Jordan Kazakov

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.

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/

Transesophageal pulmonary nodule biopsy using endoscopic ultrasonography

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

Committee I: Indications for pulmonary cytology sampling methods

OBJECTIVE Parenchymal pulmonary nodules located in proximity to the mediastinum, vertebral column, major vessels, or behind the heart can be technically challenging and dangerous to biopsy using traditional image-guided techniques. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) can be used to access some of these difficult to reach lesions. The purpose of the present study was to report our experience with this technique in a consecutive cohort of selected patients. METHODS This was a retrospective cohort study. Eligible patients were identified from a prospective database. A transesophageal approach under real-time EUS guidance was performed using a 22-gauge needle. All patients underwent postprocedural chest radiography and were followed up at 30 days. RESULTS During a 31-month period, 55 patients underwent EUS-guided lung biopsy. Confirmatory visual correlation of nodule localization within the lung parenchyma between computed tomography and EUS was possible in 100% of cases. The lung nodule distribution was 41.5% right upper lung, 18.9% right lower lung, 28.3% left upper lung, and 11.3% left lower lung. Histologic and cytologic sampling was adequate in 52 of the 55 procedures (94.5%). In all patients with adequate biopsy sampling, accurate pathocytologic diagnoses of the target parenchymal nodules were obtained. The accuracy and sensitivity of EUS-FNA were both 94.5% and consistent with the diagnosis on pathologic resection or clinical progression of disease, or both. No morbidity resulted from the procedure nor was observed at 30 days. CONCLUSIONS EUS-FNA of parenchymal pulmonary nodules is safe and accurate and allows for biopsy of perimediastinal lung lesions not attainable using traditional techniques.

Modified technique for tracheobronchial Y-stent insertion using flexible bronchoscope for stent guidance

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pulmonary cytology including indications for bronchial brushings, washings and endobronchial ultrasound‐guided fine needle aspiration, technical recommendations for cytologic sampling, recommended terminology and classification scheme, recommendations for ancillary testing and recommendations for postcytologic diagnosis management and follow‐up. All recommendation documents are based on the expertise of the authors, extensive literature review and feedback from presentations at national and international conferences. This document selectively presents the results of these discussions. The present document summarizes the recommendations for clinical and imaging evaluation of pulmonary lesions along with the indications for cytologic studies regarding these abnormalities. Preprocedural requirements regarding brushing, washing and needle aspiration procedures are discussed also. Diagn. Cytopathol. 2016;44:1010–1023.

Endobronchial and Endoscopic Ultrasound-Guided Transvascular Biopsy of Mediastinal, Hilar, and Lung Lesions

From the Thoracic Surgery Department, Centre Hospitalier de L’Universit e de Montr eal, Montreal, Canada. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication March 20, 2015; revisions receivedMay 24, 2015; accepted for publication July 3, 2015; available ahead of print Aug 12, 2015. Address for reprints: Jordan Kazakov, MD, 11100 Euclid Ave, Cleveland, OH 44106 (E-mail: JordanKazakov@ gmail.com). J Thorac Cardiovasc Surg 2015;150:1005-9 0022-5223/

Palliation of Concomitant Tracheobronchial and Esophageal Disease Using a Combined Airway and Esophageal Approach

0.00 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.07.016

Committee II: Guidelines for cytologic sampling techniques of lung and mediastinal lymph nodes

BACKGROUND Endoscopic techniques, including endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS), are the initial approach for the diagnosis and staging of lung cancer and the diagnosis of mediastinal and hilar lesions. Historically, the transvascular approach has been avoided because of concerns of bleeding. Here we review our experience with EBUS and EUS transvascular biopsy of mediastinal, hilar, and lung lesions. METHODS A prospective research database was used to retrospectively identify and review the records 33 consecutive patients who underwent EBUS and EUS transvascular biopsy in an outpatient setting over 4 years. Complications were identified as significant hematoma seen with endoscopic ultrasound, hemothorax, hemoptysis other than minor, hemodynamic instability, hospital admission, and death. RESULTS The biopsies in 14 patients were performed through branches of the pulmonary artery, and 19 were done through the aorta. All EUS biopsies were performed with a 22-gauge needle, and all EBUS biopsies were performed with a 21-gauge needle. Malignancy was diagnosed with specimens from a transvascular biopsy in 16 patients (48.5%). Samples from 8 biopsies (24%) were described as negative for malignancy, and 9 specimens (27%) were described as insufficient. No complications were seen in the immediate postprocedural period, and all 33 patients were discharged home the same day. The median follow-up after the procedure was 12 months, with no complications described. The overall yield was 73%. CONCLUSIONS In this series, EBUS- and EUS-guided transvascular approach for biopsy of mediastinal, hilar, and lung lesions was not associated with significant complications. However, careful selection of potential candidates and close periprocedural observation are mandatory.

Pulmonary Hemorrhage following Edge-to-Edge Mitral Valve Repair

BACKGROUND Neoplastic involvement of the mediastinum can contribute to both airway and esophageal pathology. That can manifest as combined esophageal and airway stenosis, or tracheobronchoesophageal fistula. Conventional palliative treatment of these problems consists of endoluminal stent insertion. The double stenting approach consists of insertion of a tracheobronchial and an esophageal stent in parallel and allows concomitant symptomatic relief of both the airway and esophageal pathology. METHODS The study consists of a retrospective case series of patients who underwent a double stenting procedure for concomitant airway and esophageal disease between August 2009 and September 2014. The type of airway stent chosen was determined based on the pathology and the level of the lesion (simple tubular in the mid trachea or mainstem bronchus, Y-stent for carina). RESULTS Thirty-nine patients were treated using the double stenting approach during a combined procedure over 5 years: 15 patients with tracheobronchoesophageal fistula and 24 with stenosis. Immediate relief of symptoms, defined as resuming oral intake and breathing without an external tracheal device, was observed in 25 patients (64%). Thirty-two patients (82%) were discharged from hospital, and 7 patients died in hospital (18%). Of these 7 deaths, 6 patients died of pulmonary complications. Inhospital complications occurred in 11 patients (28%). Of the patients discharged from the hospital, 14 died during a mean follow-up period of 54 days. Mean and median survival were 49 and 24 days, respectively (range, 1 to 448), and median hospital stay was 3 days (range, 1 to 46). CONCLUSIONS Treatment of combined airway and esophageal pathology using a double stenting approach is safe, feasible, provides reasonable immediate palliation of symptoms, and is associated with acceptable morbidity. It is a palliative procedure that allows for early hospital discharge of patients who are diagnosed with an incurable malignancy.

Neurocysticercosis in the Infant of a Pregnant Mother with a Tapeworm

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pulmonary cytology including indications for bronchial brushings, washings, and endobronchial ultrasound guided transbronchial fine‐needle aspiration (EBUS‐TBNA), technical recommendations for cytological sampling, recommended terminology and classification schemes, recommendations for ancillary testing and recommendations for post‐cytological management and follow‐up. All recommendations are based on the expertise of the authors, an extensive literature review and feedback from presentations at national and international conferences. This document selectively presents the results of these discussions. The present document summarizes recommendations regarding techniques used to obtain cytological and small histologic specimens from the lung and mediastinal lymph nodes including rapid on‐site evaluation (ROSE), and the triage of specimens for immunocytochemical and molecular studies.