Chinese expert consensus on interventional diagnosis and management of acquired digestive-respiratory tract fistulas (second edition).

Acquired digestive-respiratory tract fistulas occur with abnormal communication between the respiratory tract and digestive tract caused by a variety of benign or malignant diseases, leading to the alimentary canal contents in the respiratory tract. Although various departments have been actively exploring advanced fistula closure techniques, including surgical methods and multimodal therapy, some of which have gotten good clinical effects, there are few large-scale evidence-based medical data to guide clinical diagnosis and treatment. The guidelines update the etiology, classification, pathogenesis, diagnosis, and management of acquired digestive-respiratory tract fistulas. It has been proved that the implantation of the respiratory and digestive stent is the most important and best treatment for acquired digestive-respiratory tract fistulas. The guidelines conduct an in-depth review of the current evidence and introduce in detail the selection of stents, implantation methods, postoperative management and efficacy evaluation.

A simple and reliable adult uncuffed endotracheal tube for combined forceps and cryoprobe biopsy during bronchoscopy.

INTRODUCTION: Combined forceps and cryoprobe biopsy during bronchoscopy are increasingly used. However, the adult standard cuffed endotracheal tube (SCETT) is can be limited by general anaesthesia and neuromuscular blockade. An adult uncuffed endotracheal tube (UCETT) might provide simple and safe airway support in stable patients during forceps and cryoprobe biopsy under spontaneous respiration. METHODS: A retrospective review of stable patients undergoing forceps and cryoprobe biopsy was performed. They were divided into a UCETT group (N = 33) and a SCETT group (N = 27). The primary technical outcome was the successful intubation and completion of bronchoscopy. The primary safety outcome was the incidence of desaturation events. Recovery time and side effects were also recorded. RESULTS: UCETTs and SCETTs were successfully inserted, and bronchoscopic procedures were completed in all patients. Only 3/33 (9.1%) patients in the UCETT group exhibited a drop of SPO2 < 90% during the bronchoscopy, compared to 2/27 (7.4%) patients in the SCETT group (P = 0.545). Patients recovered faster in the UCETT group than those in the SCETT group. Major bleeding, laryngospasm and major arrhythmias did not occur in either group. Incidences of sinus tachycardia, incidences of vomiting, minor and moderate bleeding and premature atrial contractions were not significantly different between the two groups. Nausea occurred in 5/33 (15.2%) patients in the UCETT group, compared to 11/27 (40.7%) in the SCETT group. CONCLUSION: This study suggests that UCETT under spontaneous respiration can provide satisfactory airway support and a shorter recovery time in stable patients; thus, it may be an option to assist forceps and cryoprobe biopsy.

Biogeography of the Respiratory Tract Microbiome in Patients With Malignant Tracheal Tumors.

BACKGROUND: This study aimed to characterize the bacterial microbiota in the oral cavity (OC), throat, trachea, and distal alveoli of patients with primary malignant tracheal tumors (PMTT), including squamous cell carcinoma (SCC) and salivary gland carcinoma patients (SGC), for comparison with a matched non-malignant tracheal tumor (NMTT) group. METHODS: Patients with pathological diagnosis of PMTT and NMTT were included in this study. Saliva, throat swab (TS), trachea protected specimen brush (PSB), and bronchoalveolar lavage fluid (BALF) samples were collected for 16S rRNA gene sequencing. The composition, diversity, and distribution of the microbiota were compared among biogeographic sampling sites and patient groups. The relationship between the genera-level taxon abundance and tracheal tumor types was also investigated to screen for candidate biomarkers. FINDINGS: The most represented phyla in the four sites were Bacteroidetes, Firmicutes, Proteobacteria, and Fusobacteria. In SCC patients, the relative abundance of Bacteroidetes and Firmicutes gradually decreased with increasing depth into the respiratory tract, while the relative abundance of Proteobacteria gradually increased. Bacterial communities at the four biogeographic sites formed two distinct clusters, with OC and TS samples comprising one cluster and PSB and BALF samples comprising the other group. Principal coordinate analysis showed that trachea microbiota in SCC patients were distinct from that of SGC or NMTT patients. In the trachea, AUCs generated by Prevotella and Alloprevotella showed that the abundance of these genera could distinguish SCC patients from both NMTT and SGC patients. INTERPRETATION: The structure of respiratory tract microbiota in PMTT patients is related to tumor type. Certain bacteria could potentially serve as markers of SCC, although verification with large-sample studies is necessary.

Bronchial arterial embolization may reduce the risk of severe bleeding in central airway obstruction due to renal cell carcinomas during bronchoscopic procedures.

BACKGROUND: Hemorrhage is a life-threatening complication during bronchoscopic intervention in patients with central airway obstruction (CAO) due to metastatic renal cell carcinoma (RCC). Whether pre-bronchoscopic bronchial arterial embolization (BAE) can reduce the risk of severe bleeding in CAO patients due to metastatic RCC remains unclear. METHODS: A total of 31 CAO patients due to metastatic RCC were included retrospectively and divided into a BAE group (receiving pre-bronchoscopic BAE) and non-BAE group in this study. Based on computed tomography (CT) and bronchoscopic findings, tumor debulking was used to reconstruct the airway during interventional bronchoscopy. The primary outcome was the incidence of severe bleeding during bronchoscopic procedures. Bleeding-related complications, Karnofsky performance score (KPS) and dyspnea score were also analyzed over a 1-month observation period. RESULTS: There were no significant differences between the two groups in baseline characteristics, including patients' features, tumor morphology under CT scannings, tumor site, and obstruction degree under bronchoscopic examination. Procedure-related bleeding occurred in all 31 patients. Pre-bronchoscopic BAE significantly reduced the incidence of moderate and major bleeding when compared with that in the non-BAE group. The incidence of poor visualization and hypoxia was also reduced significantly in the BAE group. There was no significant difference in KPS and dyspnea score between the BAE and non-BAE groups at 1 month follow up. CONCLUSION: Pre-bronchoscopic BAE might be a feasible option to reduce the risk of severe bleeding for CAO patients due to metastatic RCC during bronchoscopic intervention. Interventional bronchoscopy was a safe and effective procedure for CAO due to metastatic RCC.The reviews of this paper are available via the supplemental material section.

Single application of airway stents in thoracogastric-airway fistula: results and prognostic factors for its healing.

BACKGROUND: Thoracogastric-airway fistula (TGAF) post-thoracic surgery is a rare and challenging complication for esophagectomy. The aim of this study was to explore the effectiveness of airway stenting for TGAF patients and find related factors coupled with healing of fistula. METHODS: This is a retrospective study involving patients with TGAF who were treated with airway stentings. Based on different TGAF locations and sizes on chest computed tomography, covered metallic or silicon airway stents were implanted to cover orifices under interventional bronchoscopy. TGAF healing was defined as the primary outcome, and complete sealing of TGAF as the second outcome. The predictors for TGAF healing were analyzed in univariate and multivariate analysis. RESULTS: A total of 58 TGAF patients were included, of whom 7 received straight covered metallic stents, 5 straight silicon stents, 3 L-shaped covered metallic stents, 21 large Y-shaped covered metallic stents, 17 large Y-shaped silicon stents, and 5 with Y-shaped covered metallic stents. Healing was achieved in 20 (34.5%) patients, and complete sealing in 45 (77.6%) patients. There were no significant differences in healing rate and complete sealing rate between patients receiving metallic stents and those with silicon stents. In univariate analysis, lacking a previous history of radiotherapy or chemotherapy, nonmalignant fistulas, small fistulas, and shorter postesophagectomy duration were found associated with a higher rate of TGAF healing. Only shorter postesophagectomy duration was associated with TGAF healing in multivariate analysis. CONCLUSIONS: Both silicon and covered metallic airway stenting are effective methods to close TGAF. A shorter postesophagectomy period may predict better TGAF healing. The reviews of this paper are available via the supplemental material section.

Chinese expert consensus on diagnosis and management of acquired respiratory-digestive tract fistulas.

Acquired respiratory-digestive tract fistulas occur with abnormal communication between the airways and digestive tract, causing the interflow of gas and liquid. Despite advances in surgical methods and the development of multimodal therapy in recent years, patients with acquired respiratory-digestive tract fistulas continue to exhibit unfavorable clinical outcomes. Therefore, in order to guide clinical practice in China, the Respiratory and Cancer Intervention Alliance of the Beijing Health Promotion Association organized a group of experienced experts in the field to develop this consensus document. Based on a study of clinical application and expert experience in the diagnosis and management of acquired respiratory-digestive tract fistulas at home and abroad, an Expert Consensus was developed. The panelists recruited comprised experts in pulmonology, oncology, thoracic surgery, interventional radiology, and gastroenterology. PubMed, Chinese Biology Abstract, Chinese Academic Journal, and Wanfang databases were used to identify relevant articles. The guidelines address etiology, classification, pathogenesis, diagnosis and management of acquired respiratory-digestive tract fistulas. The statements on treatment focus on the indications for different procedures, technical aspects, and preprocedural, post-procedural and complication management. The proposed guidelines for the diagnosis and management of acquired respiratory-digestive tract fistulas are the first to be published by Chinese experts. These guidelines provide an in-depth review of the current evidence and standard of diagnosis and management.

[Interventional Bronchoscopies for the Treatment of 112 Cases with Complex Malignant Central Airway Diseases Involved in Bifurcation].

BACKGROUND: It is very difficult to deal with the comprehensive central airway diseases, especially the malignant airway obstruction. The aim of this study is to explore the clinical effects of multiple interventional bronchoscopies for the treatment of 112 cases with comprehensive malignant central airway diseases so as to evaluate the clinical applications of thermoablation and cryosurgery. METHODS: The 112 cases with malignant airway diseases retrospectively reviewed for bronchoscopic interventions performed in more than two lesions of carina and/or bifurcation. The age was from 22 to 90 years, which including 55 cases with squamous carcinoma (SQ), 16 adenocarcinoma (AD), 15 adenocystic carcinoma (ACC), 10 metastasis tumor (MT), 8 small cell lung carcinoma (SCLC) and 8 mixed carcinoma (MC). All bronchoscopic interventions such as argon plasma coagulation (APC), cryosurgery, electronic snare and stenting were performed under rigid bronchoscopy combined with electric bronchoscopy in general anesthesia. RESULTS: The 460 bronchoscopic procedures were successfully performed in 112 cases. Cryosurgery and APC were the most used in every group. Stent was more common in patients with MT, balloon dilation was more common in patients with ACC and AD. Electric snare and radioactive seeds implantation were frequently used in cases with SCLC. Trachea stricture is more severe in MT than that in others, while bronchus stricture is more severe than that of trachea in SQ and ACC group. Karnofsky performance score (KPS) is lower and shortness of breath score (SBS) is higher in MC, MT and SCLC group. Trachea and bronchus stricture is improved after comprehensive treatment in 5 groups except of mixed group. KPS increased and SS decreased significantly in 5 groups except of adenocarcinoma. In follow-up, the overall survival time (OS) is 15 months and median survival time is 10 months, especially OS is 28.4 months in ACC and 21.7 months in AD, 8.9 months in SCLC and 7.4 months in mixed group. CONCLUSIONS: APC combination with Cryosurgery and other bronchoscopic interventions are indicated for the treatment of complex or difficult airway diseases whether they are located in trachea or bronchus. It is a safe and rapid during procedure.

Rigid bronchoscopic intervention for endobronchial metastasis of renal cell carcinoma.

BACKGROUND: Renal cell carcinoma is one of the major endobronchial metastases, and it occasionally causes life-threatening airway obstruction. Rigid bronchoscopy is useful as a palliative intervention; however, its utility for metastatic renal cell carcinoma has not been elucidated. The purpose of this study was to evaluate the safety and efficacy of rigid bronchoscopic treatment for endobronchial metastasis of renal cell carcinoma. METHODS: Among 550 patients who underwent rigid bronchoscopic intervention at a single center from January 2005 to June 2015, 9 with metastatic renal cell carcinoma were retrospectively reviewed. Procedures were performed with rigid and flexible bronchoscopes under general anesthesia. RESULTS: In total, 20 procedures were performed on 9 patients who underwent stent implantation. Bleeding was observed in 12 (60%) procedures while severe hypoxia was observed in 2 (10%). The required amount of supplemental oxygen successfully decreased after all the 10 procedures (100%) in patients who previously needed it. Median survival after the first procedure was of 260 days (range, 63-913 days). CONCLUSIONS: Rigid bronchoscopic intervention for endobronchial metastasis of renal cell carcinoma is feasible with safety and effectiveness for palliation of airway obstruction, if one prepares sufficiently for massive intraoperative bleeding.

Airway Covered Metallic Stent Based on Different Fistula Location and Size in Malignant Tracheoesophageal Fistula.

BACKGROUND: Malignant tracheoesophageal fistula (MTEF) is a devastating complication of esophageal cancer, lung cancer or other carcinoma with a shorter life-span and poor life quality. The aim of this study was to assess the effect of airway stent insertion on MTEF patients. METHODS: A total of 63 MTEF patients were included, 12 patients with lung cancer and 46 patients with esophageal cancers. Eight zones were proposed to classify various fistula locations. Airway stents were selected based on the various zones and fistula size. RESULTS: Airway stents were successfully inserted in all patients, and both airway and esophageal stents in 8 patients. Most fistula were located in locations II (18/63, 28.6%), III (22/63, 34.9%), then VII (9/63, 14.3%). The stents included 10 (15.9%) I shaped, 8 (12.7%) L shaped and 45 (71.4%) Y shaped. Different stents were placed based on different locations and sizes of fistulas. Overall, mean survival time was 163 days (2-270 days). Most symptoms relieved after stent insertion. Mean Karnofsky score jumped from 43.0 ± 10.7 before stent placement to 66.7 ± 10.8 after stent insertion (P = 0.000). Complete closure was achieved in 45 patients (71.4%), and incomplete closure and leakage were found in 18 patients. CONCLUSIONS: Airway stent insertion provides an effective approach to improve symptoms and quality of life. The choice of stent based on different fistula location and size may be a reasonable way in clinical practice.

Bronchoscopic interventions combined with percutaneous modalities for the treatment of thyroid cancers with airway invasion.

This study was designed to explore the effectiveness and safety of the combination of bronchoscopic interventions and percutaneous modalities in treating thyroid cancers with airway invasion. A total of 13 patients, 5 men and 8 women, were retrospectively included into this study. All patients received bronchoscope treatment. Rigid bronchoscope was used to explore, ventilate, and dilate airway obstruction for temporary control in nine patients. Tumors were scavenged by CO2 cryosurgery combined with argon plasma coagulation (APC) in 11 patients. Four covered Z-type recoverable tracheal stents were selected for four patients. All patients had good airway control and palliative respiratory symptoms following treatments. Ten patients were further treated with CT guided (125)I seed permanent implantation, and one patient was treated with argon-helium cryoablation. The median local control was 22 months (10-55 months). The follow-up period ranged from 10 to 55 months (median 22 months). Three patients (23.1%) died of local recurrence, one of whom was due to airway obstruction and poor physical condition, two of whom with bleeding from relapsed tumor. One patient (7.7%) died of acute myocardial infraction. Nine patients (69.2%) were still alive according to the last follow-up. (125)I seed implantation and argon-helium cryoablation did not induce apparent complications. The combination of bronchoscopic interventions and percutaneous modalities might be a feasible and safe method for thyroid cancer patients with airway invasion.

Application of interventional bronchoscopic therapy in eight pediatric patients with malignant airway tumors.

AIMS AND BACKGROUND: Malignant airway tumors in children have rarely been reported. We evaluated the safety and therapeutic effects of interventional bronchoscopic therapy in 8 children with malignant airway tumors. METHODS AND STUDY DESIGN: We retrospectively analyzed 8 children with malignant airway tumors diagnosed by pathology, and evaluated their clinical features, chest computer tomography findings and bronchoscopic manifestations. RESULTS: Two of the 8 pediatric patients had high-grade malignancies (lymphoma and sarcoma) and the others all had low-grade malignancies, including 2 cases with mucoepidermoid carcinoma and 4 cases with inflammatory myofibroblastic tumor. Their ages ranged from 4 to 8 years (mean, 5.7 ± 0.9). There were no specific clinical manifestations in the children, and all of them presented with various respiratory symptoms, including cough and gasping associated with hemoptysis. Chest CT indicated round intra-airway neoplasms. Obstructive pulmonary atelectasis occurred in the main bronchus of 4 patients (3 cases of the left main bronchus and 1 case of the right intermedius bronchus). All children (1 case with local anesthesia and 7 cases with general anesthesia) underwent interventional bronchoscopic therapy, including argon plasma coagulation and CO 2 cryosurgery. The success rate for the rigid procedures was 100.0% (7/7), and the cure rate after 3 months was 85.7% (6/7). A part of the tumor remained in the lung of 1 patient with inflammatory myofibroblastic tumor after bronchoscopic treatment. One patient with local anesthesia died of suffocation caused by tumor consolidation during the bronchoscopic procedure. There were no recurrences in 6 patients during the follow-up period. One recurred patient was cured at 6 months. CONCLUSIONS: There are no specific manifestations in children with malignant airway tumors. Interventional bronchoscopic therapy seems to be safe and effective for those tumors under general anesthesia.

Adiponectin and leptin levels in Chinese patients with HIV-related lipodystrophy: a 30-month prospective study.

The relationship of adipocytokine with the development of HIV-related lipodystrophy was investigated in a case-control study. Adipocytokine, lipid, and glycemic parameters were measured at every visit. Logistic regression analysis was used to assess the HIV-LD risk factors and the Spearman correlation coefficients test was used to assess the correlation between adiponectin with other metabolic variables. Most of the patients (96.3%) developed HIV-LD after month 12. Comparing the baseline adiponectin, the adiponectin concentration of the HIV-LD group rose by month 6 and began to decrease substantially by month 18; this reduction was maintained until month 30 (p < 0.05). Comparing the HIV-NLD group, the adiponectin concentration at months 18, 24, and 30 were significantly lower in the HIV-LD group. The leptin concentration of both the HIV-LD and HIV-NLD groups remained stable. Patients in the lower concentration of baseline adiponectin and greater adiponectin change rate at month 18 presented with increased odds ratio for HIV-LD. The adiponectin level had a correlation with serum triglycerides (r = -0.616, p < 0.0001), serum insulin concentration (r = -0.494, p = 0.001), and HDL-C (r = 0.673, p < 0.0001). The adiponectin concentration of HIV-LD began to decrease substantially by month 18. The lower baseline concentration of adiponectin and the greater change rate at month 18 were independent risk factors of HIV-LD. The adiponectin level had a correlation with serum triglycerides, serum insulin concentration, and HDL-C, suggesting that adiponectin may link the metabolic abnormalities and HIV-LD.

[Adipokines and highly active antiretroviral therapy related lipodystrophy: clinical study of 52 cases].

OBJECTIVE: To investigate the prevalence of glucose and lipid abnormalities in AIDS patients treated with highly active antiretroviral therapy (HAART) and difference thereof between the HIV-lipodystrophy (LD) and non-HIV-LD groups, and to compare the plasma levels of adiponectin (APN) and leptin (LEP) and their relationship to metabolic disturbance and fat redistribution in these 2 groups. METHODS: Fifty-two HIV-infected patients were divided into HIV-LD group and non-HIV-LD group according to the patients' reports and doctors' evaluation. Body composition was assessed by whole body dual-energy X-ray absorptiometry. Plasma samples were analyzed for cholesterol, triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), insulin, APN, and LEP. The prevalence of dyslipidemia and hyperinsulinemia, the difference of adipocytokine levels, and the relationship of adiponectin, leptin with lipids, insulin as well as fat mass in different body regions were analyzed between the groups. RESULTS: The prevalence rates of hypercholesterolaemia, hypertriglyceridaemia, and low HDL-C level were 17.3%, 50.0%, and 17.3% respectively. The rate of hyperinsulinemia and any kind of dyslipidemia were 25.0% and 59.6%. Compared with non-HIV-LD patients, HIV-LD patients had higher TG level, and lower HDL-C and APN levels. In the HIV-LD group, the APN level was correlated positively with limb/total body fat, but negatively with trunk/total body fat, and was an independent predictor of HDL-C and insulin level. However, LEP was positively correlated with the levels of total body fat, limb fat, and trunk fat in both groups. CONCLUSION: The prevalence rates of dyslipidemia and insulin resistance are high in Chinese HIV/AIDS patients receiving HAART, especially in the HIV-LD group. The APN concentration in the HIV-LD patients is closely related to fat redistribution and independently predicts the levels of HDL-C and insulin. LEP can serve as a biomarker of total body fat mass.

[A study of HIV-related lipodystrophy syndrome in 55 HIV-infected Chinese adult patients].

OBJECTIVE: To study the prevalence, clinical characteristics and risk factors of HIV-related lipodystrophy syndrome (HIV-LD) in our cohort of HIV-1 infected Chinese adults. METHODS: In a cross-sectional study, 55 HIV-infected patients were recruited from the HIV clinic of Peking Union Medical College Hospital; most of them were undergoing the first-class highly active antiretroviral therapy (HAART) of today in China. Lipoatrophy or lipohypertrophy was defined if there was concordance between the report of fat change and clinical examination of the participants. Whole body dual-energy X-ray absorptiometry (DEXA) scanning was performed. RESULTS: Prevalence of clinical body fat redistribution in the present study was 47.3%. Comparing with non-LD patients, HIV-LD patients had elder age and longer exposure to HAART (P < 0.05). HAART exposure and stavudine (d4T) usage were two independent risk factors for HIV-LD. CONCLUSIONS: HIV-related fat redistribution does exist in Chinese HIV population. Peripheral lipoatrophy occurs commonly in HIV-infected adults but is not associated with increased trunk fat. HAART exposure and especially d4T usage are independent risk factors for HIV-LD.

[Twenty-three cases of cytomegalovirus infection in acquired immunodeficiency syndrome].

OBJECTIVE: To investigate the clinical features, therapeutic approaches, outcomes and alterations of peripheral lymphocytes subsets in cytomegalovirus (CMV) infections in patients with AIDS. METHODS: Ninety-six cases of AIDS were treated in Peking Union Medical College Hospital and 23 of them had CMV infection. We analyzed the clinical features, peripheral lymphocytes subsets, outcomes, CMV pp65 antigen and/or specific anti-CMV IgM. RESULTS: In the 23 CMV patients, nonspecific symptoms including fever, cough, chest distress and diarrhea occurred in 18, 11, 9 and 8 patients, respectively. Thirteen patients had retinitis identified by ophthalmofundoscopy, 7 of them had blurred vision or floating as primary symptoms. Pneumocystis pneumonia, tuberculosis infection and other infection appeared in 18 patients. Fifteen (65.2%) of the patients had positive serum tests. The positive rates for CMV pp65 and specific anti-CMV-IgM were 43.5% and 30.4%, respectively. CD(4)(+)T cell count in CMV patients was remarkably decreased than that in non-CMV patients [14(4, 39) cells/microl vs (48(12, 128) cells/microl, P = 0.005] and the proportion of CD(8)(+)CD(38)(+)T cells in CMV patients was higher than that in non-CMV patients, whereas the difference of CD(8)(+)T cell was not statistically different between the 2 groups. CONCLUSIONS: CMV infection often occurs in advanced AIDS patients. In HIV/AIDS patients with CD(4)(+)T cell count