Gabriele Lucantoni

Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up

OBJECTIVE Interventional bronchoscopy is one of the modalities for palliation and definitive treatment of benign tracheal stenosis. There is however no general agreement on the management of this disease. Aim of this work is to define, in the largest group of patients presented in the literature, what types of tracheal stenosis are amenable to definitive treatment by interventional endoscopy. METHODS From January 1996 to June 2006 209 consecutive patients (105 men, 104 women) with benign tracheal stenosis were referred to our center. Etiology included 167 post-intubation and 34 cases of post-tracheostomy stenoses, 8 cases of other diseases. The lesions were classified into two groups: simple and complex. All but nine patients underwent interventional procedures (mechanical dilatation, laser photoresection and placement of a silicone stent). Two years follow-up was complete for all patients. RESULTS Simple stenoses (n=167) were treated by 346 endoscopic procedures (mean of 2.07 per patient), 16 stents and 1 end-to-end anastomosis. Thirty-eight granulomas were treated by 59 procedures (1.56 per patient), 97 concentrical stenoses by 228 procedures (2.35 per patient) and 32 web-like lesions with 59 operative endoscopies (1.84 per patient). Overall success rate was 96%. Among the 42 complex stenoses, 9 were immediately treated by surgical resection and the remaining 33 lesions underwent 123 endoscopic procedures (3.27 per patient), with 34 stents and 1 end-to-end anastomosis subsequent to recurrence after stent removal. In this group the success rate was 69%. CONCLUSIONS Our study shows that, after a correct classification and stratification, interventional endoscopy may have a crucial role in the treatment of tracheal stenoses. In particular, endoscopy should be considered the first choice for simple stenoses, whereas complex stenoses need a multidisciplinary approach and often require surgery.

Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment

OBJECTIVE Postintubation tracheobronchial lacerations (PITLs) are traditionally managed surgically. We sought to evaluate the rationale for non-surgical management of PITL. METHODS From January 2003 to November 2008, 30 patients with PITL were observed in our institution. PITL were graded as follows: Level I - mucosal or submucosal tracheal involvement without mediastinal emphysema and without oesophageal injury; Level II - tracheal lesion up to the muscular wall with subcutaneous or mediastinal emphysema without oesophageal injury or mediastinitis; Level IIIA - complete laceration of the tracheal wall with oesophageal or mediastinal soft-tissue hernia without oesophageal injury or mediastinitis; Level IIIB - any laceration of the tracheal wall with oesophageal injury or mediastinitis. All patients with Level I, II and IIIA PITL were treated conservatively with endoscopic instillation of fibrin glue (Tissucol, Baxter Healthcare, Deerfield, MA, USA). RESULTS All patients with Level I (n=3), II (n=24) and IIIA (n=2) PITL were successfully treated conservatively. The patient with a Level IIIB injury underwent posterolateral thoracotomy repair of the trachea. No mortality was reported. Mean hospital stay was 12.9 days. Flexible bronchoscopy at 7, 28, 90 and 180 days showed no abnormalities. Complete healing was attained in all patients by day 28. CONCLUSIONS Level I or II PITL should be managed non-surgically. When adequate respiratory status is present, Level IIIA PITL can be managed conservatively in selected institutions only, because these injuries are high-risk injuries. Any PITL associated with injury involving the oesophagus or with mediastinitis (Level IIIB) must be treated as soon as possible by surgery.

The lung cancer breath signature: a comparative analysis of exhaled breath and air sampled from inside the lungs

Results collected in more than 20 years of studies suggest a relationship between the volatile organic compounds exhaled in breath and lung cancer. However, the origin of these compounds is still not completely elucidated. In spite of the simplistic vision that cancerous tissues in lungs directly emit the volatile metabolites into the airways, some papers point out that metabolites are collected by the blood and then exchanged at the air-blood interface in the lung. To shed light on this subject we performed an experiment collecting both the breath and the air inside both the lungs with a modified bronchoscopic probe. The samples were measured with a gas chromatography-mass spectrometer (GC-MS) and an electronic nose. We found that the diagnostic capability of the electronic nose does not depend on the presence of cancer in the sampled lung, reaching in both cases an above 90% correct classification rate between cancer and non-cancer samples. On the other hand, multivariate analysis of GC-MS achieved a correct classification rate between the two lungs of only 76%. GC-MS analysis of breath and air sampled from the lungs demonstrates a substantial preservation of the VOCs pattern from inside the lung to the exhaled breath.

Bronchoscopic lung volume reduction for pulmonary emphysema: preliminary experience with a new NOVATECH® endobronchial silicone one-way valve

Bronchoscopic lung volume reduction represents a new palliative technique for the treatment of severe emphysema. We report the case of a patient with severe pulmonary emphysema that was successfully treated by the placement of a new, removable, unidirectional endobronchial silicone valve.

The Rationale for Treatment of Postresectional Bronchopleural Fistula: Analysis of 52 Patients

BACKGROUND Bronchopleural fistulas are a major therapeutic challenge. We have reviewed our experience to establish the best choice of treatment. METHODS From January 2001 to December 2013, the records of 3,832 patients who underwent pulmonary anatomic resections were retrospectively reviewed. RESULTS The overall incidence of bronchopleural fistulas was 1.4% (52 of 3,832): 1.2% after lobectomy and 4.4% after pneumonectomy. Pneumonectomy vs lobectomy, right-sided vs left-sided resection, and hand-sewn closure of the stump vs stapling showed a statistically significant correlation with fistula formation. Primary bronchoscopic treatment was performed in 35 of 52 patients (67.3%) with a fistula of less than 1 cm and with a viable stump. The remaining 17 patients (32.7%) underwent primary operation. The fistula was cured with endoscopic treatment in 80% and with operative repair in 88.2%. Cure rates were 62.5% after pneumonectomy and 86.4% after lobectomy. The cure rate with endoscopic treatment was 92.3% in very small fistulas, 71.4% in small fistulas, and 80% in intermediate fistulas. The cure rate after surgical treatment was 100% in small fistulas, 75% in intermediate fistulas, and 100% in very large fistulas. Morbidity and mortality rates were 5.8% and 3.8%, respectively. CONCLUSIONS The bronchoscopic approach shows very promising results in all but the largest bronchopleural fistulas. Very small, small, and intermediate fistulas with a viable bronchial stump can be managed endoscopically, using mechanical abrasion, polidocanol sclerosing agent, and cyanoacrylate glue. Bronchoscopic treatment can be repeated, and if it fails, does not preclude subsequent successful surgical treatment.

Syndrome of iron pill inhalation in four patients with accidental tablet aspiration: Severe airway complications are described

Iron pill inhalation represents a uncommon cause of syntomatic endobronchial foreign bodies. Unlike foreign body, the direct contact of iron tablet onto the bronchial mucosa results in severe bronchial damage in addition to obstruction and local irritation. Four patients with Iron Pill Inhalation Syndrome are described. All but one patient developed irreversible bronchial stenosis as late post inflammatory complication. Bronchoscopic features and clinical evolution are described in order to reduce the risk of severe side-effects in patients highly suspected for iron pill aspiration.

Endoscopic treatment of primary benign central airway tumors: Results from a large consecutive case series and decision making flow chart to address bronchoscopic excision

BACKGROUND Benign tracheo-bronchial neoplasms are rare, but potentially dangerous conditions with life threatening consequences. Tumor removal should be pursued by methods minimizing the procedural stress. The role of endoscopic treatment, as an alternative to open surgery, remains controversial. OBJECTIVES report the twelve-years endoscopic experience in Rome, Italy. Fifty-seven benign tracheo-bronchial tumors were diagnosed and 130 tracheo-bronchial resections by rigid bronchoscopy performed. METHODS we identified histotypes associated with higher recurrence rate and assessed their relationship with gender, age and tracheo-bronchial location. We provided data on safety and complications and suggested a decision making flow chart to address the patients to endoscopic resection. RESULTS complete eradication after a single procedure without recurrence at 2 years was obtained in 63.1% of cases (36/57). Need of a second intervention within few months but no further recurrence at follow up was seen in a further 8.8% (5/57). Histotypes associated with recurrence were papillomas and inflammatory polyp. Seven patients (12.3%) were addressed to surgery because of multiple recurrence. Ten patients (17.5%) were lost at follow up. In case of recurrence, the bronchial biopsy was always repeated and no malignant transformation was observed. No major complications, pneumothorax or pneumomediastinum occurred. CONCLUSIONS endoscopic treatment of benign tracheo bronchial tumors is safe and effective, provided that the procedure is carefully and systematically planned. The rate of eradication is satisfactory and the incidence of complications negligible. This will encourage this approach as first line treatment especially in patients, frequently elderly people, having increased surgical risk due to concomitant respiratory failure or major comorbidities.

Severity of Illness and Outcome in Patients With End-Stage Idiopathic Pulmonary Fibrosis Requiring Mechanical Ventilation

www.chestjournal.org tests before ARF onset, the associated comorbidities, and the parameters of continuous ventilation at admission were evaluated. Severity of illness was calculated using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Five patients (15%) survived and were discharged; one patient was still alive after 1 year. The in-hospital mortality rate observed in our study was different than Fernández-Pérez and coworkers’ results (85% vs 60%), but consistent with previous observations. 3 , 4 A possible explanation for the observed discrepancies could be found in the higher percentage of postoperative ARF reported by Fernández-Pérez et al (47% vs 3%); usually patients considered for surgical procedures have a better performance status and a more stable disease. 5 We identifi ed the APACHE score as the only factor associated with higher mortality rate: median 5 16, range 12 to 17 in survivors; and 20, range 11 to 32 in nonsurvivors; relative risk 5 1.64 (95% CI, 1.15-2.34) (Kaplan-Meier analysis median time 5 0 to both groups, log-rank test P 5 .015). No statistical differences (Mann-Whitney U test) were observed between survivors and nonsurvivors in age (58 years, range 47-76 vs 62 years, range 40-80, respectively), PEEP values (6.5 mm Hg, range 4-10 vs 7 mm Hg, range 5-10, respectively) and baseline PaO 2 /FiO 2 ratio (108, range 70-117 vs 100, range 49-190, respectively). On the one hand, we agree with Fernandez-Perez and coworkers that patients with IPF have little or no recruitable lung and may be susceptible to overdistension of the relatively intact lung when high PEEP levels are used during mechanical ventilation, leading to ventilator-induced lung injury. On the other hand, in our study the use of PEEP values similar to those employed by FernandezPerez et al in the survivors group was associated with a poor prognosis (in-hospital mortality rate: 85%), suggesting that the severity of disease should be considered critical for the outcome.

The Use of Polyvinyl Alcohol Sponge and Cyanoacrylate Glue in the Treatment of Large and Chronic Bronchopleural Fistulae following Lung Cancer Resection

Background: Bronchopleural fistulae represent a relatively rare complication of pulmonary resection. For inoperable patients, several endoscopic procedures have been described. In the presence of large and chronic bronchopleural fistulae, persistent air leaks require a surgical therapy, while endoscopic airway stent represents a useful palliative treatment. Objective: We describe the successful closure of large and chronic bronchopleural fistulae using an expandable polyvinyl alcohol (PVA) sponge and cyanoacrylate glue. Methods: In all patients, a rigid bronchoscope was used to insert a small cylinder of PVA sponge within the fistula. After releasing the patch, cyanoacrylate glue was applied directly on the PVA sponge using a channel catheter. This methodology induces an expansion of the clot and the closure of the air leak. The long-term outcome of treatment was checked by flexible bronchoscopy once every month for 3 months and every 6 months until 5 years. Results: We performed endoscopic treatment in 7 consecutive patients with bronchopleural fistula ranging from 4 to 8 mm. In 6 of 7 patients, the bronchial stump was the site of the fistula. In 1 patient, the fistula was visualized on the right wall of the distal trachea. A temporary complete occlusion of the fistula was achieved in 7 of 7 patients and a definitive result in 5 of 7 patients. Conclusions: The use of an expandable PVA sponge and cyanoacrylate glue is an available strategy for endobronchial closure of bronchopleural fistulae.

The technique of endoscopic airway tumor treatment

More than half of primary lung cancers are not resectable at diagnosis and 40% of deaths may be secondary to loco-regional disease. Many of these patients suffer from symptoms related to airways obstruction. Indications for therapeutic endoscopic treatment are palliation of dyspnea and other obstructive symptoms in advanced cancerous lesions and cure of early lung cancer. Bronchoscopic management is also indicated for all those patients suffering from benign or minimally invasive neoplasm who are not suitable for surgery due to their clinical conditions. Clinicians should select cases, evaluating tumor features (size, location) and patient characteristics (age, lung function impairment) to choose the most appropriate endoscopic technique. Laser therapy, electrocautery, cryotherapy and stenting are well-described techniques for the palliation of symptoms due to airway involvement and local treatment of endobronchial lesions. Newer technologies, with an established role in clinical practice, are endobronchial ultrasound (EBUS), autofluorescence bronchoscopy (AFB), and narrow band imaging (NBI). Other techniques, such as endobronchial intra-tumoral chemotherapy (EITC), EBUS-guided-transbronchial needle injection or bronchoscopy-guided radiofrequency ablation (RFA), are in development for the use within the airways. These endobronchial interventions are important adjuncts in the multimodality management of lung cancer and should become standard considerations in the management of patients with advanced lung cancer, benign or otherwise not approachable central airway lesions. We aimed at revising several endobronchial treatment modalities that can augment standard antitumor therapies for advanced lung cancer, including rigid and flexible bronchoscopy, laser therapy, endobronchial prosthesis, and photodynamic therapy (PDT).