Lung volume reduction surgery is safe and leads to functional improvement in patients who fail or cannot undergo bronchoscopic lung volume reduction.

Background: Bronchoscopic lung volume reduction (BLVR) has supplanted surgery in the treatment of patients with advanced emphysema, but not all patients qualify for it. Our study aimed to investigate the outcomes of lung volume reduction surgery (LVRS) among patients who either failed BLVR or were not candidates for it. Methods: We conducted a retrospective analysis of patients who underwent LVRS for upper lobe-predominant emphysema at a single tertiary center between March 2018 and December 2022. The main outcomes measures were preoperative and postoperative respiratory parameters, perioperative morbidity, and mortality. Results: A total of 67 LVRS recipients were evaluated, including 10 who had failed prior valve placement. The median patient age was 69 years, and 35 (52%) were male. All procedures were performed thoracoscopically, with 36 patients (53.7%) undergoing bilateral LVRS. The median hospital length of stay was 7 days (interquartile range, 6-11 days). Prolonged air leak (>7 days) occurred in 20 patients. There was one 90-day mortality from a nosocomial pneumonia (non-COVID-related) and no further deaths at 12 months. There were mean improvements of 10.07% in forced expiratory volume in 1 second and 4.74% in diffusing capacity of the lung for carbon monoxide, along with a mean decrease 49.2% in residual volume (P < .001 for all). The modified Medical Research Council dyspnea scale was improved by 1.84 points (P < .001). Conclusions: LVRS can be performed safely in patients who are not candidates for BLVR and those who fail BLVR and leads to significant functional improvement. Long-term follow-up is necessary to ensure the sustainability of LVRS benefits in this patient population.

Endoscopic tissue approximation in clinical practice and the OverStitch device: a narrative review.

Objective: The current article describes modern endoscopic technologies that allow for advanced endoscopic tissue approximation and suturing. These technologies include such devices as through the scope and over the scope clips, endoscopic suturing OverStitch device and through the scope suturing X-Tack device. Background: Since the original introduction of the diagnostic endoscopy, progress in the field has been astonishing. Over the past several decades endoscopy has made numerous advancements allowing for a minimally invasive mechanism to treat life threatening conditions such as gastrointestinal (GI) bleeding, full thickness injuries, as well as chronic medical conditions such as morbid obesity and achalasia. Methods: A narrative review of all relevant and available literature on endoscopic tissue approximation devices over the last 15 years ago was conducted. Conclusions: Multiple new devices, including endoscopic clips and endoscopic suturing devices, have been developed for endoscopic tissue approximation that allow advanced endoscopic management of a wide variety of GI tract conditions. It is critical for practicing surgeons to actively participate in the development and use of these new technologies and devices in order to maintain leadership in the field, hone expertise, and to drive innovation. Further research in minimally invasive applications for these devices is needed as they continue to be refined. This article provides a general overview of the devices available and their clinical applications.

Feasibility of Single - Encounter Telemedicine Lung Cancer Screening: A Retrospective Cohort Study in an Underserved Population.

BACKGROUND: COVID-19 forced a delay of non-essential health services, including lung cancer screening. Our institution developed a single-encounter, telemedicine (SET) lung cancer screening whereby patients receive low-dose CT in-person, but counseling regarding results, coordination of follow-up care and smoking cessation is delivered using telemedicine. This study compares outcomes of SET lung cancer screening to our pre-COVID, single-visit, in-person (SIP) lung cancer screening. METHODS: A retrospective cohort study was performed we recorded independent variables of gender, race/ethnicity, age, educational attainment, smoking status and dependent variables including cancer diagnosis, stage and treatment between March 2019 to July 2021. Using retrospective analysis, we compared outcomes of SIP lung cancer screening before COVID-19 and SET lung cancer screening amid COVID-19. RESULTS: There was a significant difference in number of patients screened pre- and amid COVID-19.673 people were screened via SIP, while only 440 were screened via SET. SIP screening consisted of 52.5% Black/African American patients, which decreased to 37% with SET lung cancer screening. There was no significant difference in gender, age, or educational attainment. There was also no significant difference in Lung-RADS score between the 2 methods of screening or diagnostic procedures performed. Ultimately telemedicine based screening diagnosed fewer cancers, 1.6% diagnosed via telemedicine vs 3.3% screened by in person. CONCLUSION: We implemented SET lung cancer screening to continue lung cancer screening during a global pandemic. Our study established feasibility of telemedicine-based lung cancer screening among our predominantly African American/Black population, though fewer patients were screened. We found no difference in distribution between age, or educational attainment suggesting other factors discouraging lung cancer screening amid COVID-19.

A rare case of combined black esophagus and stomach: a case report.

Background: Black esophagus is a relatively rare phenomenon that seems to occur in a morbid patient population, however, this entity may be more common than we currently know. Additionally, black esophagus may even be reversible in some cases. There are far fewer cases of black stomach described. The exact etiology and cause are less well known but may have similar risk factors as black esophagus. These disease pathologies are devastating to the patients they affect and can pose clinical challenges for the providers that encounter them. Case Description: This case report details our experience with a moribund patient who was found to have extensive pneumomediastinum and gastric perforation secondary to black esophagus and black stomach. This was diagnosed on endoscopy following imaging that showed extensive pneumomediastinum. Initially the intent was to temporize the disease process in an attempt to stabilize the patient however at the time of diagnosis, the degree of ischemia had led to perforation and the disease process was not reversible or recoverable. He ultimately expired after comfort directed care measures were put in place. Conclusions: To the best of our knowledge, this case will be the first reported in current literature and will hopefully shed some light on this unusual and devastating pathology.

Tracheobronchoplasty for tracheobronchomalacia.

Tracheobronchoplasty (TBP) consists of splinting of the posterior membranous wall of the central airways with the goal of restoring a normal configuration and preventing excessive collapse in patients with tracheobronchomalacia (TBM). Despite some variation in technique, it consists of sewing a mesh on the posterior membranous wall of the trachea and both main stem bronchi. Traditionally performed through a right posterolateral thoracotomy, it should be reserved for cases of severe TBM. Surgical exposure necessitates dissection of the trachea from the thoracic inlet to the carina, as well the right main stem bronchus, bronchus intermedius and left main stem bronchus. Airway management in the operating room requires manipulation of the endotracheal tube (ETT) to allow safe placement of the sutures without puncturing the balloon. Other key technical considerations include downsizing of the airway with the mesh, and appropriate spacing of the sutures to ensure a plicating effect of the posterior membranous wall. More recently the robotic platform was used to perform TBP surgery. Its fine precise wristed motion and excellent visualization offer potential advantages over a thoracotomy and early outcomes of robotic-assisted TBP are encouraging. Longitudinal follow-up is still necessary to ensure the durability of repair in a patient population with significant underlying respiratory co-morbidities.

Lung Cancer Screening in a Safety-Net Hospital: Rare Harms Inform Decision Making.

BACKGROUND: Lung cancer screening (LCS) with low-dose computed tomography (LDCT) decreases lung cancer mortality; however, screening benefits and harms are poorly described in minority populations. Our purpose is to report benefits and harms of LCS implemented in a safety-net institution. Because harms are rare, there is a paucity of clinical experience guiding shared decision making (SDM) with diverse populations. METHODS: We conducted a prospective, observational study of patients undergoing LCS between September 2014 and March 2019 with 2-year follow-up. LDCT results, lung cancer diagnosis, stage, treatment, false-positive results, false-negative procedure from a false-positive result, complication from procedures, and death were recorded. Patient cases highlighting the challenges of delivering LCS to an underserved population were evaluated in the context of current evidence. RESULTS: Among the 995 patients who underwent screening, 54.9% were African American, with 2.9% receiving a cancer diagnosis, a false-positive rate of 9.4% and a 0.7% rate of procedures resulting from a false-positive result. Five patient cases highlight challenges, namely (1) false-positive result resulting in operation, (2) false-negative result, (3) incidental finding, (4) delay in diagnosis, and (5) death from cause other than lung cancer. CONCLUSIONS: LCS of a predominantly African American population with 2-year follow-up demonstrates early detection and treatment of lung cancer with few harms. Although rare, harms must be clearly described with population-specific evidence. We report clinical perspective of rare harms that can provide guidance to providers and patients.

A History of Health Policy and Health Disparity.

Civil Rights legislation and court decisions influenced health care policy, which attempted to provide health care to elderly and low-income populations. Passing Medicaid and Medicare was monumental in increasing access to health insurance. The Affordable Care Act aimed to increase access to and affordability of health care to alleviate some disparities in health care. The Affordable Care Act established the National Institute of Minority and Health Disparity and Offices of Minority Health. However, disparities of access, care, morbidity, and mortality among marginalized populations persist. We in the thoracic community must leverage all means to mitigate the injustice of health disparities.