Eric Goudie

Thoracoscopic localization of intraparenchymal pulmonary nodules using direct intracavitary thoracoscopic ultrasonography prevents conversion of VATS procedures to thoracotomy in selected patients

OBJECTIVES To investigate the feasibility, accuracy, and effect on conversion rates of intracavitary video-assisted thoracoscopic surgery ultrasonography (VATS-US) for localization of difficult to visualize pulmonary nodules. METHODS The study consisted of a prospective cohort of VATS-US for localization of intraparenchymal peripheral pulmonary nodules. Patients with pulmonary nodules not touching the visceral pleura on the computed tomography scan, who were scheduled for VATS wedge resection, were prospectively enrolled. The lobe of interest was examined: visually, using finger palpation when possible, and using the instrument sliding method. The nodule was then sought using a sterile ultrasound transducer. The primary outcome measure was the prevention of conversion to thoracotomy or lobectomy secondary to positive VATS-US findings in patients with nodules that were not identifiable using standard VATS techniques. RESULTS Four different surgeons performed 45 individual VATS-US procedures during a 13-month period. Intracavitary VATS-US was able to detect 43 of 46 nodules. The sensitivity of VATS-US was 93%, and the positive predictive value was 100%. The lung nodules were visualized by thoracoscopic lung examination in 12 cases (27%), palpable by finger in 18 cases (40%), and palpable using the instrument sliding technique in 17 cases (38%). In 20 cases, lung nodules were not identifiable using any of the traditional techniques and were identified only with VATS-US. VATS-US, therefore, prevented conversion to thoracotomy or lobectomy without tissue diagnosis in 43% (20/46) of cases. CONCLUSIONS Intracavitary VATS-US is a real-time, feasible, reliable, and effective method of localization of intraparenchymal pulmonary nodules during selected VATS wedge resection procedures and can decrease the conversion rates to thoracotomy or lobectomy.

Pilot study of pulmonary arterial branch sealing using energy devices in an ex vivo model

OBJECTIVE Vascular endostaplers are bulky and can be dangerous when dividing small pulmonary arterial (PA) branch vessels during video-assisted thoracoscopic lobectomy. We aimed to evaluate and compare the immediate efficacy of modern energy sealing devices in an ex vivo PA sealing model. METHODS Patients undergoing anatomical lung resection or lung transplantation were recruited for a prospective cohort pilot study. Four devices were evaluated: Harmonic Ace (Ethicon, Cincinnati, Ohio), Thunderbeat (Olympus, Tokyo, Japan), LigaSure (Covidien, Boulder, Colo), and Enseal (Ethicon; Cincinnati, Ohio). After anatomical lung resection, the PA branches were dissected in vitro. Sealing was then performed with 1 of the sealing devices, the vessel was slowly pressurized, and the bursting pressure was recorded. RESULTS Forty-nine PA branches were sealed in 14 patients. The mean PA branch diameter was 7.4 mm (1.8-14.5 mm). Ten patients had normal PA pressure and 3 had PA hypertension. The mean bursting pressure in each was as follows: Harmonic Ace group, 415.5 mm Hg (137.1-1388.4 mm Hg), Thunderbeat group, 875 mm Hg (237.1-2871.3 mm Hg); LigaSure group, 214.7 mm Hg (0-579.6 mm Hg); Enseal group, 133.7 mm Hg (0-315.38 mm Hg). There were 2 complete sealing failures: LigaSure (diameter 6.78 mm) and Enseal (diameter 8.3 mm). CONCLUSIONS In this pilot study to examine energy sealing of PA branches in a simulated ex vivo model, vascular sealing using energy was effective and was able to sustain high intraluminal bursting pressures. Further research is needed to determine the in vivo and long-term safety of PA branch energy sealing.

Prospective trial evaluating sonography after thoracic surgery in postoperative care and decision making

OBJECTIVE Following thoracic surgery, daily chest X-rays (CXRs) are performed to assess patient evolution and to make decisions regarding chest tube removal and patient discharge. Sonography after thoracic surgery (SATS) has the potential to be an effective, convenient, inexpensive and easy to learn tool in the post-operative management of thoracic surgery patients. We hypothesized that SATS could alleviate the need for repetitive CXRs, thus reducing the related risks, costs and inconvenience. METHODS This study consisted of a prospective cohort trial. All patients scheduled to undergo thoracic surgery at a single academic medical centre were eligible. Post-operative bedside pleural ultrasound was performed whenever a CXR was ordered by the treating team. Investigators specifically assessed patients with the goals of identifying pleural effusions and pneumothoraces. Study investigators were blinded to CXR results. SATS findings were compared with CXRs, which were considered the gold standard in routine post-operative pleural space evaluation. RESULTS One hundred and twenty patients were prospectively enrolled over a 5.5-month period. Three hundred and fifty-two ultrasound examinations were performed (mean = 3.0 ± 2.4 exams per patient). The time interval between the ultrasound and the comparative CXR was 166 ± 149 min. The mean time required to perform SATS was 11 ± 6 min per exam. In the detection of pleural effusion, SATS yielded a sensitivity of 83.1% and a specificity of 59.3%. In the detection of pneumothoraces, a sensitivity of 21.2% and a specificity of 94.7% were obtained. CONCLUSIONS Post-operative ultrasound may alleviate the need to perform routine CXR in patients with a previously ruled out pneumothorax. SATS used selectively may be able to reduce the number of routine CXRs performed; however, it does not have high enough accuracy to replace CXRs.

Pulmonary artery sealing with ultrasonic energy in open lobectomy: A phase I clinical trial

Objective: Pulmonary artery branch sealing in video‐assisted thoracoscopic surgical lobectomy is usually achieved with vascular endostaplers. Iatrogenic pulmonary artery injury may be caused by endostaplers. We evaluated the safety of pulmonary artery sealing with an ultrasonic energy vessel‐sealing device in a phase I clinical trial evaluating in vivo safety of the device during open lobectomy. Methods: Patients scheduled to undergo elective open (thoracotomy) pulmonary lobectomy were prospectively enrolled. Target sample size was 10 patients. Pulmonary artery diameter was measured intraoperatively. All branches ≤7 mm were divided with an ultrasonic energy vessel‐sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative and postoperative bleeding were strictly recorded. Results: Eighteen patients were prospectively enrolled. Eight patients were not amenable to pulmonary artery sealing with the device. In the 10 patients included in the analysis, a total of 14 pulmonary arteries were sealed with the ultrasonic device. The mean vessel diameter was 5 mm (range, 2–7 mm). One patient underwent reoperation for bronchial artery bleeding (vessel not sealed with device). There was no intra‐ or postoperative bleeding related to ultrasonic pulmonary artery sealing. There was no postoperative mortality. Conclusions: Pulmonary artery sealing for vessels with diameter ≤7 mm was safely achieved with an ultrasonic energy vessel‐sealing device in open lobectomy. The use of ultrasonic energy vessel‐sealing devices in video‐assisted thoracoscopic surgical lobectomy may have the advantage of making small, short, pulmonary artery branch sealing safer than with vascular endostaplers. Further studies are necessary before widespread application in lobectomy, including video‐assisted thoracoscopic surgical lobectomy.

Endoscopic lung abscess drainage with argon plasma coagulation.

From CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), University of Montreal, Montreal, Quebec, Canada. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication March 3, 2013; revisions received May 10, 2013; accepted for publication May 21, 2013; available ahead of print July 15, 2013. Address for reprints: Moishe Liberman, MD, PhD, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), Division of Thoracic Surgery, Centre Hospitalier de l’Universit e de Montr eal, 1560 Rue Sherbrooke E, 8e CD, Pavillon Lachapelle, Bureau D-8051, Montreal, Quebec H2L 4M1, Canada (E-mail: moishe.liberman@umontreal.ca). J Thorac Cardiovasc Surg 2013;146:e35-7 0022-5223/

Cervical Video-Assisted Thoracoscopic Surgery Using a Flexible Endoscope for Bilateral Thoracoscopy

36.00 Copyright 2013 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2013.05.031

Present and Future Application of Energy Devices in Thoracic Surgery.

Video-assisted thoracoscopic surgery (VATS) has become the standard of care for pleural evaluation, drainage, and pleurodesis. The major limitations to standard VATS techniques include intercostal pain and the unilateral nature of the procedure. We report on a cervical VATS approach for bilateral thoracoscopy, pleural biopsy, and talc pleurodesis using a flexible video endoscope without any intercostal incision. A 64-year old male with peritoneal carcinomatosis was noted to have significant bilateral pleural effusions. A cervical video-assisted thoracoscopic surgery (C-VATS) procedure was performed through a 2-cm cervical incision using a sterile flexible gastroscope. Bilateral thoracoscopy, pleural drainage, pleural biopsies, lung biopsy, and talc pleurodesis were performed. No thoracic intercostal incisions were performed. Total operative time was 48 minutes. The procedure was successful and the recovery was uneventful. The patient was discharged 4 days after the procedure. C-VATS is an extremely minimally invasive procedure. It avoids intercostal incisions and allows for bilateral pleural procedures through a single small cervical incision.

Evaluation of the Mediastinum: Differentiating Between Stations 4L, 5, and 6 Using EBUS and EUS

In the last decade, many energy devices have entered day-to-day practice in thoracic surgery. Some have proven and recognized applications, whereas others still require further trials. Nevertheless, currently used devices continue to be improved on and new applications for current devices will be evaluated. Ultimately, novel applications of energy in thoracic surgery and refinement in technology will hopefully allow for safer and less invasive techniques for patients requiring thoracic surgical procedures. In this article, we review the present and future applications of energy devices in thoracic surgery.

ATS Core Curriculum 2017: Part IV. Adult Pulmonary Medicine

Correct identification of mediastinal lymph node stations with endoscopic ultrasound (EUS) and endobronchial ultrasound (EBUS) requires knowledge of their ultrasonic anatomical positions and relations. The ultrasonic positions of the lymph node stations located in and around the aortopulmonary window (stations 4L, 5, and 6) can be more challenging to understand. The aim of this report is to describe the endosonographic anatomic positions of stations 4L, 5, and 6 and to demonstrate their locations using EUS and EBUS.

Cervical Video-Assisted Thoracoscopic Surgery (C-VATS)

Gaëtane C. Michaud, Colleen L. Channick, Caralee Caplan-Shaw, Jonathan M. Iaccarino, Christopher G. Slatore, Brett Bade, Nichole Tanner, Catherine Robitaille, Anne V. Gonzalez, Eric Goudie, Moishe Liberman, Deepankar Sharma, Samira Shojaee, Christopher M. Merrick, Fabien Maldonado, Quyen L. Nguyen, Belinda Rivera-Lebron, and Jason T. Poston Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts; Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, Oregon; Division of Pulmonary, Critical Care, and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina; Division of Respirology, McGill University, Montreal, Quebec, Canada; Department of Surgery, Division of Thoracic Surgery, University of Montreal, Montreal, Quebec, Canada; Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, Virginia; Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois