Navigation bronchoscopy: A new tool for pulmonary infections.

Infections remain a common cause of lung nodules, masses, and cavities. Safe tissue sampling is required to establish a diagnosis, differentiate between malignant and infectious causes, and provide microbiological material for characterization and sensitivity analysis. Tissue samples could be obtained bronchoscopically, percutaneously, or through surgical biopsy. Among these, bronchoscopy is the safest by avoiding the complications of pleural and chest wall puncture including pneumothorax, pain, pleural contamination and empyema, and hemothorax. However, the diagnostic yield with conventional bronchoscopy for small, peripheral lesions is poor. Electromagnetic navigation bronchoscopy (ENB) is a technique where the bronchoscope and working channel are guided through the bronchial tree to accurately reach a peripheral lesion. It dramatically improves on the diagnostic yield of peripheral lesions especially of small lesions, and its role has developed beyond diagnosis to treatment enablement and to direct therapy. Its role in infection is less defined, but it has value especially in the diagnosis of fungal and mycobacterial infections and in cavitating lesions. This review will explore what electromagnetic navigation bronchoscopy is, its use in diagnosis and therapy, and its role in the management of pulmonary infections. The potential for local therapy delivery for infection is also discussed.

Transbronchial Microwave Ablation of Peripheral Lung Tumors: The NAVABLATE Study.

BACKGROUND: Image-guided thermal ablation is a minimally invasive local therapy for lung malignancies. NAVABLATE characterized the safety and performance of transbronchial microwave ablation (MWA) in the lung. METHODS: The prospective, single-arm, 2-center NAVABLATE study (NCT03569111) evaluated transbronchial MWA in patients with histologically confirmed lung malignancies ≤30 mm in maximum diameter who were not candidates for, or who declined, both surgery and stereotactic body radiation therapy. Ablation of 1 nodule was allowed per subject. The nodule was reached with electromagnetic navigation bronchoscopy. Cone-beam computed tomography was used to verify the ablation catheter position and to evaluate the ablation zone postprocedure. The primary end point was composite adverse events related to the transbronchial MWA device through 1-month follow-up. Secondary end points included technical success (nodule reached and ablated according to the study protocol) and technique efficacy (satisfactory ablation based on 1-month follow-up imaging). RESULTS: Thirty subjects (30 nodules; 66.7% primary lung, 33.3% oligometastatic) were enrolled from February 2019 to September 2020. The pre-procedure median nodule size was 12.5 mm (range 5 to 27 mm). Procedure-day technical success was 100% (30/30), with a mean ablative margin of 9.9±2.7 mm. One-month imaging showed 100% (30/30) technique efficacy. The composite adverse event rate related to the transbronchial MWA device through 1-month follow-up was 3.3% (1 subject, mild hemoptysis). No deaths or pneumothoraces occurred. Four subjects (13.3%) experienced grade 3 complications; none had grade 4 or 5. CONCLUSION: Transbronchial microwave ablation is an alternative treatment modality for malignant lung nodules ≤30 mm. There were no deaths or pneumothorax. In all, 13.3% of patients developed grade 3 or above complications.

Towards an optimization of bronchoscopic approaches to the diagnosis and treatment of the pulmonary nodules: a review.

The last several years have seen substantive improvements and innovation with respect to bronchoscopic approaches to the indeterminate pulmonary nodule both diagnostically and therapeutically. Indeed, these advances have only accelerated over the last year or two and extend across multiple domains and include improvements in imaging technologies and techniques, approaches and tools to access different areas of the lung, tools to acquire tissue as well as tools and methods to ablate tissue. Needless to say, there are a variety of different approaches in terms of how these issues are being solved along with differing levels of technology and infrastructure commitments necessary to utilize these various tools, with some of these approaches being farther along than others. This article reviews some of these recent advances in the domains of advanced imaging, approaches to accessing various parts of the lung, tools designed to acquire tissue, robotic endoscopy platforms, new approaches to tissue ablation as well as potential additions to these areas that are on the horizon.

Surgical trauma and immune functional changes following major lung resection.

Video-assisted thoracic surgery (VATS) has evolved greatly over the last two decades. VATS major lung resection for early stage non-small cell lung carcinoma (NSCLC) has been shown to result in less postoperative pain, less pulmonary dysfunction postoperatively, shorter hospital stay, and better patient tolerance to adjuvant chemotherapy compared with patients who underwent thoracotomy. Several recent studies have even reported improved long-term survival in those who underwent VATS major lung resection for early stage NSCLC when compared with open technique. Interestingly, the immune status and autologous tumor killing ability of lung cancer patients have previously been associated with long-term survival. VATS major lung resection can result in an attenuated postoperative inflammatory response. Furthermore, the minimal invasive approach better preserve patients' postoperative immune function, leading to higher circulating natural killer and T cells numbers, T cell oxidative activity, and levels of immunochemokines such as insulin growth factor binding protein 3 following VATS compared with thoracotomy. Apart from host immunity, the angiogenic environment following surgery may also have a role in determining cancer recurrence and possibly survival. Whether differences in immunological and biochemical mediators contribute significantly towards improved clinical outcomes following VATS major lung resection for lung cancer remains to be further investigated. Future studies will also need to address whether the reduced access trauma from advanced thoracic surgical techniques, such as single-port VATS, can further attenuate the postoperative inflammatory response.

Does repeat thymectomy improve symptoms in patients with refractory myasthenia gravis?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Does repeat thymectomy improve symptoms in patients with refractory myasthenia gravis after thymectomy? A total of 189 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The outcome measures included operative mortality and morbidity, as well as long-term remission rate. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All the studies were small (4-21 patients), retrospective, single institutional case series. There was considerable heterogeneity in the studies. The interval between the first and second operation ranged from less than a year to over 10 years. The operative approach of the initial operation included transcervical, trans-sternal and substernal approaches. The maximal medical therapy received by the patients prior to reoperation varied from anticholinesterase alone to cytotoxic therapy and regular plasmapheresis. The severity of symptoms ranged from Osserman Class IIa to V. The operative approach to re-thymectomy included resternotomy, thoracoscopy and a combination of both. There was no perioperative mortality. One study reported injury to the innominate vein at resternotomy in 3 (14.3%) patients. One study reported myasthenic crisis in 2 patients in the postoperative period. Only one study reported complete remission in 2 patients. In general, however, 52-95% of patients reported some improvement. There was no consistent, objective measure of improvement in these studies. We conclude that repeat thymectomy for patients with refractory myasthenia gravis after previous thymectomy is safe especially for patients whose first procedure was transcervical. Complete remissions are rare but, in these small series, 60-70% of patients report improvement. Clinical improvement appears to be associated with the presence of residual thymic tissue at the second operation, but these cannot be reliably identified on preoperative imaging. Patient selection remains driven by symptoms.

Defeating the pores of Kohn.

In the treatment of emphysema with an endobronchial valve, entire lobar treatment is important in achieving adequate atelectasis. This case illustrates that without treatment of the entire lobe, it can fail to collapse even after several years, leading to treatment failure. Intralobar collateral ventilation through the pores of Kohn is demonstrated in this case, as endobronchial valve blockage of the remaining patent anterior segment resulted in the desired atelectasis and significant improvements in pulmonary function.

The effects of increased provision of thoracic surgical specialists on the variation in lung cancer resection rate in England.

INTRODUCTION: There is a wide variation in the lung cancer resection rate in England. We assessed the effect of the regional provision of thoracic surgery service on the variation in lung cancer resection rate. METHODS: A retrospective observational study correlating National Lung Cancer Audit data with thoracic surgery workforce data was performed to review the lung cancer resection rate in England in 2008 and 2009. RESULTS: In 2008, there was a sixfold variation in resection rate, with a higher resection rate in hospitals where surgeons were based (base hospitals) than in peripheral hospitals (20.0% versus 11.6%, p < 0.001). The resection rate was also higher in cancer networks, which were served by two or more specialist thoracic surgeons (14.6% versus 12.7%, p = 0.028), and where surgeons were present in more than two-thirds of the lung cancer multidisciplinary team meetings (14.4% versus 12.0%, p = 0.046). In 2009, the overall resection rate increased from 14.5% to 18.4%. Four units increased their number of specialist thoracic surgeons and had a significantly higher increase in resection rate than units without expansion (relative rise 66.3% versus 19.2%; p = 0.022). CONCLUSIONS: The large variation in the resection rate seems, in part, to be related to the local availability of specialist thoracic surgeons. The greatest improvement in the resection rate was in units with expansion of specialist thoracic surgeons. We suggest the expansion of specialist thoracic surgeons will improve the resection rate and thereby the overall survival of lung cancer in England. This has significant implications for the future of training in cardiothoracic surgery and organization of cancer services.

Chronic dissection and aneurysmal dilatation of a BioValsalva conduit.

The BioValsalva (Vascutek Terumo, Renfrewshire, Scotland, UK) conduit is the first commercially available prefabricated bioprosthetic aortic valved conduit. We present a case of chronic dissection of a BioValsalva valved conduit presenting as a 7.5-cm aortic root aneurysm 1 year after a Bentall operation. Intraoperatively, the conduit was found to have dissected from the annulus upward, and the coronary buttons were avulsed from the inner layers while remaining attached to the outer layer. Both the outer layer and the coronary buttons were grossly dilatated.

Lung cancer surgery in the breathless patient--the benefits of avoiding the gold standard.

OBJECTIVE: Lung cancer resection in breathless patients with severe chronic obstructive pulmonary disease (COPD) remains controversial. Whilst open lobectomy remains the gold standard, alternative approaches have been described. We undertook a retrospective, observational study to compare the outcomes of a tailored strategy combining video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy against open lobectomy in these patients. METHOD: Clinical outcomes were studied in 84 consecutive patients (male:female ratio was 56:28, mean age 69.0 years, median preoperative-forced expiratory volume in 1s (FEV(1)) 41%) with a predicted-postoperative FEV(1) < or = 40% (median 32.8% and range 14-40%) who underwent anatomical lung resection for lung cancer. The control group consisted of 35 patients who underwent open lobectomy. The study group comprised 27 patients who underwent anatomical segmentectomy, 18 who underwent VATS lobectomy and four who underwent VATS segmentectomy. RESULTS: There were no significant inter-group differences in age (p=0.87), gender (p=0.49), preoperative FEV(1) (p=0.30) or cardiac co-morbidities (p=0.78). There were more upper lobe resections in the control group (51% vs 94%, p<0.0001). Tumour size tended to be smaller in the study group (p=0.052). There were also more incidences of stage I cancers in the study group (90% vs 71%, p=0.043). The median length of hospital stay was shorter in the study group (8 vs 12 days, p=0.054). There was no significant difference in either in-hospital mortality (8% vs 14%, p=0.48) or recurrence rate (26% vs 20%, p=0.60). However, unadjusted survival was significantly longer in the study group (median survival 54 months vs 20 months, 5-year survival 42% vs 18%, p=0.03). The survival benefit of this group remained significant in multivariate analyses (adjusted survival hazard ratio (HR) 2.39, 95% confidence interval (CI): 1.30-4.39, p=0.005). A subgroup analysis on only uncomplicated stage I cancers found a similarly worse outcome in the control group (p=0.002). After segregating surgical approach and the extent of resection, the VATS approach was identified as the critical factor conferring survival advantage to the study group (hazard ratio (HR) 2.78, 95% CI: 1.21-6.37, p=0.016). CONCLUSIONS: Despite a tailored approach to patients with severe pulmonary dysfunction, there was still significant disparity in survival between groups. Patients who underwent open lobectomy have a worse outcome despite adjusting for confounders. This survival benefit was driven by thoracotomy avoidance through VATS resection. The use of operative techniques to reduce chest-wall dysfunction should be considered in the breathless patient.

A cervical approach to investigating pleural disease.

We describe a modern cervical approach to the pleural space using video-mediastinoscopy, which allows both mediastinoscopy and pleuroscopy to be performed simultaneously. Mediastinoscopy is carried out with lymph node sampling, and the pleura are exposed and the pleural cavity is entered under direct vision. A thoracoscope is admitted into the pleural space, where lavage, biopsy, and pleurodesis can be carried out. Fifteen patients underwent mediastino-pleuroscopy to investigate pleural effusion and stage malignancy. One patient underwent bilateral pleuroscopy through a single cervical approach. There were no mortalities and the mean postoperative stay was 2.4 days. Mediastino-pleuroscopy is safe, uses a small incision, is well tolerated, and allows access to both pleura and the mediastinum.

Preassembled stentless valved-conduit for the replacement of the ascending aorta and aortic root.

Here we report the early clinical results of a new preassembled stentless valved-conduit incorporating artificial sinuses of Valsalva (BioValsalva). This new composite conduit incorporates a stentless porcine aortic valve (Elan, Vascutek Terumo, UK) suspended within a triple-layered vascular conduit (Triplex, Vascutek Terumo, UK) constructed with sinuses of Valsalva. Between December 2006 and January 2008, 17 patients with the mean age of 65 years underwent aortic valve, root and ascending aorta replacement with the BioValsalva valved-conduit. There was no perioperative mortality. There were no myocardial infarctions, cardiac failure or cerebrovascular events. Mean cardiopulmonary bypass time was 156+/-56 min and ischemic time was 112+/-33 min. Eight patients required deep hypothermic circulatory arrest for additional distal ascending aorta replacement. Mean mediastinal drainage was 499+/-262 ml. Postoperative transthoracic echocardiography and CT-scans of the aorta in all patients before discharge demonstrated well-functioning prosthetic aortic valves with small residual mean gradients, no regurgitation, and the presence of sinuses of Valsalva. In conclusion, the novel prefabricated, composite stentless valved-conduit BioValsalva possesses excellent hemodynamic performance and can be implanted with low morbidity. In addition, the conduit material has good hemostatic properties which reduced bleeding, and is easy to implant with a variety of surgical techniques.

Replacement of the ascending aorta, aortic root, and valve with a novel stentless valved conduit.

PURPOSE: Biologic valved-conduit grafts avoid the need for anticoagulation and can exploit the excellent hemodynamic performance of stentless valves. Incorporation of sinuses of Valsalva into the neoaortic root can improve the function of the stentless valves. DESCRIPTION: Here we present a novel prefabricated stentless valved conduit incorporating sinuses of Valsalva and describe the technique of implantation. The BioValsalva (Vascutek Terumo, Renfrewshire, Scotland) valved conduit incorporates a stentless porcine aortic valve (Elan; Vascutek Terumo) suspended within a triple-layered vascular conduit (Triplex; Vascutek Terumo) constructed with sinuses of Valsalva. EVALUATION: The BioValsalva valved conduit was used in 12 patients with aortic regurgitation due to annuloaortic ectasia unsuitable for aortic valve repair and concomitant ascending aorta aneurysm, with no deaths and excellent functioned result. CONCLUSIONS: The prefabricated, composite, stentless valved conduit is composed of material that is hemostatic and reduces bleeding. It is easy to implant, with a short ischemic time, and lends itself well to a variety of insertion techniques.

Iron supplementation for postoperative anaemia following major paediatric orthopaedic surgery.

INTRODUCTION: There is increasing evidence that the anaemia of surgery is not iron deficient and is, therefore, unresponsive to iron supplementation. Oral iron is best avoided postoperatively, particularly in children, due to its dose-dependent side effects. We undertook a national survey of major paediatric orthopaedic surgical units in the UK to investigate the current management of postoperative anaemia with particular reference to iron supplementation. MATERIALS AND METHODS: Middle-grade doctors and charge nurses at 23 major paediatric orthopaedic units in the UK were contacted by telephone and a structured questionnaire was used to determine the management of postoperative anaemia in major hip, pelvic and spinal surgery. RESULTS: Only one (4.3%) of the units surveyed had a formally established protocol for the management of postoperative anaemia. Only 10 out of 23 units (43.5%) did not routinely prescribe iron postoperatively. Of the remaining units, 11 commenced iron based on the postoperative haemoglobin level while only 2 used iron supplementation after investigation of serum haematinics for iron deficiency. One unit used erythropoietin in the treatment of postoperative anaemia. CONCLUSIONS: Iron supplementation continues to be used in major paediatric orthopaedic surgery in the treatment of postoperative anaemia in the absence of iron deficiency. Given the current available evidence, we call for an end to the practice of routine iron supplementation for postoperative anaemia following major paediatric orthopaedic surgery in the UK.