begun; computed tomography showed after six days an improvement of pulmonary lesion but, in the following days, health status and blood analysis got worse. Patient went on antibiotics and underwent haemotherapy (Hb: 8 gr/dl), haemodialysis because of acute renal failure but healthy status worse furthermore and she died on 18th days after admission. This case point out rhabdomyolysis with acute renal failure is suggestive for Legionnaire's disease and is associated with high rate of mortality.

Bronchoscopic lung volume reduction for pulmonary emphysema: preliminary experience with a new NOVATECH endobronchial silicone one-way valve.

Bronchoscopic lung volume reduction represents a new palliative technique for the treatment of severe emphysema. We report the case of a patient with severe pulmonary emphysema that was successfully treated by the placement of a new, removable, unidirectional endobronchial silicone valve.

Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment.

OBJECTIVE: Postintubation tracheobronchial lacerations (PITLs) are traditionally managed surgically. We sought to evaluate the rationale for non-surgical management of PITL. METHODS: From January 2003 to November 2008, 30 patients with PITL were observed in our institution. PITL were graded as follows: Level I - mucosal or submucosal tracheal involvement without mediastinal emphysema and without oesophageal injury; Level II - tracheal lesion up to the muscular wall with subcutaneous or mediastinal emphysema without oesophageal injury or mediastinitis; Level IIIA - complete laceration of the tracheal wall with oesophageal or mediastinal soft-tissue hernia without oesophageal injury or mediastinitis; Level IIIB - any laceration of the tracheal wall with oesophageal injury or mediastinitis. All patients with Level I, II and IIIA PITL were treated conservatively with endoscopic instillation of fibrin glue (Tissucol, Baxter Healthcare, Deerfield, MA, USA). RESULTS: All patients with Level I (n=3), II (n=24) and IIIA (n=2) PITL were successfully treated conservatively. The patient with a Level IIIB injury underwent posterolateral thoracotomy repair of the trachea. No mortality was reported. Mean hospital stay was 12.9 days. Flexible bronchoscopy at 7, 28, 90 and 180 days showed no abnormalities. Complete healing was attained in all patients by day 28. CONCLUSIONS: Level I or II PITL should be managed non-surgically. When adequate respiratory status is present, Level IIIA PITL can be managed conservatively in selected institutions only, because these injuries are high-risk injuries. Any PITL associated with injury involving the oesophagus or with mediastinitis (Level IIIB) must be treated as soon as possible by surgery.

Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up.

OBJECTIVE: Interventional bronchoscopy is one of the modalities for palliation and definitive treatment of benign tracheal stenosis. There is however no general agreement on the management of this disease. Aim of this work is to define, in the largest group of patients presented in the literature, what types of tracheal stenosis are amenable to definitive treatment by interventional endoscopy. METHODS: From January 1996 to June 2006 209 consecutive patients (105 men, 104 women) with benign tracheal stenosis were referred to our center. Etiology included 167 post-intubation and 34 cases of post-tracheostomy stenoses, 8 cases of other diseases. The lesions were classified into two groups: simple and complex. All but nine patients underwent interventional procedures (mechanical dilatation, laser photoresection and placement of a silicone stent). Two years follow-up was complete for all patients. RESULTS: Simple stenoses (n=167) were treated by 346 endoscopic procedures (mean of 2.07 per patient), 16 stents and 1 end-to-end anastomosis. Thirty-eight granulomas were treated by 59 procedures (1.56 per patient), 97 concentrical stenoses by 228 procedures (2.35 per patient) and 32 web-like lesions with 59 operative endoscopies (1.84 per patient). Overall success rate was 96%. Among the 42 complex stenoses, 9 were immediately treated by surgical resection and the remaining 33 lesions underwent 123 endoscopic procedures (3.27 per patient), with 34 stents and 1 end-to-end anastomosis subsequent to recurrence after stent removal. In this group the success rate was 69%. CONCLUSIONS: Our study shows that, after a correct classification and stratification, interventional endoscopy may have a crucial role in the treatment of tracheal stenoses. In particular, endoscopy should be considered the first choice for simple stenoses, whereas complex stenoses need a multidisciplinary approach and often require surgery.