Ideal Anatomical Landmark Points for Thoracic Esophagus Segmentation in the Chinese Population

Introduction: The standards of esophagus segmentation remain different between the Japan Esophageal Society (JES) guideline and the Union for International Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) guideline. This study aimed to present variations in the location of intrathoracic esophageal adjacent anatomical landmarks (EAALs) and determine an appropriate method for segmenting the thoracic esophagus based on the relatively fixed EAALs.Patients and Methods: The distances from the upper incisors to the upper border of the esophageal hiatus, lower border of the inferior pulmonary vein (LPV), tracheal bifurcation, lower border of the azygous vein (LAV), and thoracic inlet were measured in the patients undergoing thoracic surgery. The median distances between the EAALs and the specified starting points, as well as reference value ranges and ratios, were obtained. The variation coefficients of distances and ratios from certain starting points to different EAALs were calculated and compared to determine the relatively fixed landmarks.Results: This study included 305 patients. The average distance from the upper incisors to the upper border of the cardia, the midpoint between the tracheal bifurcation and esophageal hiatus (MTBEH), LPV, LAV, tracheal bifurcation, and thoracic inlet were 41.6, 35.3, 34.8, 29.4, 29.5, and 20.3 cm, respectively. The distances from the upper incisors or thoracic inlet to any intrathoracic EAALs in men were higher than in women. In addition, the height, weight, and body mass index (BMI) were correlated with the distances. The ratio of the distance between the upper incisors and tracheal bifurcation to the distance between the upper incisors and upper border of the cardia and the ratio of the distance between the thoracic inlet and tracheal bifurcation to the distance between the thoracic inlet and upper border of the cardia possessed relatively smaller coefficients of variation.Conclusion: The distances from the EAALs to the upper incisors vary with height, weight, BMI, and gender. Compared with distance, the ratios are more suitable for esophagus segmentation. Tracheal bifurcation and MTBEH are ideal EAALs for thoracic esophagus segmentation, and this is consistent with the JES guideline recommendation.

The Role of Thoracic Ultrasonography and Airway Endoscopy in the Diagnosis of Equine Asthma and Exercise-Induced Pulmonary Hemorrhage

Mild-moderate (MEA), severe (SEA) equine asthma and exercise-induced pulmonary hemorrhage (EIPH) are common respiratory disorders in horses. The present retrospective study aims to evaluate the role of ultrasonography and endoscopy in the diagnosis of these conditions. Three hundred and three horses were included and divided into SEA, MEA and MEA + EIPH groups, on the basis of history, clinical examination and bronchoalveolar lavage fluid (BALf) cytology; scores were assigned to lung ultrasonography, pharyngeal lymphoid hyperplasia (PLH), tracheal mucus (TM) and tracheal bifurcation edema (TB). These scores were compared between groups, and their associations with age, BALf cytology, tracheal wash microbiology and between endoscopic and ultrasonographic scores were statistically analyzed. Ultrasonographic scores were higher in the SEA and MEA + EIPH groups and associated with increased BALf neutrophils and hemosiderophages. The PLH score was higher in younger horses affected by MEA and EIPH and associated with increased eosinophils and hemosiderophages. TM and TB scores were greater in older horses affected by SEA, associated with increased neutrophils and inversely correlated with hemosiderophages. Moreover, TM grade was negatively correlated with mast cells. Thoracic ultrasonography and airway endoscopy can provide useful information about the inflammatory status of upper and lower airways in the horse.

Anatomical variations of bronchial distribution in the upper lobe of the right lung

Bronchial distribution in the upper lobe of the right lung is subject to many anatomical variations. The control of these variations is essential for the interpretation of endoscopic examinations. It also offers a better guarantee for safe surgery during segmentations in the right upper lobe. In this preliminary work, the operation of 30 heart-lung blocks treated by the injection-corrosion method, 100 CT chest and dissections of 3 resected specimen of right upper lobectomy, allowed us to study the bronchial distribution in the upper lobe of the right lung as well as their anatomical variations in melanoderm subjects. Our results were as follows: out of the 133 specimens, the right upper lobar bronchus was born on average 1.8 cm from the tracheal bifurcation, with an average length of 1.75 cm. There were 6 termination modes, dominated by bifurcations, which involved 52% of the specimens, and in 5 modes. Trifurcation accounted for 47.37% of cases. There was a case of quadrifurcation. These results allowed us to discuss anatomical variations of the bronchial shaft of the upper lobe of the right lung. Taking into account these variations will allow to avoid pitfalls and accidents during endoscopic examinations, medical imaging and pulmonary exeresis. KEY WORDS: Bronchi-Right Upper Lobe-Anatomy-Variations- Endoscopy-Imaging-Surgery.

New Technique for Intrathoracic Implantation of Extraluminal Spiral Prostheses in the Trachea

Background: Extraluminal surgical procedures for intrathoracic tracheal collapse in dogs are not routinely performed. The patients are normally treated with different drugs or by intraluminal stents. However, in more severe cases, drug treatment does not always have good outcomes, and intraluminal prostheses can be correlated to several postoperative problems. In order to obtain better results, we aimed to develop a surgical technique for implantation of a new extraluminal helical prosthesis in the thoracic segment of the trachea through cervical access, associated with pneumatic mediastinoscopy for certification of the technique and minimization of possible complications.Materials, Methods & Results: Seven canine corpses (CCs) from non-traumatic death, weighing between 2 and 7 kg, were used. A ventral cervical approach to the trachea was associated with blunt mediastinal dissection. Trans cervical pneumatic mediastinoscopy was used for evaluation of the dissection and location of the implant. These were compared with the necropsy findings by the exact Wilcoxon two-sample test, with P < 0.05. The results of necropsy and mediastinoscopy did not present significant differences at P < 0.05. During the examinations, the presence of some mediastinal visceral lesions caused by the prosthesis, the integrity of the mediastinum and possible lesions to RLN and blood vessels (BV) were analyzed. We also investigated the location of the distal part of the prosthesis in the thoracic segment of the trachea and its dissection. To evaluate the technique, statistical comparison was made between mediastinoscopy and necropsy findings. The data were compared by the Wilcoxon test at 5% probability. The tracheas of all CCs were efficiently dissected, but in some cases problems that can happen during the procedure were noticed. This was checked by mediastinoscopy and confirmed by necropsy. The median of the scores was 1 (good dissection and visualization), with variance of zero for mediastinoscopy and 0.14 for necropsy. In the mediastinoscopy of one CC, the prosthesis crossed the tracheal bifurcation, involving the posterior vessels of this region, which was confirmed by necropsy. However, the dissection showed no vascular lesions. The integrity of the mediastinum was assessed only by mediastinoscopy. There was no impairment caused by any of the procedures performed. This resulted in a median score of 1 (integrity) with zero variance. When the positioning of the prosthesis was evaluated in relation to the tracheal bifurcation, identical values were obtained by both methods. The median score was 1, with variance of 0.62. No statistical differences were found between the two evaluation methods for the analyzed variables. This demonstrates the strong potential of the proposed evaluation techniques.Discussion: Our results show that the execution of the technique is possible, but some complications may occur. Mediastinoscopy as an evaluation procedure can pose some complications, these considerations are important, but by using technique proposed in this study, these factors are minimized due to the ease of technical implantation of the extraluminal tracheal stent, without the need for several instruments competing in the inflated mediastinal space. We concluded that the technique is viable and a safe method with minimal invasion for investigation and treatment of mediastinal diseases, presenting low impairment of the paratracheal structures, and that mediastinoscopy can be used as a transoperative evaluation method to minimize complications.

COMPRESSION OF THE LEFT MAIN BRONCHUS IN 3-MONTHS-OLD CHILD WITH TUBERCULOSIS LESION OF THE MEDIASTINAL LYMPH NODES

The article presents a case of successful surgical treatment of a 3-month-old child with a rare pathology – tuberculosis lesion of the intrathoracic lymph nodes causing compression of the left main bronchus. The child was admitted with signs of respiratory failure. An X-ray examination revealed signs of emphysema of the left lung. According to the data of contrast CT, a volumetric hypodensive formation was detected, which slightly accumulated contrast, with a capsule up to 0,3 cm thick, located in the area of the tracheal bifurcation, causing compression of the left main bronchus, esophagus, pulmonary bifurcation. During tracheobronchoscopy, a narrowing of the main bronchus to 1 mm was found immediately after bifurcation of the trachea. During the operation, a formation with a diameter of up to 2 cm was removed. According to the results of a morphological study, the formation is regarded as tuberculous granulomatous inflammation of the lymph node. The rarity of the pathology causes difficulties in diagnosis and treatment.

18F-FDG accumulation in less-affected lung area predicts postoperative interstitial lung disease acute exacerbation in lung cancer: A case control study

Background: Pneumonectomy for lung cancer with interstitial lung disease (ILD) has been shown to cause postoperative acute exacerbation (AE) of the ILD. The accumulation of 18F-flurodeoxyglucose (FDG) on normal parenchymal or less-affected lung fields in 18F-FDG-positron emission tomography (PET)/computed tomography (CT) has been reported to be related to ILD disease activity and prognosis. To determine whether 18F-FDG accumulation in normal parenchymal or less-affected lung fields on 18F-FDG-PET/CT can predict postoperative AE of ILD in non-small cell lung cancer (NSCLC) patients with ILD.Methods: This retrospective study included 36 NSCLC patients with ILD, who underwent 18F-FDG-PET/CT at 2 institutions before pulmonary surgery. A single volume-of-interest (VOI) was placed to measure the mean standardized uptake value (SUVmean) in normal or less-affected lung fields at 12 areas on the ventral and dorsal locations of both lungs, in each level of the aortic arch, tracheal bifurcation, and the orifice of the right lower pulmonary vein into the left atrium. The region to which the target VOI was set corresponded to no or minimally increased attenuation on high resolution CT. The SUVmean was defined as the mean SUV of the target VOI, SUVtissue fraction (TF) as the corrected SUVmean by using TF and mean computed tomography density (CTDmean) as the mean attenuation of the corresponding target VOI on HRCT. We performed a phantom study to optimize SUV difference among 2 institutions. The corrected SUVmean (cSUVmean) and corrected SUVTF (cSUVTF) were calculated based on the phantom study result.Results: Among 36 NSCLC patients with ILD who underwent pulmonary surgery, 8 patients developed postoperative AE of ILD. The cSUVmean values in the ventral and dorsal locations at the aortic arch level, and in the ventral location at the tracheal bifurcation level in the group with postoperative AE were higher than in the group without postoperative AE. There was no significant difference in the value of cSUVTF and CTDmean between the groups with and without postoperative AE.Conclusion: 18F-FDG accumulation in the normal or less-affected lung fields can potentially predict postoperative AE of ILD in NSCLC patients with ILD.

Management of Nonmalignant Tracheo- and Bronchoesophageal Fistula after Esophagectomy

Background Tracheo- or bronchoesophageal fistula (TBF) occurring after esophagectomy represent a rare but devastating complication. Management remains challenging and controversial. Therefore, the purpose of this study was to evaluate the outcome of different treatment approaches and to propose recommendations for the management of TBF. Methods From 2008 to 2018, 15 patients were treated because of TBF and were analyzed with respect to fistula appearance, treatment strategy (stenting, endoscopic vacuum therapy and/or surgical reintervention) and outcome. Results In each case, the fistula was small, located close to the tracheal bifurcation and associated simultaneously (n = 6, 40%) or metachronously (n = 9, 60%) with an anastomotic leakage. Latter was covered by esophageal stents in six patients which in turn resulted in occurrence of TBF at a later time in five patients. Management of TBF included conservative therapy (n = 3), stenting (n = 6), or suturing (n = 6). Ten patients underwent rethoracotomy. Treatment failure was observed in eight patients (53%). In all patients, treatment was accompanied by progressive sepsis. On the contrary, all seven patients with successful defect closure remained in good general condition. Conclusion Fistula appearance was similar in all patients. Implementation of esophageal stents cannot be recommended because of possibility of TBF at a later time point. Surgery is usually required and should preferably be performed when the patient's condition has been optimized at a single-stage repair. Esophageal diversion can only be recommended in patients with persisting mediastinitis. The key element for successful treatment of TBF, however, is control over sepsis; otherwise, outcome of TBF is devastating.