Electromagnetic Navigational Bronchoscopy Learning Curve Regarding Pneumothorax Rate and Diagnostic Yield.

Electromagnetic navigational bronchoscopy (ENB) has emerged as an innovative technique for diagnosing peripheral and central nodules, offering an improved diagnostic yield compared to conventional bronchoscopy with fewer complications. That being said, pneumothorax remains a frequent complication. This retrospective study conducted at Castle Hill Hospital, UK, analysed ENB procedures over four years to assess the diagnostic yield and pneumothorax rates, exploring learning curves and procedural improvements specifically focusing on the diagnostic yield and pneumothorax rate as markers of change. A total of 246 patients underwent 358 peripheral lung biopsies, revealing an overall diagnostic yield of 61.3%. The diagnostic yield increased from 58.2% in 2020-2021 to 66.0% in 2022-2023 while the pneumothorax rate decreased significantly from 9.8% to 3.4% (p = 0.021*). The majority of pneumothorax cases occurred following upper lobe procedures. The study depicts the importance of procedural experience in improving outcomes, suggesting a learning curve effect. Additionally, it emphasizes the potential for technological advancements, such as robotic assistance, to mitigate operator-dependent variability and improve reproducibility in ENB procedures. These findings contribute to optimizing diagnostic pathways for lung lesions and improving patient safety in ENB interventions.

Impact of lung cancer screening on surgical stage distribution and surgical practice: a regional analysis of patients operated in and out of a screening program.

OBJECTIVES: The aim of this study was to assess variations in surgical stage distribution in 2 centres within the same UK region. One centre was covered by an active screening program started in November 2018 and the other was not covered by screening. METHODS: Retrospective analysis of 1895 patients undergoing lung resections (2018-2022) in 2 centres. Temporal distribution was tested using Chi-squared for trends. A lowess curve was used to plot the proportion of stage 1A patients amongst those operated over the years. RESULTS: The surgical populations in the 2 centres were similar. In the screening unit (SU), we observed a 18% increase in the proportion of patients with clinical stage IA in the recent phase compared to the early phase (59% vs 50%, P = 0.004), whilst this increase was not seen in the unit without screening. This difference was attributable to an increase of cT1aN0 patients in the SU (16% vs 11%, P = 0.035) which was not observed in the other unit (10% vs 8.2%, P = 0.41). In the SU, there was also a three-fold increase in the proportion of sublobar resections performed in the recent phase compared to the early one (35% vs 12%, P < 0.001). This finding was not evident in the unit without screening. CONCLUSIONS: Lung cancer screening is associated with a higher proportion of lung cancers being detected at an earlier stage with a consequent increased practice of sublobar resections.

An analysis of long-term survival after pneumonectomy for lung cancer: A retrospective study of 20 years.

INTRODUCTION: The incidence of pneumonectomy for lung cancer in the UK is continuing to decline in the era of minimally invasive thoracic surgery totalling approximately 3.5% of lung cancer resections annually. Literature is lacking for long-term survival of pneumonectomies. This study updates our previous results. Between 1998 and 2008, 206 patients underwent pneumonectomy compared to 98 patients between 2009 and 2018. METHODS: From January 1998 until December 2018, 304 patients underwent pneumonectomy. This was a retrospective study; data was analysed for age, gender, laterality, histology and time period. RESULTS: Operative mortality was 4.3% overall which was lower than the national average of 5.8%. In the last five years, there were no in-hospital, operative or 30-day mortality. During this period, 90-day mortality was 9.2%. Left-sided pneumonectomies had significantly better overall survival (3.00 vs. 2.03 years; p = 0.0015), squamous cell carcinoma (3.23 vs. 1.54 years; p = 0.00012) as well as those aged less than 70 (2.79 vs. 2.13 years; p = 0.011). There was no significant difference in survival between gender (p = 0.48). Intervention from 1998 to 2008 had significantly greater survival compared to the latter 10 years (2.68 vs. 2.46 years; p = 0.031). The Cox model shows that laterality, age, histology and time period remain significant with multivariate testing. No patient survived after 16 years. DISCUSSION: Our updated retrospective study has built on our previous results by reinforcing the success of pneumonectomies. The incidence of pneumonectomies is likely to decrease with the deployment of nation-wide lung cancer screening in the UK due to earlier detection.

Rare presentation of pneumothorax in a young woman with underlying congenital pulmonary airway malformation.

Congenital pulmonary airway malformation (CPAM) is the most common among a rare group of congenital anomalies of the lower respiratory tract. It has variable presentation depending on its subtype and the patient's age. It may lead to respiratory distress in neonates. It can be a particularly challenging diagnosis in children born asymptomatic but present with complications later in life such as haemoptysis, recurrent chest infections, breathlessness and pneumothorax. Prenatal ultrasound, chest X-ray, CT scan and MRI are helpful in making a radiological diagnosis.A woman in her late teens presented with shortness of breath and right pleuritic chest pain. CT's chest showed a number of bullae of varying sizes on the right, including one huge bulla compressing all three lobes. She underwent lung volume reduction surgery via video-assisted thoracoscopy, and the histology specimen confirmed the diagnosis of CPAM type 1.

Detection of microplastics in human lung tissue using µFTIR spectroscopy.

Airborne microplastics (MPs) have been sampled globally, and their concentration is known to increase in areas of high human population and activity, especially indoors. Respiratory symptoms and disease following exposure to occupational levels of MPs within industry settings have also been reported. It remains to be seen whether MPs from the environment can be inhaled, deposited and accumulated within the human lungs. This study analysed digested human lung tissue samples (n = 13) using µFTIR spectroscopy (size limitation of 3 µm) to detect and characterise any MPs present. In total, 39 MPs were identified within 11 of the 13 lung tissue samples with an average of 1.42 ± 1.50 MP/g of tissue (expressed as 0.69 ± 0.84 MP/g after background subtraction adjustments). The MP levels within tissue samples were significantly higher than those identified within combined procedural/laboratory blanks (n = 9 MPs, with a mean ± SD of 0.53 ± 1.07, p = 0.001). Of the MPs detected, 12 polymer types were identified with polypropylene, PP (23%), polyethylene terephthalate, PET (18%) and resin (15%) the most abundant. MPs (unadjusted) were identified within all regions of the lung categorised as upper (0.80 ± 0.96 MP/g), middle/lingular (0.41 ± 0.37 MP/g), and with significantly higher levels detected in the lower (3.12 ± 1.30 MP/g) region compared with the upper (p = 0.026) and mid (p = 0.038) lung regions. After subtracting blanks, these levels became 0.23 ± 0.28, 0.33 ± 0.37 and 1.65 ± 0.88 MP/g respectively. The study demonstrates the highest level of contamination control and reports unadjusted values alongside different contamination adjustment techniques. These results support inhalation as a route of exposure for environmental MPs, and this characterisation of types and levels can now inform realistic conditions for laboratory exposure experiments, with the aim of determining health impacts.

A risk-adjusted financial model to estimate the cost of a video-assisted thoracoscopic surgery lobectomy programme.

OBJECTIVE: To develop a clinically risk-adjusted financial model to estimate the cost associated with a video-assisted thoracoscopic surgery (VATS) lobectomy programme. METHODS: Prospectively collected data of 236 VATS lobectomy patients (August 2012-December 2013) were analysed retrospectively. Fixed and variable intraoperative and postoperative costs were retrieved from the Hospital Accounting Department. Baseline and surgical variables were tested for a possible association with total cost using a multivariable linear regression and bootstrap analyses. Costs were calculated in GBP and expressed in Euros (EUR:GBP exchange rate 1.4). RESULTS: The average total cost of a VATS lobectomy was €11 368 (range €6992-€62 535). Average intraoperative (including surgical and anaesthetic time, overhead, disposable materials) and postoperative costs [including ward stay, high dependency unit (HDU) or intensive care unit (ICU) and variable costs associated with management of complications] were €8226 (range €5656-€13 296) and €3029 (range €529-€51 970), respectively. The following variables remained reliably associated with total costs after linear regression analysis and bootstrap: carbon monoxide lung diffusion capacity (DLCO) <60% predicted value (P = 0.02, bootstrap 63%) and chronic obstructive pulmonary disease (COPD; P = 0.035, bootstrap 57%). The following model was developed to estimate the total costs: 10 523 + 1894 × COPD + 2376 × DLCO < 60%. The comparison between predicted and observed costs was repeated in 1000 bootstrapped samples to verify the stability of the model. The two values were not different (P > 0.05) in 86% of the samples. A hypothetical patient with COPD and DLCO less than 60% would cost €4270 more than a patient without COPD and with higher DLCO values (€14 793 vs €10 523). CONCLUSIONS: Risk-adjusting financial data can help estimate the total cost associated with VATS lobectomy based on clinical factors. This model can be used to audit the internal financial performance of a VATS lobectomy programme for budgeting, planning and for appropriate bundled payment reimbursements.

High-risk patients and postoperative complications following video-assisted thoracic surgery lobectomy: a case-matched comparison with lower-risk counterparts†.

OBJECTIVES: To assess the postoperative incidence of major complications in high-risk patients following video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer compared with their lower risk counterparts. METHODS: A retrospective analysis on prospectively collected data of 348 consecutive patients subjected to VATS lobectomy (August 2012-September 2014) was performed. Patients were defined as high risk if one or more of the following characteristics were present: age >75 years, forced expiratory volume in 1 s (FEV1) <50%, carbon monoxide lung diffusion capacity (DLCO) <50%, history of coronary artery disease (CAD). Severity of complications was graded using the Thoracic Morbidity and Mortality (TM&M) score; major complications were defined if the TM&M score was greater than 2. The propensity score was used to match high-risk patients with their lower risk counterparts in order to minimize the influence of other confounders on outcome. The following variables were used to construct the propensity score: gender, side of operation, body mass index, American Society of Anaesthesiologists score, Eastern Cooperative Oncology Group score, Charlson's Comorbidity Index, number of functioning segments resected. RESULTS: The high-risk group consisted of 141 patients (age >75 years: 84 patients; FEV1 <50: 14 patients; DLCO <50: 25 patients; history of CAD: 37 patients). The propensity score yielded two groups of 135 patients (high-risk vs low-risk) well matched for several baseline characteristics except for a lower performance status in the higher-risk group. Compared with their low-risk counterparts, high-risk patients had a higher incidence of cardiopulmonary complications (28 cases, 21% vs 14 cases, 10%; P < 0.0001) and major cardiopulmonary complications (12 cases, 9% vs 3 cases, 2%; P < 0.0001). Postoperative stay was 3 days longer in high-risk patients (8.6 vs 5.5 days, P = 0.0031). The 30-day or in-hospital mortality rates were not different between the two groups (2 cases, 1.5% vs 3 cases, 2.2%, P = 0.93). CONCLUSIONS: The incidence of major complications after VATS lobectomy in high-risk patients is low, but not negligible. This information can be used when discussing surgical risk with the patient during preoperative counselling.

An aggregate score to predict the risk of large pleural effusion after pulmonary lobectomy.

OBJECTIVES: The volume of pleural effusion is one of the determinants of chest drain removal following pulmonary resection. Recent research suggests that values up to 400 ml/day are safe. The objective of this study was to develop an aggregate risk score to identify patients at higher risk of developing a large pleural effusion (LPE) (>400 ml/day) on postoperative day 2 (POD2) after pulmonary lobectomy. METHODS: An observational study on 229 consecutive patients was conducted prospectively in two European centres (June 2012-September 2013). All patients underwent pulmonary lobectomy for lung cancer (thoracotomy: 131, video-assisted thoracic surgery: 98) and managed by single chest tube connected to an electronic-regulated suction device. Exclusion criteria were chest wall or diaphragm resection and postoperative-assisted mechanical ventilation. To build the aggregate score, variables were initially screened by univariable analysis, and then used in stepwise logistic regression analysis (validated by bootstrap). The scoring system was developed by proportional weighing of the significant predictor estimates, and patients were grouped in classes of incremental risk according to their total score. RESULTS: The incidence of LPE on POD2 was 23% (53 of 229 patients). The independent risk factors associated with LPE on POD2 were age greater than 70 years (P = 0.01, bootstrap frequency 71%), a lower lobectomy (P = 0.03, bootstrap frequency 59%) and presence of COPD (P = 0.02, bootstrap frequency 63%). Each predictor received a weighted score of 1, and patients were grouped into three risk classes showing an incremental risk of LPE (P < 0.001): Class A (Score 0) 5 LPE in 66 patients, 7.5%; Class B (Score 1) 19 LPE in 88 patients, 22%; Class C (Score >1) 29 LPE in 75 patients, 39%. CONCLUSIONS: The aggregate score is a reliable tool for identifying high-risk patients for LPE and assists in the selection of patients that can safely proceed to chest drain removal early after surgery.

Poor awareness of symptoms of oesophageal cancer.

Oesophageal cancer presents as advanced disease; in the majority of patients the symptoms are present for many months prior to diagnosis. Dysphagia has been described as the key to an early diagnosis of oesophageal cancer. This study aims to assess the public perception of the importance of this symptom. Ninety-six patients completed a questionnaire. This evaluated patient understanding of symptoms of dysphagia compared to the finding of a breast lump, haemoptysis, chest pain and loss of weight concerning urgency, probable cause of symptoms and treatment required. Sixty-five patients (71%) would visit their GP within 24 h of finding a breast lump or suffering from haemoptysis (82%) or having chest pain (82%). Forty-seven patients (51%) who experienced dysphagia would seek medical advice after one week and further 18 (19%) after one month (P<0.0001). Only eight patients (10%) associated dysphagia with cancer compared to 53 patients (57%) with the finding of a breast lump (P<0.031). This study concludes that there is poor understanding of the main symptoms of oesophageal cancer. New health campaigns are needed if the cancer is to be detected at an earlier and potentially curable stage.