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Background: Image-guided percutaneous thermal ablation is an established treatment option for early-stage lung cancer in medically inoperable patients but carries a high risk of pleura-related complications, particularly pneumothorax. Objective: This study aimed to determine if image-guided transbronchial microwave ablation (tMWA) is a feasible approach to treat peripheral stage 1 lung cancer. Method: A prospective, single-arm, multicenter study sought to enroll 40 adults who were medically inoperable or declined surgery for peripheral stage 1 lung tumors (≤20 mm). Ablation was performed using navigational bronchoscopy and a flexible MWA probe, guided by cone-beam CT with augmented fluoroscopy. Follow-up at 1, 6, and 12 months included CT imaging of the ablation zone and possible tumor recurrence, adverse events (AEs), pulmonary function, and quality of life. Results: Across 2 sites, 11 tumors (10 NSCLC, 1 carcinoid) were treated in 10 enrolled patients. Median tumor diameter was 13 × 14 mm (7–19 mm) and median minimum ablative margin was 11 mm (5–19 mm). Technical success and technique efficacy were achieved in all patients. No tumor recurrence was seen during 12-month follow-up. No pneumothorax, pleural effusion, or bronchopleural fistula were noted. Minor AEs included scant hemoptysis, pain, cough, and dyspnea. Two serious AEs occurred ≤30 days of ablation and included a COPD exacerbation (day 9) and a death of unknown cause (day 15). The death led the sponsor to halt enrollment. Pulmonary function and quality-of-life indices remained stable. Conclusions: Image-guided tMWA is a technically feasible approach for peripheral early-stage lung cancer but warrants further evaluation of safety and efficacy in larger cohorts.

BACKGROUND: Percutaneous ablation is an alternative treatment for lung cancer in non-operable patients. This is a prospective clinical trial for percutaneous microwave ablation (pMWA) of biopsy-proven lung cancer to demonstrate safety and efficacy. METHODS: A prospective trial from 6-1-2016 to 1-1-2019 enrolled patients with biopsy-proven primary or metastatic lung cancer

This report describes the Ion Endoluminal System (Intuitive Surgical, Inc, Sunnyvale, CA) and practices for safe and effective use in patients with small peripheral pulmonary nodules (PPNs).This shape-sensing robotic-assisted bronchoscopy system allows airway visualization and navigation to reach and biopsy small PPNs through a stable platform. The system provides 3-dimensional mapping and visualization of the airways, a flexible and fully articulating 3.5-mm (outer diameter) catheter, a peripheral vision probe, and system-specific biopsy needles.The Ion Endoluminal System was evaluated in an ongoing prospective, multicenter trial including 241 patients with 270 PPNs (largest mean cardinal measurement, 18.8 ± 6.5 mm). Mean time to register and navigate decreased from 10 minutes in the first 10 cases to 7 minutes in the subsequent cases. Asymptomatic pneumothorax occurred in 8 patients (3.3%), 1 (0.4%) with pigtail catheter placement. Two patients (0.8%) experienced airway bleeding; both cases of bleeding resolved within 5 minutes of tamponade.The Ion Endoluminal System's unique shape-sensing technology can be leveraged to facilitate localization and sampling of PPNs and potentially improve diagnostic accuracy.

BACKGROUND Contemporary data on lung volume reduction surgery (LVRS) is sparse, particularly in regard to utilization and surgical outcomes. In this context, we analyzed the practice patterns and outcomes of LVRS nationally. METHODS We identified all patients (n = 1617) undergoing LVRS at 165 hospitals between 2001 and 2017 from The Society of Thoracic Surgeons (STS) General Thoracic Database. Practice patterns were assessed at the hospital and STS regional levels. In addition, we obtained regional chronic obstructive pulmonary disease prevalence data from the Centers for Disease Control. We used hierarchical logistic regression to estimate associations with each outcome of interest and calculate risk- and reliability-adjusted outcome rates. RESULTS Since 2011, national LVRS utilization has been increasing with decreasing mortality rates (3.1% risk-adjusted mortality in 2016). There is wide regional variation in LVRS average caseload that is not congruent with national chronic obstructive pulmonary disease prevalence (Pearson correlation coefficient -0.11). On multivariable analysis, only older age (adjusted odds ratio 1.05, P < .001), male sex (adjusted odds ratio 1.5, P = .007), underweight body mass index (adjusted odds ratio 1.94, P = .027), and ECOG score of 4 (adjusted odds ratio 5.17, Z-score 3.91, P = .001) were associated with the occurrence of the composite outcome of major morbidity or mortality. At the hospital level, six hospitals performed 40% of all LVRS nationally with adjusted national 30-day mortality rate of 4.3% and composite outcome rate of 15.8%. Despite this, there was minimal variation in adjusted outcome rates. CONCLUSIONS National utilization of LVRS is increasing and it has become safer overall, even at lower volume hospitals. There is regional variation in LVRS use that does not mirror national chronic obstructive pulmonary disease prevalence, suggesting access disparities. The findings have potential policy implications.

SARS-CoV-2 mRNA vaccination induces robust humoral and cellular immunity in the circulation; however, it is currently unknown whether it elicits effective immune responses in the respiratory tract, particularly against variants of concern (VOCs), including Omicron. We compared the SARS-CoV-2 S–specific total and neutralizing antibody responses, and B and T cell immunity, in the bronchoalveolar lavage fluid (BAL) and blood of COVID-19–vaccinated individuals and hospitalized patients. Vaccinated individuals had significantly lower levels of neutralizing antibody against D614G, Delta (B.1.617.2), and Omicron BA.1.1 in the BAL compared with COVID-19 convalescents despite robust S-specific antibody responses in the blood. Furthermore, mRNA vaccination induced circulating S-specific B and T cell immunity, but in contrast to COVID-19 convalescents, these responses were absent in the BAL of vaccinated individuals. Using a mouse immunization model, we demonstrated that systemic mRNA vaccination alone induced weak respiratory mucosal neutralizing antibody responses, especially against SARS-CoV-2 Omicron BA.1.1 in mice; however, a combination of systemic mRNA vaccination plus mucosal adenovirus-S immunization induced strong neutralizing antibody responses not only against the ancestral virus but also the Omicron BA.1.1 variant. Together, our study supports the contention that the current COVID-19 vaccines are highly effective against severe disease development, likely through recruiting circulating B and T cell responses during reinfection, but offer limited protection against breakthrough infection, especially by the Omicron sublineage. Hence, mucosal booster vaccination is needed to establish robust sterilizing immunity in the respiratory tract against SARS-CoV-2, including infection by the Omicron sublineage and future VOCs.

Background A prolonged air leak (PAL) is the most frequent complication after pulmonary resection. This study aimed to assess the safety and efficacy of autologous blood patch pleurodesis (ABPP) to treat PAL. Methods A prospectively maintained database identified patients with a PAL after pulmonary resection for lung cancer between 2015-2019. In this observational cohort study, clinical data were collected to retrospectively compare patients undergoing ABPP to no ABPP in a propensity-matched analysis. Kaplan Meier estimates and Cox models accounting for inverse probability weighting (IPTW) were used to assess the association of ABPP with each outcome. Results Of the 740 patients undergoing lung resection, 110 (15%) were identified as having a PAL at postoperative day (POD) 5. There was no difference between baseline characteristics among those undergoing ABPP (n=34) versus no ABPP (n=76). Propensity-weighted analysis did not reveal a significant association of ABPP treatment with in-hospital complication (P=0.18), hospital length of stay (LOS) (P=0.13), or post-discharge complication (P=0.13). However, ABPP treatment was associated with a lower risk of hospital readmission [P=0.02, hazard ratio (HR) 0.16] and reoperation for air leak or empyema (P=0.05, HR 0.11). Although not statistically significant, the mean chest tube (CT) removal of 11 days for the ABPP group was less than the no ABPP group (16 days) (P=0.14, HR 1.5-2). Those treated with ABPP were less likely to be discharged with a CT (ABPP 7/34, 21% vs. no ABPP 40/76, 53%). There was no statistical difference in empyema development between groups (ABPP 0/34, 0% vs. no ABPP 4/76, 5%, P=0.39, HR 0.24). Conclusions ABPP administration is safe compared to traditional PAL management. In a retrospective propensity-matched analysis, postoperative patients treated with ABPP required less readmission and reoperation for PAL. Larger powered randomized trials may demonstrate the magnitude of benefit from treatment with ABPP.

Robotic assisted bronchoscopy represents a major turning point in bronchoscopic history. The management strategies to address significant airway bleeding in this “robotic era” are not well documented, and further guidance is required. We present a case report that exemplifies our approach and management strategy using a combined and simultaneous flexible/robotic bronchoscopy if this complication is encountered.

Objective: To assess the contribution and safety of bronchoscopic cryobiopsy vs traditional forceps biopsy used in clinical practice for diagnosing diffuse parenchymal lung disease (DPLD). Patients and Methods: We identified 271 patients who underwent bronchoscopic biopsy for DPLD at Mayo Clinic, MN (June 1, 2013, through September 30, 2017). Medical records were reviewed including prebiopsy clinical and radiographic impressions. Diagnostic yield was assessed in terms of a specific histologic pattern resulting in a diagnosis when combined with the clinical-radiologic context. Clinical utility was defined as a biopsy result deemed useful in patient management. Results: The cohort included 120 cryobiopsy and 151 forceps biopsy cases with mean age 61±14 years and 143 (53%) men. Diagnostic yield (55% vs 41%; odds ratio [OR], 1.73; 95% CI, 1.07 to 2.83; P=.026) and clinical utility (60% vs 40%; OR, 2.21; 95% CI, 1.36 to 3.63; P=.001) were higher for the cryobiopsy group, and the association remained after control for prebiopsy clinical impressions (OR, 2.21; 95% CI, 1.22 to 4.08; P=.010 and OR, 3.23; 95% CI, 1.76 to 6.10; P

Background Patient-reported reflux is among the most common symptoms after esophagectomy. This study aimed to determine predictors of patient-reported reflux and to ascertain whether a preserved pylorus would protect patients from symptomatic reflux. Methods A prospective clinical study recorded patient-reported reflux after esophagectomy from August 2015 to July 2018. Eligible patients were at least 6 months from creation of a traditional posterior mediastinal gastric conduit, had completed at least 1 reflux questionnaire, and had the pylorus treated either temporarily (≥100 IU Botox [onabotulinumtoxinA]) or permanently (pyloromyotomy or pyloroplasty). Results Of the 110 patients meeting inclusion criteria, the median age was 65 years, and 88 of the 110 (80%) were male. Botox was used in 15 (14%) patients, pyloromyotomy in 88 (80%), and pyloroplasty in 7 (6%). A thoracic anastomosis was performed in 78 (71%) patients, and a cervical anastomosis was performed in 32 (29%). Esophagectomy was performed for malignant disease in 105 of 110 (95%), and 78 of 110 (71%) patients were treated with perioperative chemoradiation. Multivariable linear regression analysis revealed that patient-reported reflux was significantly worse in patients with shorter gastric conduit lengths (P = .02) and in patients who did not undergo perioperative chemoradiation (P = .01). No significant difference was found between patients treated with pyloric drainage and those treated with Botox. Conclusions The absence of perioperative chemoradiation therapy and a shorter gastric conduit were predictors of patient-reported reflux after esophagectomy. Although few patients had Botox, preservation of the pylorus did not appear to affect patient-reported reflux. Further objective studies are needed to confirm these findings.

SARS-CoV-2 mRNA vaccination induces robust humoral and cellular immunity in the circulation; however, it is currently unknown whether it elicits effective immune responses in the respiratory tract, particularly against variants of concern (VOCs), including Omicron. We compared the SARS-CoV-2 S-specific total and neutralizing antibody (Ab) responses, and B and T cell immunity, in the bronchoalveolar lavage fluid (BAL) and blood of COVID-19 vaccinated individuals and hospitalized patients. Vaccinated individuals had significantly lower levels of neutralizing Ab against D614G, Delta and Omicron in the BAL compared to COVID-19 convalescents, despite robust S-specific Ab responses in the blood. Further, mRNA vaccination induced significant circulating S-specific B and T cell immunity, but in contrast to COVID-19 convalescents, these responses were absent in the BAL of vaccinated individuals. Using an animal immunization model, we demonstrate that systemic mRNA vaccination alone induced weak respiratory mucosal neutralizing Ab responses, especially against SARS-CoV-2 Omicron; however, a combination of systemic mRNA vaccination plus mucosal adenovirus-S immunization induced strong neutralizing Ab response, not only against the ancestral virus but also the Omicron variant. Together, our study supports the contention that the current COVID-19 vaccines are highly effective against severe disease development, likely through recruiting circulating B and T cell responses during re-infection, but offer limited protection against breakthrough infection, especially by Omicron. Hence, mucosal booster vaccination is needed to establish robust sterilizing immunity in the respiratory tract against SARS-CoV-2, including infection by Omicron and future variants.

Objective To collect patient-reported outcomes after esophagectomy to establish a set of preliminary normative standards to aid in symptom-score interpretation. Patients and Methods Patients undergoing esophagectomy often have little understanding about postoperative symptom management. The Mayo Clinic esophageal CONDUIT tool is a validated questionnaire comprising 5 multi-item symptom-assessment domains and 2 health-assessment domains. A prospective nonrandomized cohort study was conducted on adult patients who have had esophagectomies using the CONDUIT tool from August 17, 2015, to July 30, 2018 (NCT02530983). The Statistical Analysis System v9.4 (SAS Institute Inc., Cary, NC) was used to calculate and analyze the scores. Results Over the study period, 569 patients were assessed for eligibility, and 241 patients consented and were offered the tool. Of these, 188 patients (median age: 65 years; range: 24 to 87 years; 80% male patients) had calculable scores. Of the 188 patients, 50 (26.6%) patients were identified as potential beneficiaries for educational intervention to improve symptoms (received moderate scores for a domain), and 131 (69.7%) patients were identified as needing further testing or provider intervention (received poor scores for a domain) based on the tool. Conclusion The CONDUIT tool scores, when compared with standardized scales with established preliminary normative scores, could be used to identify and triage patients who need targeted education, further testing, or provider interventions. These score ranges will serve as the first set of normative standards to aid in the interpretation of conduit performance among providers and patients.

Introduction Bronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBVs) has emerged as an important treatment method for patients with severe chronic obstructive pulmonary disease (COPD). Acute exacerbations of COPD (AECOPD) are a frequent complication following BLVR with EBV. However, there is no consensus on the prevention of AECOPD. Objectives Our study aims to compare the outcomes of different prophylactic measures on the occurrence of AECOPD after BLVR with EBV. Methods We conducted a multicenter, retrospective study of patients who underwent BLVR with EBV at six different institutions. Emphasis was directed towards the specific practices aimed at preventing AECOPD: antibiotics, steroids, antibiotics plus steroids, or no prophylaxis. Subgroups were compared, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated. Results A total of 170 patients were reviewed. The rate of AECOPD was 21.2% for the full cohort. Patients who received prophylaxis had a significantly lower rate of AECOPD compared with those who did not (16.7% vs. 46.2%; p = 0.001). The rate was lowest in patients who received antibiotics alone (9.2%). There was no significant difference in the rate of AECOPD between patients who received steroids alone or antibiotics plus steroids, compared with the other subgroups. The OR for AECOPD was 4.3 (95% CI: 1.8-10.4; p = 0.001) for patients not receiving prophylaxis and 3.9 (95% CI: 1.5-10.1; p = 0.004) for prophylaxis other than antibiotics alone. Conclusions Administration of antibiotics after BLVR with EBV was associated with a lower rate of AECOPD. This was not observed with the use of steroids or in combination with antibiotics.

Background Patients with chronic obstructive pulmonary disease (COPD) commonly have comorbidities which may impact both symptoms and prognosis. Endoscopic lung volume reduction (ELVR) with endobronchial valves (EBV) is an innovative, effective and safe treatment for patients with severe emphysema who remain symptomatic despite optimal medical therapy. Objectives To evaluate medical comorbidities associated with increased risk of complications after EBV procedure. Method This was a retrospective cohort review of patients with severe, heterogeneous emphysema who underwent Zephyr® EBV installation for ELVR. Demographics, baseline comorbidities, dyspnea scores, data regarding procedure, pulmonary function test, minimal clinically important difference and post-EBV complications were recorded. Results Of a total 82 participants, 24 were identified as having a post procedure complication. There was a significant difference in the incidence of type 2 diabetes mellitus (T2DM) at baseline (25%) in complication group compared with non-complication group (5.1%) (p value = 0.01). There was also a significant difference between baseline coronary artery disease (CAD) in those with (58.3%) or without (29.3%) complication (p = 0.01). Multivariate analysis of other covariables, identified associations of both CAD and T2DM with a heightened risk of complication (adjusted OR 4.19 CI: 1.23-14.2, p value = 0.02 and adjusted OR of 6.1 CI: 1.3-26.1, p value = 0.02 respectively). Conclusions Our study found that patients with severe, heterogeneous emphysema who undergo ELVR utilizing Zephyr® EBV and suffer complications during post-procedure period are more likely to have CAD or T2DM as baseline comorbidity. These data suggest that baseline CAD and T2DM might be predictive of increased risk of complications following ELVR with EBV.

Bronchoscopy in thrombocytopenic patients remains a controversial topic as traditionally varying platelet thresholds have been stablished as “safe,” ranging from 20,000 to 50,000. A lower threshold may be safe for a routine airway inspection with bronchoalveolar lavage but will be far from safe for more invasive interventions such as needle biopsy, transbronchial biopsy, or cryo‐biopsy. Currently, a minimal platelet threshold during robotic‐assisted bronchoscopy (RAB) has not been established. In addition, the absolute platelet number does not guarantee appropriate platelet function. The literature regarding the safety of bronchoscopy and its bleeding risk, considering broader and more functional tests such as thromboelastography (TEG), is also lacking. We present our RAB approach to safely sample lung nodules in a patient with thrombocytopenia. Our precautionary strategy for high‐risk bleeding cases during RAB utilizing TEG and parallel flexible bronchoscopy with segmental balloon occlusion may be an appropriate technique to minimize bleeding risk., We present a precautionary strategy for high‐risk bleeding cases during robotic‐assisted bronchoscopy (RAB) utilizing thromboelastography and parallel flexible bronchoscopy with segmental balloon occlusion may be an appropriate technique to minimize bleeding risk.

BackgroundTraditional bronchoscopy provides limited approach to peripheral nodules. Shape-sensing robotic-assisted bronchoscopy (SSRAB, Ion™ Endoluminal System) is a new tool for minimally invasive peripheral nodule biopsy. We sought to answer the research question: Does SSRAB facilitate sampling of pulmonary nodules during bronchoscopists’ initial experience?MethodsThe lead-in stage of a multicenter, single-arm, prospective evaluation of the Ion Endoluminal System (PRECIsE) is described. Enrolled subjects ≥ 18 years old had recent computed tomography evidence of one or more solid or semi-solid pulmonary nodules ≥ 1.0 to ≤ 3.5 cm in greatest dimension and in any part of the lung. Subjects were followed at 10- and 30-days post-procedure. This stage provided investigators and staff their first human experience with the SSRAB system; safety and procedure outcomes were analyzed descriptively. Neither diagnostic yield nor sensitivity for malignancy were assessed in this stage. Categorical variables are summarized by percentage; continuous variables are summarized by median/interquartile range (IQR).ResultsSixty subjects were enrolled across 6 hospitals; 67 nodules were targeted for biopsy. Median axial, coronal and sagittal diameters were ConclusionsBronchoscopists leveraged the Ion SSRAB’s functionality to drive the catheter safely in close proximity of the virtual target and to obtain biopsies. This initial, multicenter experience is encouraging, suggesting that SSRAB may play a role in the management of pulmonary nodules.Clinical Trial Registration identifier and dateNCT03893539; 28/03/2019.

Vaccination is the key for controlling COVID-19 pandemic. SARS-CoV-2 mRNA vaccines have been demonstrated to induce robust and persistent humoral and cellular immunity in the circulation, but the vaccine-induced immune responses in the respiratory tract remain largely elusive. Here, we examined SARS-CoV-2 S-specific antibody, B and T cell immune responses in the bronchoalveolar lavage (BAL) fluid and blood from unvaccinated, COVID-19 vaccinees or COVID-19 convalescents that recovered from prior moderate to severe SARS-CoV-2 infection. We found that mRNA vaccination induced significant SARS-CoV-2 S-specific CD4+ and CD8+ T cell responses in the blood but not in the BAL. Similarly, mRNA vaccination failed to provoke detectable SARS-CoV-2 S RBD-specific B cell responses in the BAL despite marked RBD-specific B cells were observed in the blood of COVID-19 vaccinees. In contrast, robust SARS-CoV-2 S-specific B and T cell responses were present in the BAL of COVID-19 convalescents. Furthermore, significant neutralizing antibody responses were only observed in the BAL from convalescents but not vaccinees, while both COVID-19 vaccinee and convalescent groups mounted marked neutralizing antibody responses in the blood. Thus, despite their induction of robust circulating humoral and cellular immunity, the current COVID-19 vaccines provoke relatively weak cellular and neutralizing antibody responses in the lower respiratory tract. Our results indicate that a mucosal booster vaccine may be needed to establish robust immunity in the respiratory mucosa, which could provide a strong first line of defense against SARS-CoV-2 re-infection.

Objectives Esophagectomy is associated with significant morbidity and mortality. The authors assessed the relationship between intraoperative fluid (IOF) administration and postoperative pulmonary outcomes in patients undergoing a transthoracic, transhiatal, or tri-incisional esophagectomy. Design Retrospective cohort study (level 3 evidence). Setting Tertiary care referral center. Participants Patients who underwent esophagectomy from 2007 to 2017. Interventions The IOF rate (mL/kg/h) was the predictor variable analyzed both as a continuous and binary categorical variable based on median IOF rate for this cohort (11.90 mL/kg/h). Measurements Primary outcomes included rates of acute respiratory distress syndrome (ARDS) within ten days after esophagectomy. Secondary outcomes included rates of reintubation, pneumonia, cardiac or renal morbidity, intensive care unit admission, length of stay, procedure-related complications, and mortality. Multivariate regression analysis determined associations between IOF rate and postoperative outcomes. Analysis was adjusted for age, sex, body mass index, procedure type, year, and thoracic epidural use. Main Results A total of 1,040 patients comprised this cohort. Tri-incisional esophagectomy was associated with a higher hospital mortality rate (7.8%) compared with transthoracic esophagectomy (2.6%, p = 0.03) or transhiatal esophagectomy (0.7%, p = 0.01). Regression analysis revealed a higher IOF rate was associated with greater ARDS within ten days (adjusted odds ratio [OR] = 1.03, p = 0.01). For secondary outcomes, a higher IOF rate was associated with greater hospital mortality (adjusted OR = 1.05, p = 0.002), although no significant association with 30-day hospital mortality was identified. Conclusions Increased IOF administration during esophagectomy may be associated with worse postoperative pulmonary complications, specifically ARDS. Future well-powered studies are warranted, including randomized, controlled trials comparing liberal versus restrictive fluid administration in this surgical population.

Symptomatic rib nonunions are a rare complication after rib fractures. Methods used to address these nonunions range from pain management, rib resection, and rib fixation with plates and occasional autologous bone grafting. Given potential complications associated with rib resections such as pulmonary hernia, we hypothesized that plate fixation and autologous bone grafting would yield satisfactory long-term outcomes and a high union rate. Patients (aged ≥18 years) at a single institution with a symptomatic rib nonunion who underwent surgical rib stabilization of the nonunion coupled with bone autograft were evaluated (2010–2014). Pertinent clinical, operative, radiologic, and follow-up data were abstracted. Univariate analyses to assess the relationship of clinical outcomes were performed. Six patients underwent nonunion repair with autograft and plating. The mean time from injury to surgical repair of nonunion was 15 (66.1) months. A median of 3 [1–3] ribs were repaired with surgery. Postoperative radiographic union was demonstrated on cross-sectional imaging at three months in four patients (57%) and in all patients at five months postoperatively. No patients developed postoperative pulmonary hernia during follow-up. All patients had a significant reduction in median patient-reported pain at follow-up. Surgical rib fixation and bone autograft can provide acceptable outcomes for patients with rib fracture nonunion. This method provides pain relief and promotes healing of the nonunion gap without pulmonary hernia development. Operative fixation and bone autograft should be considered as a viable technical alternative to resection alone for rib nonunion.

Introduction: Bronchopleural fistula (BPF) is a feared complication of pulmonary resection. Fistula plugs (FP) have been described as an adequate treatment in anorectal disease. We describe our early experience placing an FP in the treatment of BPF. Materials and methods: We retrospectively reviewed 5 patients for whom a FP was placed for BPF at our institution. Demographic data, initial perioperative information, method and technique of FP placement, and success is reported. Results: Five patients (4 male, 1 female) with a median age of 63 years (range, 57–76 years) underwent 6 FP placements for BPF. Two patients were post-pneumonectomy and 3 patients post-lobectomy. The median time to presentation following surgery was 118 days (range 22–218). Upon bronchoscopic or operative re-evaluation, 3 patients had successful cessation of their air leak at 0, 1 and 4 days. Two of three patients subsequently underwent a thoracic muscle flap placement to augment healing. One patient had a persistent air leak despite 2 separate FP placements. The air leak stopped with endobronchial valves (EBV) which were deployed proximal to the FP, 9 days after placement of the FP. Another patient had a successful muscle flap placed 80 days after FP placement. There were no complications associated with the FP. Three of five patients were deemed successfully treated with FP placement alone. Conclusion: In patients with a postoperative BPF and pleural window, placement of a FP had a modest success rate and can be considered as a treatment modality option for BPF. Keywords: Bronchopleural fistula, Fistula plug, Persistent air leak, Prolong air leak

Summary Tissue macrophages self-renew during homeostasis and produce inflammatory mediators upon microbial infection. We examined the relationship between proliferative and inflammatory properties of tissue macrophages by defining the impact of the Wnt/β-catenin pathway, a central regulator of self-renewal, in alveolar macrophages (AMs). Activation of β-catenin by Wnt ligand inhibited AM proliferation and stemness, but promoted inflammatory activity. In a murine influenza viral pneumonia model, β-catenin-mediated AM inflammatory activity promoted acute host morbidity; in contrast, AM proliferation enabled repopulation of reparative AMs and tissue recovery following viral clearance. Mechanistically, Wnt treatment promoted β-catenin-HIF-1α interaction and glycolysis-dependent inflammation while suppressing mitochondrial metabolism and thereby, AM proliferation. Differential HIF-1α activities distinguished proliferative and inflammatory AMs in vivo. This β-catenin-HIF-1α axis was conserved in human AMs and enhanced HIF-1α expression associated with macrophage inflammation in COVID-19 patients. Thus, inflammatory and reparative activities of lung macrophages are regulated by β-catenin-HIF-1α signaling, with implications for the treatment of severe respiratory diseases.

This report describes the case of a 56-year-old woman with a 6-year history of severe epigastric pain after chest compressions for cardiac arrest. A comprehensive gastrointestinal workup was negative. However, an abdominal computed tomographic scan demonstrated an elongated xiphoid process. After a xiphoid trigger point injection, she experienced pain relief lasting 4 days, and thus her symptoms were attributed to xiphoidalgia secondary to heterotopic ossification after trauma. She underwent open resection of the xiphoid process. Heterotopic ossification of the xiphoid process is rare. This report documents a case of heterotopic ossification secondary to trauma from chest compressions.

Symptomatic rib nonunions are a rare complication after rib fractures. Methods used to address these nonunions range from pain management, rib resection, and rib fixation with plates and occasional autologous bone grafting. Given potential complications associated with rib resections such as pulmonary hernia, we hypothesized that plate fixation and autologous bone grafting would yield satisfactory long-term outcomes and a high union rate. Patients (aged ≥18 years) at a single institution with a symptomatic rib nonunion who underwent surgical rib stabilization of the nonunion coupled with bone autograft were evaluated (2010-2014). Pertinent clinical, operative, radiologic, and follow-up data were abstracted. Univariate analyses to assess the relationship of clinical outcomes were performed. Six patients underwent nonunion repair with autograft and plating. The mean time from injury to surgical repair of nonunion was 15 (±6.1) months. A median of 3 [1-3] ribs were repaired with surgery. Postoperative radiographic union was demonstrated on cross-sectional imaging at three months in four patients (57%) and in all patients at five months postoperatively. No patients developed postoperative pulmonary hernia during follow-up. All patients had a significant reduction in median patient-reported pain at follow-up. Surgical rib fixation and bone autograft can provide acceptable outcomes for patients with rib fracture nonunion. This method provides pain relief and promotes healing of the nonunion gap without pulmonary hernia development. Operative fixation and bone autograft should be considered as a viable technical alternative to resection alone for rib nonunion.

A persistent air leak (PAL) can be caused by either an alveolar-pleural fistula (APF) or bronchopleural fistula (BPF). Complications from PAL lead to an increase in morbidity and mortality, prolonged hospital stay, and higher resource utilization. Pulmonary physicians and thoracic surgeons are often tasked with the difficult and often times frustrating diagnosis and management of PALs. While most patients will improve with chest tube thoracostomy, many will fail requiring alternative bronchoscopic or surgical strategies. Herein, we review the bronchoscopic and surgical diagnostic and treatment options for PAL as it pertains to the field of interventional pulmonology and thoracic surgery.

Pulmonary metastasis due to rectal adenocarcinoma is common, noted to be 5.8% in 5 years in patients presenting with rectal adenocarcinoma. However, direct extension into the cardiac chambers is rare. Here we describe an unusual presentation of metastatic rectal adenocarcinoma.

Introduction Solitary fibrous tumors (SFTs) are rare mesenchymal neoplasms. Most follow a benign course, but a subset will recur or metastasize. Various risk stratification schemes have been proposed for SFTs, but none has been universally endorsed and few have focused on pleuropulmonary SFTs. Methods Histologic sections from surgically resected pleuropulmonary SFTs were examined, with confirmatory immunohistochemistry. Patients were risk-stratified by using four prediction models as proposed by de Perrot, Demicco (original and modified), and Tapias. Kaplan-Meier analysis was used to estimate overall survival (OS) and progression-free survival (PFS). Results The 147 study patients included 78 females (53.1%) with a median age of 61.5 years (range 25–87). The median follow-up was 5.5 years (range 0–33). Recurrence or metastasis occurred in 15 patients (10.2%), with five deaths from disease. Significant predictors of worse OS included male sex, age at least 55 years, tumor size at least 10 cm, nonpedunculated growth, severe atypia, necrosis, and mitotic count of at least four per 10 high-power fields. Predictors of recurrence included tumor size of at least 10 cm, severe atypia, necrosis, at least four mitoses per 10 high-power fields, and Ki67 labeling index of at least 2%. All systems predicted PFS, but only the Demicco and Tapias systems significantly predicted OS. The modified Demicco system provided the best discrimination for PFS (C-statistic = 0.80 compared with 0.78). Conclusion The risk scoring systems proposed by Tapias et al. and Demicco et al. were both predictive of OS and PFS. The Demicco system has the advantages of simplicity and applicability to SFTs from other sites, as well as provision of the best discrimination for PFS, and thus may be the best system to apply in general practice.

Background Postoperative chylothorax can be managed by any or all of observation, parenteral nutrition, surgical duct ligation, pleurodesis, or thoracic duct embolization. The objective of this study was to determine the efficacy of standard therapies, such as surgical duct ligation and observation, compared with newer treatment methods (thoracic duct embolization). Methods A prospectively maintained database at a single institution was used to identify and review patients with postoperative chylothorax from 2008 to 2015. Results Postoperative chylothorax occurred in 97 patients, including 54 men (56%). The median age was 61 years (range, 24 to 87 years). Thoracic duct leak followed esophagectomy in 46 patients (47%), pulmonary resection in 30 (31%), mediastinal mass resection in 7 (8%), and after other procedures in 15. Of 28 medically observed patients achieving resolution without intervention, the median peak chest tube output in 24 hours was 725 mL compared with 1,910 mL in the group that required intervention ( p = 0.0001). Thoracic duct ligation was successful in 44 of 52 patients that proceeded to the operating room (85%). Of the 40 patients undergoing diagnostic lymphangiography, a leak was identified in 34 (85%), but the cisterna chyli could only be cannulated in 19 (48%) and was subsequently successful in 15 (38%). Conclusions Patients with chylous chest tube outputs of 1,100 mL or more in 24 hours postoperatively should be considered for intervention. Intention-to-treat analysis shows surgical duct ligation is more effective than thoracic duct embolization, with the ability to cannulate the cisterna chyli being the limiting factor. Lymphangiography may help determine which patients are better treated with ligation or embolization.

Background Pulmonary artery (PA) aneurysms are rare and have been reported only in case reports or small series. We reviewed our experience with surgical repair of PA aneurysms. Methods We reviewed all patients with a true PA aneurysm undergoing cardiac operations between 1995 and 2015. We excluded aneurysms and pseudoaneurysms related to right ventricular outflow tract patches or previous conduits. Results There were 38 patients (24 women [63%]; mean age, 46 ± 15 years), and 14 patients (37%) were asymptomatic. The main PA was involved 35 patients (92%). The mean aneurysm diameter was 5.8 ± 1.8 cm. The most common associated pathology was pulmonary valve stenosis/regurgitation in 23 patients (64%). High-pressure (right ventricular systolic pressure >35 mm Hg) aneurysms were present in 23 patients. Operative strategies included reduction arterioplasty in 30 patients (79%) and resection with graft interposition in 8 (21%). The average length of stay was 6.0 ± 2.2 days. There were no early deaths. Late deaths occurred in 3 patients (8%) and were noncardiac related. Late reoperations occurred in 8% and were not related to the PA aneurysm. All high-pressure aneurysms and those larger than 8 cm demonstrated advanced medial necrosis on pathologic examination of the specimens. Conclusions PA aneurysms are a real entity, and surgical repair can be done with low morbidity and mortality. Aneurysmorrhaphy or aneurysmectomy can be performed, depending on the anatomic location. Regardless of the size of the PA, we recommend intervention on high-pressure aneurysms due to the occurrence of advanced medial necrosis.

Although lobectomy remains the “gold standard” for resectable non-small cell lung cancer, the technical challenges to this operation rely on a sound knowledge of arterial and bronchial anatomy, as well as their variations. One study of 140 patients undergoing thoracic anatomic resections found abnormalities of vasculature in 23 patients, contributing to an observed frequency of 16.4% (1). In 1986, a separate radiographic study in 107 right and 113 left lower lobes (2) demonstrated variation of segmental venous tributaries of the inferior pulmonary vein in as many as 20% of cases. We wish to congratulate the authors for their intricate and detailed description of right upper, middle and lower lobectomies. We applaud their attention to anatomic detail and would highlight the following points.

Rib fracture nonunion represents failure of normal fracture healing. Although randomized controlled trials have demonstrated benefit to acute rib stabilization, the role of open reduction and internal fixation (ORIF) for symptomatic nonunion fractures is unknown and limited to case reports.