Laura Donahoe

CT-guided microcoil VATS resection of lung nodules: a single-centre experience and review of the literature

BACKGROUNDnVideo-assisted thoracoscopic surgery (VATS) is standard of care for small lung resections at many centres. Computed tomography (CT)-guided insertion of microcoils can aid surgeons in performing VATS resections for non-palpable lung nodules deep to the lung surface.nnnMETHODSnRetrospective analysis of CT-guided microcoil insertions prior to VATS lung resection at a single institution from October 2008 to January 2014.nnnRESULTSnA total of 63 patients were included (37% male, mean age 61.6±11.4 years). Forty-two patients (67%) had a history of smoking, with 10 current smokers. Sixty one (97%) patients underwent wedge resection and 3 (5%) patients had segmentectomy. Three (5%) patients required intra-operative staple line re-resection for positive or close margins. Eleven (17%) patients had a completion lobectomy, 5 of which were during the same anaesthetic. The average time between the CT-guided insertion and start of operation was 136.6±89.0 min, and average operative time was 84.0±53.3 min. The intra-operative complication rate was 5% (n=3), including 1 episode of hemoptysis, and 2 conversions to thoracotomy. The post-operative complication rate was 8% (5 patients), and included 2 air leaks, 1 hemothorax (drop in hemoglobin), 1 post chest tube removal pneumothorax, and one venous infarction of the lingula after lingula-sparing lobectomy requiring completion lobectomy. . Average post-operative length of stay was 2.2 days. A diagnosis was made for all patients.nnnCONCLUSIONSnCT-guided microcoil insertion followed by VATS lobectomy is safe, with short operative times, short length of stay and 100% diagnosis of small pulmonary nodules. This technique will become more important in the future with increasing numbers of small nodules detected on CT as part of lung cancer screening programs.

Extracorporeal life support as a bridge to lung transplantation–experience of a high-volume transplant center

Objectives: Extracorporeal life support (ECLS) is increasingly used to bridge deteriorating patients awaiting lung transplantation (LTx), however, few systematic descriptions of this practice exist. We therefore aimed to review our institutional experience over the past 10 years. Methods: In this case series, we included all adults who received ECLS with the intent to bridge to LTx. Data were retrieved from patient charts and our institutional ECLS and transplant databases. Results: Between January 2006 and September 2016, 1111 LTx were performed in our institution. ECLS was used in 71 adults with the intention to bridge to LTx; of these, 11 (16%) were bridged to retransplantation. The median duration of ECLS before LTx was 10 days (range, 0‐95). We used a single dual‐lumen venous cannula in 23 patients (32%). Nine of 13 patients (69%) with pulmonary hypertension were bridged by central pulmonary artery to left atrium Novalung. Twenty‐five patients (35%) were extubated while on ECLS and 26 patients (37%) were mobilized. Sixty‐three patients (89%) survived to LTx. Survival by intention to treat was 66% (1 year), 58% (3 years) and 48% (5 years). Survival was significantly shorter in patients undergoing ECLS bridge to retransplantation compared with first LTx (median survival, 15 months (95% CI, 0‐31) versus 60 months (95% CI, 37‐83); P = .041). Conclusions: In our center experience, ECLS bridge to first lung transplant leads to good short‐term and long‐term outcomes in carefully selected patients. In contrast, our data suggest that ECLS as a bridge to retransplantation should be used with caution.

High Risk for Thoracotomy but not Thoracoscopic Lobectomy

BACKGROUNDnPulmonary lobectomy is the standard of care for resection of non-small cell lung cancer (NSCLC). Patients with compromised lung function who are considered high risk may be denied surgical treatment; thus, proper identification of those truly at high risk is critical. Video-assisted thoracic surgery (VATS) may reduce the operative risk. This study reviews our institutional experience of pulmonary lobectomy by open thoracotomy or VATS techniques in patients deemed to be high risk.nnnMETHODSnA retrospective review of an institutional database was performed for all patients undergoing lobectomy from 2002 to 2010. Patients were grouped into high-risk (HR) and standard-risk (SR) cohorts according to the American College of Surgeons Oncology Group Z4099/Radiation Therapy Oncology Group 1021 criteria.nnnRESULTSnFrom 2002 to 2010, 72 HR and 536 SR patients underwent lobectomy. Mean age was 73 years for HRxa0and 66 years for SR (p < 0.0001). Rates of overall (pxa0<xa00.0001) and pulmonary complications (p < 0.0001) were significantly higher in the HR group. However, when HR patients were resected by VATS, there was no significant difference in overall (pxa0= 0.1299) or pulmonary complications (pxa0= 0.2292) compared with the SR VATS group. Moreover, overall survival was significantly lower for HR patients who had an open operation compared with VATS lobectomy or SR open (pxa0= 0.0028).nnnCONCLUSIONSnVATS lobectomy offers patients who are considered to be at increased risk for open lobectomy a feasible procedure, with no difference in overall survival compared with SR patients, and decreased morbidity compared with open lobectomy. VATS lobectomy should be considered for patients who historically may not have been considered for surgical resection.

Role of extracorporeal life support after pulmonary endarterectomy: a single-centre experience

OBJECTIVESnExtracorporeal life support (ECLS) for rescue after pulmonary endarterectomy (PEA) has become a viable option. This study aims to present a single-centre experience looking at the indications and outcome of ECLS after PEA.nnnMETHODSnRetrospective analysis of all patients undergoing PEA from January 2008 to January 2015 in our institution.nnnRESULTSnAmong 144 consecutive patients undergoing PEA for chronic thromboembolic pulmonary hypertension, 6 (4%) received ECLS postoperatively for right ventricular (RV) failure (n = 3), severe hypoxaemia (n = 2) and haemorrhagic pulmonary oedema (n = 1). ECLS configuration was central veno-arterial (cVA) in 3 patients, peripheral VA (pVA) in 1 and veno-venous (VV) in 2. One patient with cVA was switched to VV after 5 days. Overall ECLS duration ranged between 3 and 39 (median 5) days. ECLS patients had higher preoperative total pulmonary vascular resistance (TPR) compared with non-ECLS patients (1477 ± 671 vs 954 ± 462 Dynes.s.cm(-5), P = 0.009) and more frequently required hospital admission for RV failure before surgery (50 vs 9%, P = 0.02). The overall in-hospital mortality rate for all patients was 2% (3/144), including one ECLS patient on pVA. The remaining 5 ECLS patients (83%) were discharged from the hospital and are alive after a median follow-up of 11 (range 6-27) months. Two ECLS patients (40%) are on therapy for residual PH compared with 13 (10%) in the non-ECLS patients (P = 0.09).nnnCONCLUSIONSnECLS is a safe and important rescue option after PEA. The use of ECLS may expand eligibility for PEA by allowing sicker patients to undergo surgery.

Developing a National, Simulation-Based, Surgical Skills Bootcamp in General Thoracic Surgery

BACKGROUNDnThe use surgical simulation across all subspecialties has gained widespread adoption in the last decade. A number of factors, including the small number of trainees, identified gaps in surgical skill training from cross-sectional surveys, increased national collaboration, and support from the national specialty committee identified a need to construct a surgical skills bootcamp in thoracic surgery in Canada.nnnOBJECTIVEnThe goals of the surgical skills bootcamp, as identified by the residency training program directors and the national specialty committee were to create a national, centralized, simulation-based skills workshop that focused on key foundational procedures within thoracic surgery, particularly those identified as areas of weakness by former residents; to smooth the transition to intraoperative teaching; to provide exposure to important but not necessarily universally available procedures such as advanced endoscopy; to teach non-medical expert competencies, and lastly to provide a venue for networking for residents across the country.nnnDESIGNnThe curriculum committee has constructed a 3.5 day curriculum, with a focus on hands-on skills simulation, as well as lectures, on a breadth of topics including benign esophageal disorders, lung cancer staging, minimally invasive lung surgery, crisis management and advanced bronchoscopy and endoscopy. All residents across the country attend as well as faculty from a variety of institutions.nnnSETTINGnThe course is hosted centrally at the University of Toronto, Ontario over 3.5 days. A combination of auditorium and both animal and human operating room facilities are utilized.nnnMETHODSnA needs-assessment based on a formal meeting of the program directors, as well feedback from surveys identified the target areas for curriculum development. A committee of interested faculty developed the content as well as the local construct and logistics required. Iterative feedback has evolved the duration and content over the initial 3 years.nnnRESULTSnThrough formal resident feedback, national subspecialty committee review, and program director meetings the support for the bootcamp has been overwhelmingly positive. Specific resident feedback for structure, content and specific simulations has been favorable, but has also been used to modify the program.nnnCONCLUSIONnIn response to identified weaknesses in training, with the support of the national specialty committee, the residency program directors, and the faculty at the University of Toronto, an intensive simulation based thoracic surgery bootcamp has successfully been created for Canadian thoracic surgery residents.

Contemporary Management of Idiopathic Laryngotracheal Stenosis

Idiopathic laryngotracheal stenosis is a rare but well-described indication for subglottic tracheal resection. Initially described by Pearson in 1975, the 1-stage subglottic tracheal resection with reconstruction of the airway ensures preservation of the recurrent laryngeal nerves while resulting in an effective and durable repair of the stenosis.

Induction radiotherapy and mesothelioma surgery

Malignant pleural mesothelioma (MPM) continues to be one of the most difficult malignancies to diagnose and treat. Despite many attempts to improve the prognosis, the disease remains almost uniformly fatal with little hope for long-term survival. Many studies of radiation and surgery, either alone or combined, have been performed, but the results of treatment remain poor and most patients recur either locally or distally. In an effort to prolong survival and improve the prognosis of MPM, the Surgery for Mesothelioma After Radiation Therapy (SMART) trial was developed. Based on the idea that local control, and potentially overall survival, could be improved with high-dose radiation followed by aggressive surgery, this protocol involves a total of 25 Gy of radiation delivered in 5 daily fractions over one week to the entire ipsilateral hemithorax by intensity modulated radiation therapy (IMRT) with a concomitant boost of 5 Gy to volumes at high risk based on computed tomography (CT) and positron emission tomography (PET) scan findings. Within two weeks of completion of the radiation therapy, extra-pleural pneumonectomy (EPP) is performed. The interim results of this study have shown encouraging outcomes for select patients with MPM.

P2.01-76 The Impact of Concordance with a Lung Cancer Diagnosis Pathway Guideline on Treatment Access in Patients with Stage IV Lung Cancer

patients with non-surgical stage disease (n1⁄410); 2) imprinted cytological samples from positive mediastinoscopies during the intraoperative staging of patients with lung cancer (n1⁄411); 3) positive pleural fluid in patients with pulmonary nodule (n1⁄42). Then we performed FISH technique, evaluated the quality of the signal obtained, and compared the results with those obtained on paraffin sections. FISH technique on paraffin blocks was performed using 2XSSC/ proteinase K pretreatment as standardized by our lab. Cytology smears were destained and fixed in 10% methanol and incubated with FISH probe (ALK, ROS1 and MET). Result: All cytology cases had scorable signals and were easy to interpret. Also, as no pretreatment was required, assay time was shorter. Depending on cellularity, one same slide was useful for analysis of the three probes. When comparing with IHC and FISH studies, we obtained a 100% correlation with ALK (n1⁄423; positive1⁄42, negative1⁄421), ROS1 (n1⁄45, all negative) and MET (n1⁄45, all negative). Conclusion: This work allowed us to optimize the use of different cytology samples frequently available in advance stage NSCLC for FISH studies. The use of cytological material might improve turnaround time for results and can become a useful tool in pathology labs, in particular when paraffin included material is limited. Keywords: cytology, FISH

Intraoperative extracorporeal support during lung transplantation in patients bridged with venovenous extracorporeal membrane oxygenation

BACKGROUNDnVenovenous (VV) extracorporeal membrane oxygenation (ECMO) is the preferred configuration for bridging respiratory failure patients while awaiting lung transplantation. However, there is no consensus on intraoperative extracorporeal cardiopulmonary support during lung transplantation in these patients.nnnMETHODSnThe configuration of the intraoperative extracorporeal circuit after VV ECMO bridge was reviewed and correlated with clinical outcomes. This retrospective cohort study performed at our university hospital included 34 patients who were successfully bridged solely with VV ECMO to lung transplantation during the period 2007 to 2016. Indications to switch to intraoperative venoarterial (VA) ECMO were hemodynamic compromise (systemic hypotension or mean pulmonary artery pressure >40 mm Hg) or when this scenario was thought to be highly likely.nnnRESULTSnThe median duration of bridging was 12 (IQR 7 to 19) days. Intraoperatively, 3 patients (8.8%) required cardiopulmonary bypass. Twenty patients (58.8%) stayed on VV ECMO and 11 (32.3%) were switched to central VA ECMO. Between the 2 types of intraoperative ECMO (VV vs VA), there were no significant differences in post-operative ECMO duration, chest reopening for bleeding, or renal replacement therapy. There was no significant difference in 90-day mortality (0% and 9.0%, pu202f=u202f0.35) or in long-term survival (pu202f=u202f0.59). The intraoperative transfusion of red blood cells tended to be higher in the VA group (5 [4 to 9] vs 8 [6 to 13] units, pu202f=u202f0.06). Use of intraoperative VA ECMO was associated with the use of low-flow VV device bridging and lobar transplantation.nnnCONCLUSIONSnUsing the existing VV ECMO bridge intraoperatively during lung transplantation is feasible and provides comparable outcomes to patients converted to central VA ECMO for compromised hemodynamics.

Symptoms Are More Useful Than Echocardiography in Patient Selection for Pulmonary Endarterectomy

BACKGROUNDnChronic thromboembolic pulmonary hypertension (CTEPH) is still largely underdiagnosed in the general population. Although transthoracic echocardiogram (TTE) is recommended to screen for CTEPH, it may not detect patients with chronic thromboembolic disease (CTED) and mild or exercise-induced pulmonary hypertension (PH) who could also benefit from pulmonary endarterectomy (PEA).nnnMETHODSnAll patients referred to our CTEPH program with persistent mismatched perfusion defects on ventilation-perfusion (VQ) scan between January 2005 and June 2015 were divided into three groups according to TTE and right heart catheterization (RHC) as follows: (1)xa0typical CTEPH group (PH on RHC and TTE), (2) TTE-negative (neg) CTEPH group (PH on RHC, but not TTE), or (3) CTED group (no PH on RHC and TTE).nnnRESULTSnOf 225 patients with abnormal VQ scans, 188 (84%) had typical CTEPH, 15 had TTE-neg CTEPH, and 22 had CTED. PEA was performed in 179 patients (80%). Reasons for exclusion in CTEPH patients included primarily distal disease (nxa0= 11) and comorbidities (nxa0= 10). In contrast, the absence of functional limitation was the main cause of exclusion in CTED patients (75% versus 3% in CTEPH patients, p < 0.0001). The 90-day mortality rate after PEA was 4% in the typical CTEPH group and 0% in the TTE-neg CTEPH and CTED groups. Pulmonary arterial pressures and functional class significantly improved after PEA in all three groups.nnnCONCLUSIONSnPatients with mild CTEPH can benefit from PEA, but may not be detected by TTE. Symptomatic patients with functional limitation and persistent mismatched perfusion defects on VQ scan should undergo further investigations with pulmonary angiogram and RHC.