January 2022 medical image of the month: bronchial obstruction due to pledget in airway following foregut cyst resection

No abstract available. Article truncated after 150 words. A 37-year-old woman complaining of chest pain and cough underwent resection of a mediastinal foregut duplication cyst complicated by a 10-day hospitalization with a prolonged air leak. Seven years later, she presented with worsening cough and shortness of breath, complaining of similar symptoms intermittently in the 7 years between her surgery and presentation. Chest CT showed a hyperattenuating lesion obstructing the medial basal segmental airways, with bronchoscopy revealing suture and a pledget obstructing the medial basal segmental right lower lobe bronchus. The pledget and suture were successfully removed. Repeat bronchoscopy several months later showed no residual airway foreign body, although medial basal subsegmental bronchial stenosis prevented advancement of the bronchoscope distally; this finding correlated with the CT impression of airway stenosis or occlusion in this region on the follow up CT. Bronchogenic cysts result from abnormal lung budding and development of the ventral foregut during the first trimester (1). Many …

Risk factors for prolonged air leak and need for intervention following lung resection

OBJECTIVES Prolonged air leak (PAL; >5 days) following lung resection is associated with postoperative morbidity. We investigated factors associated with PAL and PAL requiring intervention. METHODS Retrospective review of all patients undergoing lobectomy, segmentectomy or wedge resection from 2016 to 2019 at our institution. Bronchoplastic reconstructions and lung-volume reduction surgeries were excluded. Incidence and risk factors for PAL and PAL requiring intervention were evaluated. RESULTS In total, 2384 patients were included. PAL incidence was 5.4% (129/2384); 22.5% (29/129) required intervention. PAL patients were more commonly male (56.6% vs 39.7%), older (mean age 69 vs 65 years) and underwent lobectomy or thoracotomy (all P < 0.001). Patients with PAL had longer length of stay (9 vs 3 days), more discharge needs and increased odds of complication (all P < 0.050). Twenty-nine patients required intervention (9 chest tubes; 4 percutaneous drains; 16 operations). In 50% of operative interventions, an air leak source was identified; however, the median time from intervention to resolution was 13 days. Patients requiring intervention had increased steroid use, lower diffusion capacity for carbon monoxide and twice the length of stay versus PAL patients (all P < 0.050). On univariable analysis, forced expiratory volume in 1 s (FEV1) <40%, diffusion capacity for carbon monoxide <50%, steroid use and albumin <3 had increased odds of intervention (P < 0.050). CONCLUSIONS Age, gender and operative technique were related to PAL development. Patients with worse forced expiratory volume in 1 s or diffusion capacity for carbon monoxide, steroid use or poor nutrition were less likely to heal on their own, indicating a population that could benefit from earlier intervention.

Technical Aspects And Early Results of Uniportal Video-Assisted Thoracoscopic Complex Segmentectomy: A 30 Case-Series Study

Background. With the advantages of better cosmetic incision and faster recovery, uniportal video-assisted thoracoscopic surgery (UP-VATS) has developed rapidly worldwide in recent decades and indications for UP-VATS were further expanded as those for conventional VATS. Complex segmentectomy that makes several, or intricate intersegmental planes, with more a complex procedure, continues to be a difficulty in minimally invasive techniques. However, there are few reports as yet on UP-VATS complex segmentectomy. In this report, we describe the perioperative clinical data and operative techniques and present our early results of UP-VATS complex segmentectomy in our hospital. Methods. The records of a total of 30 patients who underwent UP-VATS complex segmentectomy by a single surgeon between January 2021 and June 2021 were retrospectively reviewed. We defined cases as complex segmentectomy if they required resection of segment 9, 10, combined segmentectomy, segmentectomy+subsegmentectomy, subsegmentectomy, or combined subsegmentectomy. Results. The mean age was 52.8±9.9 years old; mean nodule size was 0.84±0.36 cm; the mean margin width was 2.307±0.309 cm; median operative time was 229.0±58.06 minutes; mean operative hemorrhage was 56.60±17.95 mL; 5.58±1.74 lymph nodes dissected had not metastasized; mean duration of postoperative chest tube drainage was 4.7±1.4 days; and mean postoperative hospital stay was 6.5±3.0 days. Although 1 patient experienced a prolonged air leak, the other 29 recovered uneventfully. Another patient failed to reach the 2cm safe margins who received completion lobectomy later. Conclusions. UP-VATS complex segmentectomy is a safe and effective procedure in the treatment of lung cancers, sparing more pulmonary parenchyma and ensuring safe margins, the disadvantage being lengthy operative times during early acquisition of skills.

Toward a Next-Generation Digital Chest Tube

Chest tubes in patients who have undergone pulmonary resection with pleural air leak are painful, impair ventilatory mechanics, and increase hospital length of stay and costs. Despite these well-documented concerns, current protocols for chest tube management in this setting are not well supported by evidence. Excessive suction applied to chest tubes has been associated with prolonged air leak due to alveolar over-distension, and most practitioners intuit that suction should be minimized to the lowest level needed to maintain desired pleural apposition. Unfortunately, there is no evidence-based protocol for the establishment of minimal adequate suction. Digital suction devices in current clinical use can identify air leak resolution preventing the delay of chest tube removal but cannot guide suction minimization while an air leak persists. We recently described a monitor of lung expansion in a porcine model of pleural air leak that could detect loss of pleural apposition continuously in real-time based on electrical impedance readings obtained directly from the surface of the lung via chest tube-embedded electrodes. The value of the impedance signal was “in-range” when pleural apposition was present but became abruptly “out-of-range” when pneumothorax due to inadequate suction developed. These findings suggested that a digitally controlled suction pump system could be programmed to recognize the development of pneumothorax and automatically identify and set the minimum level of suction required to maintain pleural apposition. We present here preliminary proof of concept for this system.

Hybrid minimally invasive treatment of intralobar pulmonary sequestration: a single-centre experience

Pulmonary sequestrations are rare congenital malformations. They are often located in the lower lobes, and they are supplied by an aberrant systemic vessel arising from the thoracic aorta or abdominal arteries. These pulmonary malformations are divided into intra- and extralobar sequestrations, depending on the respective lack or presence of an independent pleural covering. Pulmonary sequestration can be asymptomatic or lead to recurrent pulmonary infections. The goal of this study was to analyse the feasibility and safety of a hybrid sequential approach. We report a small series of intralobar pulmonary sequestrations, from November 2017 to December 2018, successfully treated with a hybrid minimally invasive approach consisting of endovascular embolization of the aberrant arterial branch followed by video-assisted thoracoscopic lobectomy the day after. Thoracic pain following endovascular embolization was noted in all cases. Patients were discharged early in the absence of major postoperative complications. Prolonged air leak was observed in only 1 case. Despite the presence of sequestration-related pulmonary inflammation, in our experience, hybrid treatment for intralobar pulmonary sequestration is a safe and reproducible approach in terms of postoperative complications and hospital stay.