Arve Sundset

Endoscopic treatment of bronchial carcinoids in comparison to surgical resection: a retrospective study.

Background:Surgery is the gold standard of lung carcinoid treatment. However, bronchoscopic treatment may provide a complete cure in selected patients. The aim of the study was to review the results of laser treatment of bronchial carcinoids and to compare the outcome after laser resection against the outcome after surgical resection. Methods:Seventy-three patients, 29 men and 44 women, median age 53 years (range, 23 to 78 y), with bronchial carcinoids were treated by surgical resection (n=48) or endobronchial ablation (n=25). Bronchoscopic treatment was also performed in 5 of 48 surgical patients as a part of the surgical treatment strategy. Results:Among 25 patients treated endoscopically, 16 were successfully treated with laser, whereas 9 were operated subsequently. One major complication was registered, as an inadvertent ventilation caused a nonfatal fire of the bronchoscope during Nd:YAG laser procedure. Forty-eight patients underwent surgical resection. Most of the patients underwent lobectomy and bilobectomy (30 and 5 patients, respectively). Four of the patients were dead by the end of the study, 1 was treated with laser, and 3 treated with surgical resection. The overall survival was 94.5% in the surgical group and 94.4% in the group treated with endoscopic ablation (P=0.9). None of the 69 survivors had any sign of recurrence on computed tomographic scans and bronchoscopy by the end of the study. Conclusions:This is a retrospective study and no randomization has been performed. However, the results add evidence to the view that transbronchial laser treatment may be offered as a safe, stand-alone procedure in the treatment of typical carcinoid tumor in the central airways.

Airway complications after lung transplantation: long-term outcome of silicone stenting.

Background: Airway complications remain a significant cause of morbidity after lung transplantation. The majority of the centres that have published their results have used metal stents. Objectives: We report the long-term outcome of silicone stenting and subsequent stent removal in lung transplant recipients with stenotic airway complications. Method: From 1990 to 2008, 279 patients received 88 single, 170 double, and 21 heart-and-lung transplantations. Of 470 anastomoses at risk, 44 airway complications developed and were treated in 35 patients. Six lesions were treated with Nd:YAG laser and balloon dilatations only. Thirty-two silicone stents of Hood or Dumont type were inserted in 27 patients. Results: Symptoms were relieved and FEV1 increased in all patients (median 0.7 litres, range 0.1-1.8 litres, p < 0.0001). In 8 patients, stents had to be repositioned or reinserted, in 19 patients only one insertion and one removal procedure were necessary. One patient suffered a serious complication with haemorrhage and pneumonectomy, 3 patients had minor airway wall injuries resolving spontaneously. Six patients died with the stents from causes not related to the airway complications. Twenty-five stents could be removed after a median of 6 months (range 1-22) in 21 patients, and 22 airways remained patent. Median FEV1 was 2.3 litres immediately after stent removal, and remained 2.3 litres after 24 months. Conclusion: Stenotic airway complications after lung transplantation can be successfully treated with silicone stents, which can ultimately be removed, leaving a patent airway.

Transbronchial laser ablation of benign and malignant tumors

An overview is given over different methods for thermal ablation in central airways. The most widely used method, endoscopic laser photocoagulation (Nd:YAG laser) is described in some detail. Other methods are electrocautery, argon plasma coagulation, photodynamic treatment and cryotherapy. Thermal ablation is usually a palliative treatment, but is sometimes performed with a curative intent. Such treatment should be performed in specialized centres for interventional bronchoscopy, with a broad range of methods available.

Survival and complications after interventional bronchoscopy in malignant central airway obstruction: a single-center experience.

Background Patients with malignant airway obstruction may need endobronchial intervention to relieve the associated symptoms. We report our experience of interventional bronchoscopy with regard to complications and survival. Methods A total of 257 patients (167 men, 90 women, median age 67 y) were treated with 360 endobronchial procedures at our department in the period from 1998 to 2009. Kaplan-Meier and Cox regression methods were used for survival analysis. The log-rank test was used for comparison. Results Median survival after interventional bronchoscopy was 15 weeks. Eighteen patients died within 2 weeks after the procedure. Survival in the primary lung and metastatic cancer groups was 15 and 18 weeks, respectively (P=0.25). Survival in patients with small-cell lung carcinoma and nonsmall-cell lung carcinoma was 7 and 17 weeks, respectively (P=0.04). Serious complications such as bleeding (5), pneumothorax (1), and airway obstruction during the procedure (1) were rare (1.9%). All cases of serious hemorrhage occurred in patients with metastases from renal carcinoma. Conclusion Life expectancy in patients with malignant airway obstruction is short. There was no difference in survival between patients with primary and metastatic lung disease. Bronchoscopic treatment is safe and serious complications are rare. Serious hemorrhage is frequent when treating lung metastases from renal carcinoma.

Critical airway obstruction: challenges in airway management and ventilation during therapeutic bronchoscopy.

Background:Endobronchial interventions are used to alleviate symptoms of airway stenosis. The ventilatory management may be challenging during these procedures, and may influence the choice of airway device. We report our experiences from 902 procedures. Methods:Patients undergoing interventional bronchoscopy procedures were consecutively registered from 1999 to 2012. Critical airway obstruction (CAO) was defined as stridor, tracheal diameter <5 mm, stenosis of both the main bronchi, or clots/tumor fragments occluding the trachea or both main bronchi. Choice of airway, ventilation strategy, and survival are reported. Results are presented as median (interquartile range), and P⩽0.05 was considered significant. Results:A total of 561 patients underwent 902 interventional bronchoscopy procedures (mechanical debulking, laser resection, balloon dilatation, and stent placement). The procedures were performed using flexible bronchoscope through an endotracheal tube (68.2%) or laryngeal mask airway (10.4%), or by rigid bronchoscopy (9.3%). All patients were primarily ventilated by volume-controlled ventilation. CAO was classified in 60 procedures, with more frequent use of laryngeal mask airway (21.7%), and change of airway device in 20/60 procedures. The survival for patients with malignant disease with or without CAO was 100 and 182 days, respectively, with 90 days survival probability of 0.65 and 0.51 (P=0.14). Conclusions:Bronchoscopic treatment in patients with CAO may require a change of ventilatory and airway strategy during the procedure. Despite various challenges in the management of patients with CAO, the short-term survival in these patients is comparable to that in patients without CAO.

Changes in quality of life, dyspnea scores, and lung function in lung cancer patients with airway obstruction after a therapeutic bronchoscopy.

Background:Quality of life (QoL) has been closely linked with symptom intensity in lung cancer patients. It is therefore important to relieve respiratory distress in these severely ill patients, especially because their short life expectancy. This prospective study aimed to evaluate the impact of a therapeutic bronchoscopy on QoL, dyspnea, and lung function in patients with malignant airway obstruction. Methods:Fifteen cancer patients with airway obstruction were enrolled in the study. All patients were followed up during 2 months by 4 assessments that consisted of a clinical examination, QoL assessment using European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire with LC-13 module, Borg Dyspnea Scale, and lung function tests. Results:The study showed that therapeutic bronchoscopy had a rather persistent effect on QoL and dyspnea, which were sustained for at least 2 months after the procedure. The study population had also a significant improvement in lung function. Conclusion:Therapeutic bronchoscopy has a positive impact on QoL, dyspnea scale values, and lung function in patients with advanced lung cancer and airway obstruction.

Current Practice of Airway Stenting in the Adult Population in Europe: A Survey of the European Association of Bronchology and Interventional Pulmonology (EABIP).

Background: Airway stenting (AS) commenced in Europe circa 1987 with the first placement of a dedicated silicone airway stent. Subsequently, over the last 3 decades, AS was spread throughout Europe, using different insertion techniques and different types of stents. Objectives: This study is an international survey conducted by the European Association of Bronchology and Interventional Pulmonology (EABIP) focusing on AS practice within 26 European countries. Methods: A questionnaire was sent to all EABIP National Delegates in February 2015. National delegates were responsible for obtaining precise and objective data regarding the current AS practice in their country. The deadline for data collection was February 2016. Results: France, Germany, and the UK are the 3 leading countries in terms of number of centres performing AS. These 3 nations represent the highest ranked nations within Europe in terms of gross national income. Overall, pulmonologists perform AS exclusively in 5 countries and predominately in 12. AS is performed almost exclusively in public hospitals. AS performed under general anaesthesia is the rule for the majority of institutions, and local anaesthesia is an alternative in 9 countries. Rigid bronchoscopy techniques are predominant in 20 countries. Amongst commercially available stents, both Dumon and Ultraflex are by far the most commonly deployed. Finally, 11 countries reported that AS is an economically viable activity, while 10 claimed that it is not. Conclusion: This EABIP survey demonstrates that there is significant heterogeneity in AS practice within Europe. Therapeutic bronchoscopy training and economic issues/reimbursement for procedures are likely to be the primary reasons explaining these findings.

Q-Monitoring of ambulatory care in Switzerland – with the participation of the SRS!

Doctors want to ensure their patients receive the best possible treatment. With this in mind, their daily work is committed to quality assurance by means of case discussions, further training, reviewing standards of treatment etc. This commitment to quality is still insufficiently perceived by the general public and politicians, particularly in the ambulatory sector. This is where the “Q-Monitoring of ambulatory care in Switzerland” project (“Q-Monitoring”) plays an important part: using statistics, it aims to illustrate the spectrum of quality activities already being performed by doctors specializing in ambulatory treatment.