Early comparison robotic bronchoscopy versus electromagnetic navigational bronchoscopy for biopsy of pulmonary nodules in a thoracic surgery practice.

Pulmonary nodules are frequently encountered in high-risk patients. Often these require biopsy which can be challenging. We relate our experience comparing use of electromagnetic navigational bronchoscopy (ENB) to a robotic bronchoscopy system (RB). A retrospective review of patients undergoing bronchoscopic biopsy from 2015 to 2021. The timeframe overlapped with transition from ENB using Veran SPiN system to RB using Ion system by Intuitive. Patient and nodule characteristics were collected. Primary end point was overall diagnostic yield which was defined by pathologic confirmation of malignancy or benign finding. Secondary outcomes included diagnostic yield based on overall size of nodules and need for further work up and testing. 116 patients underwent ENB or RB of 134 nodules. No perioperative complications occurred. Diagnostic yield of ENB was 49.5% (41/91 nodules) versus 86.1% (37/43 nodules) for RB. Average nodule size for ENB was 2.55 cm versus 1.96 cm for RB. When divided based on size, ENB had a 30% diagnostic yield for nodules 1-2 cm (11/37 nodules, mean size 1.46 cm) and 64% yield for nodules 2-3 cm (14/22 nodules, mean size 2.38 cm). RB had an 81% yield for nodules 1-2 cm (mean size 1.41 cm) and 100% yield for nodules 2-3 cm (mean 2.3 cm). RB showed superiority over ENB in early implementation trials for biopsy of suspicious pulmonary nodules. It is a safe technology allowing for increased access to all lung fields and utilization in the thoracic surgical practice will be paramount to advancing the field.

Predictors of Success When Implementing an Electromagnetic Navigational Bronchoscopy Program.

INTRODUCTION: With the advent of lung cancer screening, lung nodules are being discovered at an increasing rate. With improvements in transbronchial biopsy technology, it is important for thoracic surgeons to be involved with diagnostic procedures. The aim of this project is to relate the thoracic surgeon experience in implementing an electromagnetic navigational bronchoscopy (ENB) program at our institution and describe the factors that led to successful navigation (the ability to position a biopsy instrument in range for biopsy) and diagnostic biopsy of nodules. METHODS: The thoracic surgery ENB program was initiated in 2014. A retrospective analysis of patients referred to thoracic surgery from 2014 to 2019 for lung nodule evaluation was performed. Patients who underwent ENB and biopsy were included. Recursive partitioning (CART) and multivariable regression analyses were used to identify predictors of successful navigation and biopsy. RESULTS: There were 73 patients who underwent ENB evaluation of 91 nodules from 2014 to 2019. There was successful navigation in 75.8% of nodules, and on multivariable analysis, bronchus sign, lesion size, and pleural distance were significant predictors of successful navigation. Of the lesions that had successful navigation, 65.2% had a diagnostic biopsy. Based on CART analysis, positive bronchus sign and lesion size ≥ 1.3 cm were most predictive of obtaining a diagnostic biopsy with a probability of 0.75. CONCLUSIONS: Nodule size, distance to the pleura, and bronchus size are independent variables of successful navigation when using ENB. However, of the lesions that were successfully reached, combined lesion size >1.3 cm and a positive bronchus sign were most predictive of obtaining a diagnostic biopsy. These factors should be considered when implementing an ENB program in a thoracic surgery practice.

A case of invasive pulmonary mucormycosis resulting from short courses of corticosteroids in a well-controlled diabetic patient.

A patient with well-controlled type 2 diabetes mellitus developed a severe pulmonary infection secondary to Rhizopus spp. after receiving short courses of corticosteroids for a respiratory tract infection. He recovered after an aggressive surgical intervention and treatment with isavuconazole. Patients on chronic corticosteroid therapy have a higher risk for pulmonary mucormycosis, but there are much fewer reports of mucormycosis occurring in patients after only short courses of steroid therapy.

Analysis of Patients Discharged From the Hospital With a Chest Tube in Place.

BACKGROUND: Persistent air leak can complicate pulmonary resection, and one management option is dismissal with a chest tube in place. This study evaluated the rate of empyema and readmission after dismissal with a chest tube. METHODS: A retrospective review of our prospective database from January 2004 to December 2013 identified 236 patients who were discharged from our institution with an indwelling chest tube and attached one-way valve for air leak. Empyema was defined by leukocytosis or fever and undrained effusion on chest roentgenogram or computed tomography. Readmission was defined as readmission for any reason. Logistic regression analyses were performed to identify risk factors for empyema or readmission. RESULTS: Median age was 67 years (range, 18 to 91 years). Median chest tube duration was 18 days (range, 6 to 90 days). Empyema occurred in 40 patients (16.9%), and 62 patients (26.3%) were readmitted. Treatment required included antibiotics alone in 45% (18 of 40), further drainage in 30% (12 of 40), fibrinolytic therapy in 12.5% (5 of 40), and operative decortication in 12.5% (5 of 40). Predictors of empyema included male sex, coronary artery disease, and peripheral vascular disease. A secondary analysis grouping patients into an earlier era (2004 to 2008) vs a later era (2009 to 2013) revealed that the use of thoracoscopy increased from 34% to 48% of lung resections and dismissal with a chest tube increased from 3.4% to 4.5% (p = 0.03). CONCLUSIONS: Dismissal with an indwelling chest tube is not without consequence, having significant risk for further complications and potential need for additional interventions.

A novel strategy to initiate a peroral endoscopic myotomy program.

OBJECTIVES: The standard of care for achalasia remains laparoscopic Heller myotomy with partial fundoplication. Peroral endoscopic myotomy (POEM) has been introduced as an alternative, but safety and long-term comparative efficacy are not yet established. We report our experience in developing a POEM program using a novel hybrid approach. METHODS: We developed a hybrid approach to POEM with a POEM followed by laparoscopic evaluation, extension of the myotomy, if necessary, and partial fundoplication. We reviewed the results of the programme from April 2012 until May 2015. Starting in 2014, we began offering patients stand-alone POEM. Patient data were collected. Preoperative and postoperative Eckardt scores were compared. RESULTS: A total of 28 patients underwent POEM or POEM plus laparoscopic evaluation with partial fundoplication. Patient characteristics and perioperative and postoperative data were recorded. The median preoperative Eckardt score was 6 (range 4-11). The mean follow-up period was 136 days (range 41-330) and the median postoperative Eckardt score was 0 (range 0-6) at 6 weeks. Of our initial 10 patients, 6 required laparoscopic extension of the myotomy; 7 subsequent patients did not require an additional myotomy. Three patients who underwent POEM without laparoscopy continued to have dysphagia postoperatively. One patient had an attempted POEM that was aborted secondary to bleeding, and a standard laparoscopic modified Heller myotomy with partial fundoplication was performed. CONCLUSIONS: The excellent results of laparoscopic myotomy with partial fundoplication are challenging to duplicate during the initial adoption of a POEM approach. We present a program developed to steepen the learning curve and enhance patient safety while implementing this new procedure.

Survival After Surgical Resection of Stage IV Esophageal Cancer.

BACKGROUND: Five-year survival of stage IV esophageal cancer is rare. The treatment of advanced esophageal cancer is typically palliative and the role of surgery remains controversial. We sought to understand the impact of curative surgery on survival and identify any favorable tumor or patient characteristics that might make surgical resection appropriate when treating stage IV esophageal cancer. METHODS: A retrospective review of 3,500 esophagectomies performed at our institution from 1985 to 2013 identified 52 (1.5%) patients with stage IV esophageal cancer who underwent surgical resection with intent for cure. In 46 (88.5%) patients, M1 disease was discovered at the time of surgery and 6 (11.5%) patients had known M1 disease prior to surgery. RESULTS: Median age at the time of surgery was 60 years (range, 31 to 81 years). The majority of patients were men (82.7%) with adenocarcinoma (88.5%). Neoadjuvant therapy was used in 18 (34.6%) patients; all patients operated on after 1999 received neoadjuvant therapy. An Ivor Lewis esophagectomy was performed in 39 (75%) patients. Follow-up was complete in all patients for a median of 324 days (range, 4 days to 8.5 years). Overall, 1-year survival was 29% and 5-year survival was 6%. There was no significant difference in survival between patients with known preoperative versus intraoperative discovery of M1 disease. Factors associated with improved survival included neoadjuvant treatment, low T stage, and lack of alcohol use. CONCLUSIONS: Few patients with stage IV esophageal cancer survive long term after surgical resection, though 5-year survival can occur. Our current recommendation is that esophagectomy should not be performed for stage IV disease.

Overview of uniportal video-assisted thoracic surgery (VATS): past and present.

Single incision video-assisted thoracic surgery (VATS), better known as uniportal VATS, has taken the world of thoracic surgery by storm over the previous few years. Through advances in techniques and technology, surgeons have been able to perform increasingly complex thoracic procedures utilizing a single small incision, hence avoiding the inherent morbidity of the standard open thoracotomy. This was a natural extension of what most recognize as the standard of care for early stage lung cancer, the VATS lobectomy, generally performed through a three- or four-incision technique. Improved camera optics have allowed the use of smaller cameras, making the uniportal approach technically easier. Improvement in articulating staplers and the development of other roticulator instruments have also aided working through a small single access point. The uniportal technique further brings the operative fulcrum inside the chest cavity, enabling better visualization, and creates working conditions similar to the open thoracotomy. Currently, uniportal VATS is being used for minor thoracic procedures and lung resections up to complex thoracic procedures typically requiring open approaches, such as chest wall resections, pneumonectomy, and bronchoplastic and pulmonary artery sleeve resections. Uniportal VATS is a clear advance in the field of general thoracic surgery and provides but a glimpse into the untold future.

External validation of the Ferguson pulmonary risk score for predicting major pulmonary complications after oesophagectomy†.

OBJECTIVES: Pulmonary complications remain a frequent cause of morbidity in patients undergoing oesophagectomy. Risk screening tools assist in patient stratification. Ferguson proposed a risk score system to predict major pulmonary complications after oesophagectomy. Our objective was to externally validate this risk score system. METHODS: We analysed our institutional database for patients undergoing oesophagectomy for cancer from August 2009 to December 2012. We analysed patients who had complete documentation of variables used in the Ferguson risk score calculation: forced expiratory volume in the 1 s, diffusion capacity of the lung for carbon monoxide, performance status and age. One hundred and thirty-six patients qualified for analysis in the validation study. Outcome variables measured included major pulmonary complications, defined as need for reintubation for respiratory failure and pneumonia. The risk score was then calculated for each individual based on the model. Incidence of major pulmonary events was assessed in the five risk class groupings to assess the discriminative ability of the Ferguson score. RESULTS: Major pulmonary complications occurred in 35% of patients (47/136). Overall mortality was 6% (8/136). Patients were grouped into five risk categories according to their Ferguson pulmonary risk score: 0-2, 8 patients (6%); 3-4, 24 patients (18%); 5-6, 49 patients (36%); 29 patients (21%); 9-14, 26 patients (19%). The incidence of major pulmonary complications in these categories was 0, 17, 20, 41 and 77%, respectively. The accuracy of the risk score system for predicting major pulmonary complications was 76% (P < 0.0001). CONCLUSIONS: This pulmonary risk scoring system is a reliable instrument to be used during the preoperative phase to differentiate patients who may be at higher risk for pulmonary complications after oesophagectomy. These data can assist in patient selection, and in patient education/informed consent and can guide postoperative management.

Individualizing Management of Complex Esophageal Pathology Using Three-Dimensional Printed Models.

PURPOSE: In complex esophageal cases, conventional two-dimensional imaging is limited in demonstrating anatomic relationships. We describe the utility of three-dimensional (3D) printed models for complex patients to individualize care. DESCRIPTION: Oral effervescent agents, with positive enteric contrast, distended the esophagus during computed tomography (CT) scanning to facilitate segmentation during post-processing. The CT data were segmented, converted into a stereolithography file, and printed using photopolymer materials. EVALUATION: In 1 patient with a left pneumonectomy, aortic bypass, and esophageal diversion, 3D printing enabled visualization of the native esophagus and facilitated endoscopic mucosal resection, followed by hiatal dissection and division of the gastroesophageal junction as treatment. In a second patient, 3D printing allowed enhanced visualization of multiple esophageal diverticula, allowing for optimization of the surgical approach. CONCLUSIONS: Printing of 3D anatomic models in patients with complex esophageal pathology facilitates planning the optimal surgical approach and anticipating potential difficulties for the multidisciplinary team. These models are invaluable for patient education.

Frequency of EGFR and KRAS mutations in lung adenocarcinomas in African Americans.

INTRODUCTION: The detection of mutations in the epidermal growth factor receptor (EGFR) gene, which predict sensitivity to treatment with EGFR tyrosine kinase inhibitors, represents a major advance in the treatment of lung adenocarcinoma. KRAS mutations confer resistance to EGFR-tyrosine kinase inhibitors. The prevalence of these mutations in African American patients has not been thoroughly investigated. METHODS: We collected formalin-fixed, paraffin-embedded material from resected lung adenocarcinomas from African American patients at three institutions for DNA extraction. The frequencies of EGFR exon 19 deletions, exon 21 L858R substitutions, and KRAS mutations in tumor specimens from African American patients were compared with data in white patients (n = 476). RESULTS: EGFR mutations were detected in 23 of the 121 specimens from African American patients (19%, 95% confidence interval [CI]: 13-27%), whereas KRAS mutations were found in 21 (17%, 95% CI: 12-25%). There was no significant difference between frequencies of EGFR mutations comparing African American and white patients, 19% versus 13% (61/476, 95% CI: 10-16%; p = 0.11). KRAS mutations were more likely among whites, 26% (125/476, 95% CI: 23-30%; p = 0.04). CONCLUSIONS: This is the largest study to date examining the frequency of mutations in lung adenocarcinomas in African Americans. Although KRAS mutations were somewhat less likely, there was no difference between the frequencies of EGFR mutations in African American patients, when compared with whites. These results suggest that all patients with advanced lung adenocarcinomas should undergo mutational analysis before initiation of therapy.