Clinicopathological factors associated with sentinel lymph node detection in non-small-cell lung cancer.

BACKGROUND: Mapping of the pulmonary lymphatic system by near-infrared (NIR) fluorescence imaging might not always identify the first lymph node relay. The aim of this study was to determine the clinicopathologic factors allowing the identification of sentinel lymph nodes (SLNs) by NIR fluorescence imaging in thoracic surgery for non-small-cell lung cancer (NSCLC). METHODS: We conducted a retrospective review of 92 patients treated for suspected or confirmed cN0 lung cancer with curative intent who underwent an intraoperative injection of indocyanine green (ICG) either by direct peritumoral injection or by endobronchial injection using electromagnetic navigational bronchoscopy (ENB). After exclusion of patients for technical failure, benign disease and metastasis, we analyzed the clinicopathologic findings of 65 patients treated for localized-stage NSCLC, comparing the group with identification of SLNs (SLN-positive group) with the group without identification of SLNs (SLN-negative group). RESULTS: Forty-eight patients (73.8%) were SLN-positive. Patients with SLN positivity were more frequently female (50%) than the SLN-negative patients were (11.8%) (p = 0.006). The mean value of diffusing capacity for carbon monoxide (DLCO) was lower among the patients in the SLN-negative group (64.7% ± 16.7%) than the SLN-positive group (77.6% ± 17.2%, p < 0.01). The ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FCV) was higher in the SLN-positive group (69.0% vs. 60.8%, p = 0.02). Patients who were SLN-negative were characterized by a severe degree of emphysema (p = 0.003). There was no significant difference in pathologic characteristics. On univariate analyses, age, female sex, DLCO, FEV1/FVC, degree of emphysema, and tumor size were significantly associated with SLN detection. On multivariate analysis, DLCO > 75% (HR = 4.92, 95% CI: 1.27-24.7; p = 0.03) and female sex (HR = 5.55, 95% CI: 1.25-39.33; p = 0.04) were independently associated with SLN detection. CONCLUSIONS: At a time of resurgence in the use of the sentinel lymph node mapping technique in the field of thoracic surgery, this study enabled us to identify, using multivariate analysis, two predictive factors for success: DLCO > 75% and female sex. Larger datasets are needed to confirm our results.

Sublobar resection or lobectomy and postoperative respiratory complications in emphysematous lungs.

OBJECTIVES: Pulmonary resection in patients with severe emphysema may impact postoperative respiratory complications. Low-attenuation areas evaluated using three-dimensional computed tomography to assess emphysematous changes are strongly associated with postoperative respiratory complications. Herein, we investigated the relationship between low-attenuation area, the surgical procedure and resected lung volume, which has not been explored in previous studies. METHODS: We retrospectively evaluated patients with primary or metastatic lung cancer who underwent surgical resection. The low-attenuation area percentage (low-attenuation area/total lung area × 100) and resected lung volume were calculated using three-dimensional computed tomography software, and the relationship with postoperative respiratory complications was analysed. RESULTS: Postoperative respiratory complications occurred in 66 patients (17%) in the total cohort (n = 383). We set the median value of 1.1% as the cut-off value for low-attenuation area percentage to predict postoperative respiratory complications, which occurred in 24% and 10% of patients with low-attenuation area >1.1% and <1.1%, respectively (P < 0.001). Postoperative respiratory complications occurred in approximately one-third of the patients with low-attenuation area >1.1%, whose resected lung volume was ≥15.8% or ≥5 resected subsegments. Multivariable analysis revealed that sublobar resection was associated with a significantly lower risk of postoperative respiratory complications in patients with low-attenuation area >1.1% (odds ratio 0.4, 95% confidence interval 0.183-0.875). CONCLUSIONS: Emphysema is a risk factor for postoperative respiratory complications, and lobectomy is an independent predictive risk factor. Preserving more lung parenchyma may yield better short-term prognoses in patients with emphysematous lungs.

Application of 3D computed tomography in emphysematous parenchyma patients scheduled for bronchoscopic lung volume reduction.

Bronchoscopic lung volume reduction (BLVR) is a feasible, safe, effective and minimally invasive technique to significantly improve the quality of life of advanced severe chronic obstructive pulmonary disease (COPD). In this study, three-dimensional computed tomography (3D-CT) automatic analysis software combined with pulmonary function test (PFT) was used to retrospectively evaluate the postoperative efficacy of BLVR patients. The purpose is to evaluate the improvement of lung function of local lung tissue after operation, maximize the benefits of patients, and facilitate BLVR in the treatment of patients with advanced COPD. All the reported cases of advanced COPD patients treated with BLVR with one-way valve were collected and analysed from 2017 to 2020. Three-dimensional-CT image analysis software system was used to analyse the distribution of low-density areas <950 Hounsfield units in both lungs pre- and post- BLVR. Meanwhile, all patients performed standard PFT pre- and post-operation for retrospective analysis. We reported six patients that underwent unilateral BLVR with 1 to 3 valves according to the range of emphysema. All patients showed a median increase in forced expiratory volume in 1 second (FEV1) of 34%, compared with baseline values. Hyperinflation was reduced by 16.6% (range, 4.9%-47.2%). The volumetric measurements showed a significant reduction in the treated lobe volume among these patients. Meanwhile, the targeted lobe volume changes were inversely correlated with change in FEV1/FEV1% in patients with heterogeneous emphysematous. We confirm that 3D-CT analysis can quantify the changes of lung volume, ventilation and perfusion, to accurately evaluate the distribution and improvement of emphysema and rely less on the observer.

Surgical and bronchoscopic pulmonary function-improving procedures in lung emphysema.

COPD is a highly prevalent, chronic and irreversible obstructive airway disease without curative treatment. Standard therapeutic strategies, both non-pharmacological and pharmacological, have only limited effects on lung function parameters of patients with severe disease. Despite optimal pharmacological treatment, many patients with severe COPD still have a high burden of dyspnoea and a poor quality of life. If these patients have severe lung emphysema, with hyperinflation as the driver of symptoms and exercise intolerance, lung volume reduction may be an effective treatment with a significant impact on lung function, exercise capacity and quality of life. Currently, different lung volume reduction approaches, both surgical and bronchoscopic, have shown encouraging results and have been implemented in COPD treatment recommendations. Nevertheless, choosing the optimal lung volume reduction strategy for an individual patient remains challenging. Moreover, there is still room for improving durability of effect and safety in all available procedures. Ongoing and innovative research is essential to push this field forwards. This review provides an overview of results and limitations of the current lung volume reduction options for patients with severe lung emphysema and hyperinflation.

Recurrent idiopathic pancreatitis complicating as emphysematous pancreatitis and gastroduodenal artery pseudoaneurysm: A rare case report.

Emphysematous pancreatitis (EP) is a rare and potentially fatal condition of the pancreas. It is associated with gas-forming bacteria and is characterized by the presence of gas in or around the pancreas. It is identified by a computed tomography scan of the abdomen. Although predisposing factors are not precisely known, diabetes mellitus, which predisposes to gas gangrene, is seen to be commonly associated with patients of EP. EP being potentially fatal requires immediate management. Surgery is generally indicated in EP. However, EP can also managed conservatively. In our case, the patient developed recurrent pancreatitis, the cause being idiopathic, and the second episode of acute pancreatitis was complicated by EP and gastroduodenal artery pseudoaneurysm.

Résumé La pancréatite emphysémateuse (EP) est une condition rare et potentiellement mortelle du pancréas. Il est associé à des bactéries de formation de gaz et se caractérise par la présence de gaz dans ou autour du pancréas. Il est identifié par une tomodensitométrie calculée de l'abdomen. Bien que les facteurs prédisposants ne soient pas précisément connus, le diabète sucré, qui prédispose à la gangrène du gaz, est considéré comme communément associé aux patients du PE. EP étant potentiellement mortel nécessite une gestion immédiate. La chirurgie est généralement indiquée dans EP. Cependant, EP peut également gérer de manière conservatrice. Dans notre cas, le patient a développé une pancréatite récurrente, la cause étant idiopathique, et le deuxième épisode de pancréatite aiguë a été compliqué par l'EP et le pseudo-anévrisme de l'artère gastroduodénale. Mots-clés: Pancréatite emphysémateuse, pseudo-anévrisme gastroduodénal, pancréatite.

Bronchoscopic Lung Volume Reduction: A Clinical Review.

Bronchoscopic lung volume reduction (BLVR) for the treatment of emphysema was originally developed in the early 2000s as a minimally invasive alternative to lung volume reduction surgery. Endobronchial valves for BLVR are an advancing "guideline treatment" in the treatment of advanced emphysema. Placement of small, one-way valves into segmental or subsegmental airways can induce lobar atelectasis for portions of diseased lung. This results in the reduction of hyperinflation along with improvements in diaphragmatic curvature and excursion.

EXTENSIVE ORBITAL AND PARAPHARYNGEAL EMPHYSEMA REQUIRING URGENT CANTHOTOMY AND CANTHOLYSIS AFTER PARS PLANA VITRECTOMY.

PURPOSE: The authors report the emergent management of a case of orbital and parapharyngeal emphysema causing orbital compartment syndrome and signs of peripheral neuropathy days after pars plana vitrectomy. METHODS: Case report. RESULTS: A 20-year-old woman underwent 3-port 23-gauge pars plana vitrectomy in the right eye for total retinal detachment under general anesthesia. All sclerotomies were secured with 7-0 polyglactin 910 (Vicryl; Ethicon) sutures before instillation of 15% C3F8 gas. On the third postoperative day, the patient presented with a 3-mm proptosis, near-total ophthalmoplegia, jaw protrusion, head deviation, tongue protrusion, and facial twitching. Computed tomography showed extensive subcutaneous gas in the right orbit and bilateral parapharyngeal spaces, and a tethered right optic nerve with globe tenting. A decision was made to perform urgent lateral canthotomy and cantholysis. Three hours after canthotomy and cantholysis, her neurologic signs had resolved except for intermittent tongue protrusion, which resolved thereafter. At postoperative Week 7, the patient's vision was 20/70 and her intraocular pressure was 13 mmHg. CONCLUSION: To the authors' knowledge, this is the only report of a modern small-gauge vitrectomy procedure being complicated by orbital compartment syndrome and extensive emphysema causing peripheral neuropathy, and successfully treated with urgent canthotomy and cantholysis.

A Prototype Implantable Artificial Bronchus Reduces Lung Hyperinflation in Recently Deceased Patients with Emphysema.

BACKGROUND: Several minimally invasive treatments have been offered to patients with severe emphysema over the last two decades. Currently, endobronchial valves (EBVs) are the only approved therapeutic option, but this method has drawbacks: only a few can undergo this therapy and the incidence of pneumothorax remains high. A minimally invasive technique, appropriate for a broader patient population and posing fewer risks, would represent a desirable alternative to improve lung function in these patients. OBJECTIVE: The objective of this study was to demonstrate whether a new prototype implantable artificial bronchus (IAB) releases trapped air from the lungs of recently deceased patients with emphysema. METHOD: Seven recently deceased patients with emphysema were mechanically ventilated and the respiratory rate increased from 12 bpm (resting) to 30 bpm (exercise), inducing air trapping and dynamic hyperinflation. This protocol was performed twice, before and after IAB placement. Ventilation parameters and the fraction of inspired oxygen were similar in all patients. Respiratory system plateau pressure (Pplat,rs) and intrinsic positive end-expiratory pressure (iPEEP) were measured. RESULTS: IAB implantation significantly reduced Pplat,rs (p = 0.017) in 6 of 7 deceased patients with emphysema and iPEEP (p = 0.03) in 5 of 7 patients. CONCLUSIONS: Placement of one or two IABs in segmental bronchi (up to 15th generation) proved to be feasible and improved lung function. These findings should provide a basis for subsequent clinical studies to assess the safety and efficacy of IAB in patients with emphysema, as well as identify short- and long-term effects of this innovative procedure.

Predictors of mortality and nephrectomy in emphysematous pyelonephritis: a tertiary care centre study.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a deadly disease due to its associated morbidity and mortality. Attempts have been made to identify predictors of severity, mortality and need for nephrectomy in EPN with little success. METHODS: We conducted an ambispective study of EPN patients between March 2014 and September 2019. Retrospective data were collected which included age, sex, comorbidities, symptoms, signs, laboratory investigations including imaging, need for dialysis, management and any complications. All patients were then followed prospectively for renal dynamic scan, stone surgery or nephrectomy. Univariate analysis was performed to identify factors affecting mortality and need for elective nephrectomy. RESULTS: In total, 112 patients were included. Mean patient age was 50.01 years, 55% were female and 5% had bilateral involvement. Fever and flank pain were the most common symptoms. Diabetes was seen in 75% of cases and 30% of cases required haemodialysis at initial presentation. About 60% of patients improved with pigtail drainage. Need for nephrectomy was greater in Huang-Tseng stage 3a (14.8%). Huang-Tseng stages 3b and 4 had higher mortality rates (25%) than the other stages (2.2%). Twelve of 99 patients had non functional kidney on follow-up and underwent elective nephrectomy. Low platelet counts, high body mass index, septic shock, dialysis and higher Huang-Tseng stage were found to be predictive of mortality and renal parenchymal thickness on computed tomography scan was predictive of follow-up nephrectomy. CONCLUSIONS: Thrombocytopaenia, high body mass index, septic shock, haemodialysis and higher Huang-Tseng stage are predictors of mortality and renal parenchymal thickness <5mm is a predictor of poor salvage of affected kidney on follow-up.

Lung Volume Reduction Surgery Reduces Pulmonary Arterial Hypertension Associated With Severe Lung Emphysema and Hypercapnia.

Lung volume reduction surgery (LVRS) represents a standard surgical approach for patients with severe pulmonary emphysema. One of the relevant risk factors for LVRS is the presence of pulmonary arterial hypertension (PAH). The aim of this study is to assess the postoperative changes in pulmonary arterial pressure (PAP) after LVRS for patients with severe pulmonary emphysema compared with preoperative measures. N = 61 consecutive patients with severe pulmonary emphysema and preoperative evidence for PAH (pulmonary arterial systolic pressure [PASP] ≥ 35 mmHg) were prospectively included into this study. In all patients, thoracoscopic LVRS was performed. PASP was assessed by echocardiography before surgery, early postoperatively, and 3 months after surgery. Data were prospectively recorded and analyzed retrospectively. Primary end points were the postoperative changes in PASP as well as the 90 day mortality rate. Secondary endpoints included: pulmonary function test, exercise capacity, quality of life, and dyspnea symptoms (Borg scale). Early after surgery, a significant reduction in PASP was observed at the day of discharge and at 3 month follow-up. In n = 34 patients, no tricuspid valve regurgitation was detectable anymore suggesting normal PAP. In n = 3 patients, venovenous extracorporeal lung support (VV ECLS) was already implemented preoperatively. In the remaining cases, VV ECLS was applied intraoperatively and continued postoperatively. Mean duration of postoperative ECLS support was 2 days. Four patients died due to acute right heart failure, two patients from sepsis with multiorgan failure, and one patient from acute pulmonary embolism. Ninety day mortality was 11.5 %. A significant improvement was postoperatively observed regarding the performance status, dyspnea scale, as well as quality of life. This study suggests a beneficial effect of LVRS on PAP, which may ultimately help to protect and stabilize right ventricular function. Further studies, implementing pre- and postoperative right heart catheterizations including invasive PAP evaluation, are necessary to support the findings in this study in greater detail.

Anatomic and physiologic approach for trans-conjunctival needle decompression of orbital emphysema.

A 19-year-old with blunt trauma and repeated nose blowing presented with orbital emphysema and orbital compartment syndrome. Orbital emphysema is the abnormal presence of air within the orbit, typically secondary to trauma. Most cases will resolve with observation alone, however orbital compartment syndrome is a feared complication that necessitates urgent decompression. A superior fornix, trans-conjunctival approach was safely utilized to decompress the orbit while avoiding unwanted complications. Various decompression techniques have previously been described, most of which describe trans-palpebral approaches. The key safety benefit to the trans-conjunctival approach is direct visualization of the needle tip adjacent to the superior fornix, therefore posterior to the equator of the globe. With the needle positioned parallel to the curvature of the globe at the equator, the posterior sclera surface curves away from the tip, rendering it difficult to pierce the globe. In addition, the needle needs to be advanced only 3-4 millimeters and traverses only the conjunctiva and Tenon's to enter the central surgical space - the most direct route to the air pocket. The trans-conjunctival approach lowers the risk of damage to eyelid neurovascular structures and is less painful.

Dual-energy Computed Tomographic Pulmonary Angiography Accurately Estimates Lobar Perfusion Before Lung Volume Reduction for Severe Emphysema.

PURPOSE: To assess if dual-energy computed tomographic pulmonary angiography (DECTPA) derived lobar iodine quantification can provide an accurate estimate of lobar perfusion in patients with severe emphysema, and offer an adjunct to single-photon emission CT perfusion scintigraphy (SPECT-PS) in assessing suitability for lung volume reduction (LVR). MATERIALS AND METHODS: Patients with severe emphysema (forced expiratory volume in 1 s <49% predicted) undergoing evaluation for LVR between May 2018 and April 2020 imaged with both SPECT-PS and DECTPA were included in this retrospective study. DECTPA perfused blood volume maps were automatically segmented and lobar iodine mass was estimated and compared with lobar technetium (Tc99m) distribution acquired with SPECT-PS. Pearson correlation and Bland-Altman analysis were used for intermodality comparison between DECTPA and SPECT-PS. Univariate and adjusted multivariate linear regression were modelled to ascertain the effect sizes of possible confounders of disease severity, sex, age, and body mass index on the relationship between lobar iodine and Tc99m values. Effective radiation dose and adverse reactions were recorded. RESULTS: In all, 123 patients (64.5±8.8 y, 71 men; mean predicted forced expiratory volume in 1 s 32.1 ±12.7%,) were eligible for inclusion. There was a linear relationship between lobar perfusion values acquired using DECTPA and SPECT-PS with statistical significance ( P <0.001). Lobar relative perfusion values acquired using DECTPA and SPECT-PS had a consistent relationship both by linear regression and Bland-Altman analysis (mean bias, -0.01, mean r2 0.64; P <0.0001). Individual lobar comparisons demonstrated moderate correlation ( r =0.79, 0.78, 0.84, 0.78, 0.8 for the right upper, middle, lower, left upper, and lower lobes, respectively, P <0.0001). The relationship between lobar iodine and Tc99m values was not significantly altered after controlling for confounders including symptom and disease severity, age, sex, and body mass index. CONCLUSIONS: DECTPA provides an accurate estimation of lobar perfusion, showing good agreement with SPECT-PS and could potentially streamline preoperative assessment for LVR.

Effect of Chest Computed Tomography Kernel Use on Emphysema Score in Severe Chronic Obstructive Pulmonary Disease Patients Evaluated for Lung Volume Reduction.

BACKGROUND: Chest computed tomography (CT) emphysema quantification is a vital diagnostic tool in patient evaluation for bronchoscopic lung volume reduction (BLVR). Smooth kernels for CT image reconstruction are generally recommended for quantitative analyses. This recommendation is not always followed, which may affect quantification of emphysema extent and eventually, treatment decisions. OBJECTIVE: The main goal is to demonstrate the influence of CT reconstruction kernels on emphysema quantification in patients with severe COPD, considered for BLVR. METHODS: Chest CT scans were acquired with one multi-detector CT system and reconstructed using three different kernels: smooth, medium smooth, and sharp. Other parameters were kept constant. Emphysema scores (ESs), meaning the percentage of voxels below -950 Hounsfield units, were calculated and compared to the smooth reference kernel using paired t tests. Bland-Altman plots were made to assess the biases and limits of agreement between kernels. RESULTS: Ninety-eight COPD patient CT scans were analyzed. The sharp kernel had a systematic bias of 6.2% and limits of agreement of 16.6% to -4.2% compared to the smooth kernel. The medium smooth kernel had a systematic bias of 5.7% and limits of agreement of 9.2% and 2.2% compared to the smooth kernel. The ES differed, for a single patient, up to 18% for different kernels. CONCLUSIONS: Chest CT kernel reconstruction can lead to a significant difference in emphysema severity quantification. This may cause invalid treatment selection in COPD patients evaluated for BLVR. Standardization of a smooth CT kernel setting and/or normalization to a standard kernel is strongly recommended.

Current interventional treatment options for severe emphysema.

Chronic obstructive pulmonary disease (COPD) is one of the three leading causes of death worldwide. If the feature of the disease is dominated by emphysema, we speak of an emphysematic phenotype. Interventional treatment is a standard part of the management of patients with the emphysematic phenotype of COPD. Interventional methods are surgical and endoscopic. An important point in the indication of these methods is the correct selection of profitable patients. In addition to the correct execution of the individual procedure, periprocedural management, anticipation, and optimal handling of complications in the field of severe functional disability have an important effect on the care results.

[Lung Cancer Surgery for Severe COPD with Emphysema: Tumor Resection with Improvement of Lung Function]. / Lungenkrebschirurgie bei schwerer COPD mit Emphysem: Tumorresektion mit Verbesserung der Lungenfunktion.

Lung Cancer Surgery for Severe COPD with Emphysema: Tumor Resection with Improvement of Lung Function Abstract. The golden standard for the therapy of early stage non-small cell lung cancer consists of surgical resection, usually performed as lobectomy or segmentectomy. These procedures demand a certain operability, including certain lung functional reserves. Patients with COPD and emphysema usually have lung function values far below that. Nevertheless, these patients can be offered treatmentif at the same time they qualify for concomitant lung volume reduction surgery (LVRS). LVRS with simultaneous tumor resection can consolidate the diagnosis, provide definite histology, correct staging, and thorough tumor resection might even improve the postoperative lung function. As with all patients with a (possible) diagnosis of cancer, the indication must be discussed in an interdiscplinary tumor board.

[In Vitro Fatigue Test of Lung Volume Reduction Loop].

Lung volume reduction loop uses bronchoscopic lung volume reduction(BLVR) technology to compress and collapse the necrotic emphysema tissue and exhaust the internal gas to achieve the purpose of lung volume reduction to treat emphysema. After the lung volume reduction loop is implanted into the human body, the compressed part of the lung tissue tends to expand with breathing, which makes the lung volume reduction loop expand into a linear trend periodically. Fatigue resistance is one of the most important performance indexes of the lung volume reduction loop. In the paper, Z-direction vibration fatigue machine was used to simulate the changes of human respiratory cycle movement to test the fatigue performance of lung volume reduction loop, which can provide some reference for the test method of in vitro fatigue performance of lung volume reduction related products in the future.

Current status of interventional therapy for pulmonary emphysema with bronchoscopy. / è‚ºæ°”è‚¿çš„æ”¯æ°”ç®¡é•œä»‹å ¥æ²»ç–—çŽ°çŠ¶.

Pulmonary emphysema is one of phenotypes of lung disease that can progress to chronic obstructive pulmonary disease (COPD). The pathogenesis is unknown, which may be closely related to smoking, infection, gene mutation, and air pollution. Pathological features of emphysema include the decreased airway elasticity at the distal end of the bronchioles and over-hyperinflation. As the incidence and mortality of COPD increase, emphysema has become the focus of research. The efficacy of drugs for COPD is limited, and currently the treatment of emphysema mainly depends on surgery. Since the concept of lung volume reduction surgery was proposed in the 1990s, many studies have confirmed improvement of lung function and exercise capacity, but the large wound, high mortality, and high cost have reduced its benefits. Lung volume reduction surgery with bronchoscopy technology, including valves, coils, sclerosants, vapor thermal ablation, etc., has the advantages of minimal invasive and decreased mortality under the basis of effectiveness. This article aims to review the current status of interventional therapy for pulmonary emphysema with bronchoscopy, compare and summarize the characteristics and applicable populations of interventional therapy, and provide theoretical support for patients' early referral and clinicians' decision-making.

Bronchoscopic Lung Volume Reduction for Emphysema: Review and Update.

In carefully selected patients with severe chronic obstructive pulmonary disease, characterized by emphysema and hyperinflation, lung volume reduction is an option to reduce lung hyperinflation, improve lung function, quality of life, and exercise capacity. Currently, there are several bronchoscopic and surgical treatment options to achieve lung volume reduction. It is important to carefully phenotype these patients, to select the optimal treatment option, with consideration of possible adverse events or contraindications, and it is highly recommended to discuss these treatment strategies in a multidisciplinary team. The treatment with one-way endobronchial valves has been investigated most extensively and more data are available regarding the treatment of more "marginal cases," or subsequent lung volume reduction surgery. Other bronchoscopic lung volume reduction options include treatment with coils, thermal vapor ablation, and sclerosant agents. In this review, we aim to summarize the current clinical evidence on the bronchoscopic lung volume reduction therapies and important aspects regarding optimal patient selection.