Eitan Podgaetz

Use of One-Way Intrabronchial Valves in Air Leak Management after Tube Thoracostomy Drainage

BACKGROUND A persistent air leak represents significant clinical management problems, potentially affecting morbidity, mortality, and health care costs. In 2008, a unidirectional, intrabronchial valve received humanitarian device exemption for use in managing prolonged air leak after pulmonary resection. Since its introduction, numerous reports exist but no large series describe current utilization or outcomes. Our aim was to report current use of intrabronchial valves for air leaks and review outcome data associated with its utilization. METHODS A multicenter, retrospective review of intrabronchial valve utilization from January 2013 to August 2014 was performed at eight centers. Data regarding demographics, valve utilization, and outcomes were analyzed. RESULTS We identified 112 patients undergoing evaluation for intrabronchial valve placement, with 67% (75 of 112) undergoing valve implantation. Nearly three quarters of patients underwent valve placement for off-label usage (53 of 75). A total of 195 valves were placed in 75 patients (mean 2.6 per patient; range, 1 to 8) with median time to air leak resolution of 16 days (range, 2 to 156). CONCLUSIONS We present the largest, multicenter study of patients undergoing evaluation for intrabronchial valve use for air leak management. Our data suggest the majority of intrabronchial valve placements are occurring for off-label indications. Although the use of intrabronchial valves are a minimally invasive intervention for air leak management, the lack of rigorously designed studies demonstrating efficacy remains concerning. Prospective randomized controlled studies remain warranted.

Cryotechnology in diagnosing and treating lung diseases.

Cryotechnology has been used in treating lung cancer for many years, now it is emerging to have a new indication in diagnosing lung diseases. Cryoprobe transbronchial lung biopsy has been introduced into clinical practice as a new technique, providing a larger biopsy specimen, potentially improving the diagnostic yield of transbronchial biopsies in parenchymal lung diseases. Although recent small pilot studies suggest that cryotransbronchial lung biopsies are comparable to conventional transbronchial biopsies in terms of diagnostic yield and safety profile in lung transplant patients, cryoprobe transbronchial lung biopsy is still being evaluated and its role in clinical practice is not well defined. Cryotherapy has been proven as a safe and effective method to debulk endobronchial lesions, providing palliation for advanced central obstructive tumors. Its use and efficacy is also studied in direct cryosurgery and percutaneous application in lung cancer. Cryoprobes can also be used to extract foreign bodies from the airways by causing cryoadhesion. We aim to summarize the therapeutic and diagnostic application of cryotechnology in pulmonary diseases.

Endobronchial Treatment of Bronchopleural Fistulas by Using Intrabronchial Valve System: A Case Series.

Air leaks, alveolopleural or bronchopleural fistulas, either spontaneous, iatrogenic, or postsurgical, can be difficult to treat, and if prolonged in spite of proper chest tube thoracostomy they may require surgical or chemical pleurodesis with variable success. Intrabronchial valve (IBV) treatment is minimally invasive and has a potential to shorten the duration of air leaks in well-selected patients with ongoing air leaks. The study included 19 patients with prolonged air leaks treated with IBVs spiration, with a total of 71 valves placed at a tertiary university hospital. Internal Board Review approval was obtained to use IBVs for off-label indication. IBVs were placed in desired airways with 100% accuracy in patients with air leaks without complications, including self-migration. All 19 patients with air leaks were initially treated with chest tube thoracostomy and in addition chemical pleurodesis in 2 and blood patch in a patient without success. After IBV placement, all patients but one with air leak had successful resolution of the air leak and removal of chest tube in a median of 3 days (range: 2-45 days). In conclusion, the use of IBVs for prolonged air leaks in various etiologies is effective and safe.

Endobronchial ultrasonography versus mediastinoscopy: a single-institution cost analysis and waste comparison.

BACKGROUND Mediastinoscopy (MED) and endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) have similar accuracy for mediastinal lymph node sampling (MLNS). The threatened financial and environmental sustainability of our health care system mandate that surgeons consider cost and environmental impact in clinical decision making of similarly effective procedures. We performed a cost and waste comparison of MED versus EBUS-TBNA for MLNS to raise awareness of the financial and environmental implications of our practices. METHODS We conducted a retrospective review of outpatients who underwent MLNS under general anesthesia in the OR with MED or EBUS-TBNA (September 2007 to December 2009). We analyzed direct costs based on hospital charges, calculated expected payment using a decision support model, and profit margins (modeled expected payment-direct costs). Our waste comparison was measured in kilograms of solid waste per case. RESULTS We performed MLNS in 148 patients (89 EBUS-TBNA, 39 MED, 20 EBUS + MED). Direct costs were lower for MED (

An Expectorated "Stent": An Unexpected Complication of EBUS-TBNA.

2,356) compared with EBUS-TBNA (

Best Approach and Benefit of Plication for Paralyzed Diaphragm.

2,503), whereas expected payment was greater (MED,

Intrabronchial Valve Treatment for Prolonged Air Leak: Can We Justify the Cost?

3,449; EBUS-TBNA,

Endobronchial valve therapy for a refractory air leak after lung transplantation in a patient with multiple connective tissue disorders.

3,249), resulting in a profit margin that was

Ultrasound-Guided Paravertebral Catheter Versus Intercostal Blocks for Postoperative Pain Control in Video-Assisted Thoracoscopic Surgery: A Prospective Randomized Trial

347 greater for MED. The amount of solid waste for each MED was 1.8 kg versus 0.5 kg for EBUS-TBNA. CONCLUSIONS MED costs less than EBUS-TBNA in the OR setting but generates 3.6 times the amount of EBUS-TBNA waste. The cost of EBUS-TBNA may improve by performance in the endoscopy suite, and surgical pack revision could reduce the amount of MED solid waste. This comparison sets the stage for sophistication of our clinical decision making, taking into consideration the major threats to our health care system.

Therapeutic Pneumoperitoneum: Relevant or Obsolete in 2015?

Endobronchial ultrasound-guided transbronchial needle aspiration has a low complication rate and is a cost-effective procedure for mediastinal staging and diagnosis when compared with the more invasive mediastinoscopy. There are increasing case reports of unexpected complications including equipment failures with and without significant medical consequences. Knowledge of complications, including those that are rare, is essential for the physician performing this minimally invasive procedure. We report a case of a retained foreign body from the unexpected separation of a distal spring/coil mechanism from the Olympus ViziShot Aspiration needle following early needle deployment within the working channel of the bronchoscope.