Safety and efficacy of video DLT (VDLT) for lung isolation during the COVID-19 pandemic.

One lung ventilation (OLV) with collapse of the ipsilateral lung is a prerequisite for most thoracic surgical procedures. Double-lumen tube (DLT) is still the preferred method to isolate the lungs and fiberoptic bronchoscopy (FOB) is the gold standard for the confirmation of correct placement of the DLT. However, both these procedures are considered as a high-aerosol-generating procedures and are hazardous to the health workers, particularly at this time of the COVID-19 pandemic. We did nine thoracic surgery cases categorized as essential, requiring OLV during the ongoing period of the COVID-19 between April 2020 and May 2020 where we used Full view DLT for lung isolation. We present our case series which shows that the Full view VDLT can minimize or circumvent the use of FOB during OLV, and reduce the time taken to isolate the lungs thus reducing aerosol in the theater. None of the nine patients required FOB for confirmation of initial positioning nor for diagnosis of intraoperative malposition. The time taken to isolate the lungs was significantly less and the surgical positioning was done under real-time monitoring by visualizing the blue cuff distal to carina at all times. The real-time monitoring by the Full view VDLT offers the additional advantage of detecting any malposition even before it results in loss of isolation or desaturation. We conclude that the Full view VDLT is an efficient and safe alternative for lung isolation at this time of the COVID-19 pandemic.

Massive lung necrosis due to microwave ablation in an octogenarian required urgent lobectomy.

We present a rare complication of microwave ablation (MWA) in a male patient in his 80s. His massive pulmonary necrosis and tension pneumothorax required urgent surgery. However, the damage to the lung tissue was too large, deep and fragile. We failed to suture or conduct wedge resection on the lung lesion, so, left upper lobectomy was necessary. Therefore, we suggest that it is probably possible to reduce the frequency and time threshold when performing MWA for the elderly with comorbidities.

Congenital lung malformation patients experience respiratory infections after resection: A population-based cohort study.

PURPOSE: The benefit of elective resection of congenital lung malformations continues to be debated. Proponents of resection endorse a decreased risk of respiratory complications as one indication for surgery. Our study aimed to compare the prevalence of respiratory infections in cases, before and after resection of congenital lung malformations, to controls without a history of congenital lung malformation. METHODS: We performed a retrospective cohort study of children born from 1991 to 2007 who underwent congenital lung malformation resection. Patients were identified from Winnipeg´s Surgical Database of Outcomes and Management (WiSDOM), and a 10:1 date-of-birth matched control group was generated from a population-based administrative data repository. International Classification of Disease codes were used to assess pulmonary infection outcomes. Relative rates (RR) were calculated to compare the frequency of pneumonia, respiratory infections and influenza between cases and controls. RESULTS: We included 31 congenital lung malformation cases and 310 controls. Cases consisted of 14 (45.16%) congenital pulmonary airway malformations, 9 (29.03%) bronchopulmonary sequestrations and 8 (25.81%) hybrid lesions. Before resection, pneumonia was more common in cases than controls (RR 6.85; 95%CI 3.89, 11.9), while the risk of acute respiratory infections (RR 1.21; 95%CI 0.79, 1.79) and influenza (RR 0.46; 95%CI 0.01, 3.22) were similar to controls. Post-resection, the risk of pneumonia (RR 9.75; 5.06, 18.50) was still higher in cases than controls, and respiratory infections (RR 1.77; 95%CI 1.20, 2.53) and influenza (RR 3.98; 95%CI 1.48, 9.36) were more common in cases than controls. CONCLUSION: Our study demonstrated that after resection of congenital lung malformations, children experience more frequent respiratory infections compared to the general population. Resection does not eliminate the increased risk of pneumonia.

Powered articulation by the SigniaTM stapling system for stapling position adjustments: optimizing safe surgical margins in thoracoscopic sublobar resection.

Accumulation of experience and advances in techniques and instruments have enabled surgeons to perform video-assisted thoracic surgery (VATS) safely for sublobar resection, including segmentectomy and wedge resection. A key to successful VATS sublobar resection is to have adequate resection margins and the appropriate use of articulated surgical staplers is essential for this purpose. The SigniaTM stapling system (Covidien Japan, Tokyo) has been used extensively in the fields of thoracic surgery. Its features include high maneuverability with fully powered articulation, rotation, clamping, and firing, which the surgeon can control with one hand. We introduce the "sliding technique" using the SigniaTM system, which allows for adjustment of the resection lines of the pulmonary parenchyma to optimize safe surgical margins with minimal stapler movement, and without repetitively moving the stapler in and out of the pleural cavity, during VATS sublobar resection.

Imaging Findings for Identifying and Evaluating Complications After Lung Transplantation in Patients with Advanced COVID-19: Two Case Reports.

BACKGROUND: Lung transplantation might be a viable alternative for patients with irreversible lung injury secondary to coronavirus disease 2019 (COVID-19). Here, we describe two patients with end-stage COVID-19 that received lung transplantations, the clinical-radiologic manifestations of postoperative complications, and the imaging features of allograft rejection. CASE PRESENTATION: In case 1, a 66-year-old woman presented severe hypoxia after lung transplantation. Chest imaging revealed diffuse homogeneous infiltration in the donor's lung. Dramatic resolution of the imaging abnormalities after intravenous administration of methylprednisolone favored a diagnosis of hyperacute rejection. The second is a 70-year-old man who was infected with bacterial postoperatively. During the empiric antibiotic therapy, chest CT showed newly developed groundglass opacities with septal thickening, suggesting a diagnosis of acute rejection. High-dose corticosteroids therapy was initiated, and the patient recovered gradually. CONCLUSION: This is the first report describing postoperative complications of lung transplantation in patients with advanced COVID-19. We presumed that imaging procedures could be a useful tool in early detecting lung transplant complications and selecting specific interventions for patients with COVID-19.

Case report: double lung en bloc procurement from a donor after arterial switch operation.

The growing unmet demand for suitable organ donors increases each year. Despite relative contraindications for thoracic organ donation after previous cardiac surgery, experienced programmes and surgeons can successfully utilise the lungs from select donors who have undergone prior cardiac surgery. This is the first reported case of double lung en bloc procurement from a donor who had a previous arterial switch operation as an infant.

Development of cavitary lung disease as a long-term complication of coronavirus disease 2019 in a young previously healthy patient: a case report.

BACKGROUND: Cavities are frequent manifestations of a wide variety of pathological processes involving the lung. There has been a growing body of evidence of coronavirus disease 2019 leading to a cavitary pulmonary disease. CASE PRESENTATION: A healthy 29-year-old Filipino male presented to the hospital a couple of months after convalescence from coronavirus disease 2019 with severe pleuritic chest pain, fever, chills, and shortness of breath, and was found to have a cavitary lung lesion on chest computed tomography. While conservative management alone failed to improve the patient's condition, he ultimately underwent left lung video-assisted thoracoscopic surgery decortication. Even though the surgical pathology revealed only necrosis with dense acute inflammation and granulation tissue with no microorganisms, he gradually improved with medical therapy adjunct with surgical therapy. CONCLUSION: Documented cases of cavitary lung disease secondary to coronavirus disease 2019 have been mostly reported in the acute or subacute phase of the infection. However, clinicians should recognize this entity as a late complication of coronavirus disease 2019, even in previously healthy individuals.

COVID-19 After Lung Resection in Northern Italy.

We reviewed surgical cases from 4 Thoracic Surgery departments in the Lombardia region of Italy, the area mostly affected by Coronavirus pandemic in Europe, with the aim to describe the impact of COVID-19 on the treatment of thoracic surgical patients. Clinical, radiological and laboratory data from patients who underwent lung resection from December 2019 to March 2020 were retrospectively collected until June 2020. Univariable Cox regression models were estimated to evaluate potential prognostic factors for developing COVID-19 and to investigate postoperative mortality among patients who developed symptomatic COVID-19 infection. We examined data from 107 patients. (74 lobectomies, 32 wedge/segmentectomies and 1 pneumonectomy). Twelve patients developed COVID-19 (Group 1), whereas 95 patients were not infected (Group 2). In Group 1, 6 patients (50%) died from complications related to infection; in Group 2, one patient (1%) died because of non-COVID-19-related causes. Median days from surgery to first symptoms, CT confirmation, clinical confirmation and PCR positivity was 48.1, 54.3, 55.1, and 55.2 respectively. At univariable analysis, DLCO/VA% (P = 0.008), duration of the surgery (P = 0.009), smoking history (pack/year) (P < 0.001), BMI (P< 0.001) and number of segments resected (P = 0.010) were associated with COVID-19 onset. Moreover, CCI (P < 0.001), DLCO/VA% (P = 0.002), cigarette pack/year (P < 0.001), BMI (P < 0.001) and COVID-19 (P < 0.001) were associated with death. Patients who undergo lung resection and then develop symptomatic COVID-19 infection are at higher risk of developing severe respiratory complications and postoperative death. Insidious symptoms' onset may lead to a delay in diagnosis. We suggest two mitigating strategies: (1) Improve symptoms surveillance and isolation during recovery period, (2) Be aware of a potential greater risk of developing symptomatic COVID-19 and death correlated with elevated CCI, BMI, smoking history, DLCO/VA%, number of resected segments and duration of surgery.

Lung transplantation for patients with severe COVID-19.

Lung transplantation can potentially be a life-saving treatment for patients with nonresolving COVID-19-associated respiratory failure. Concerns limiting lung transplantation include recurrence of SARS-CoV-2 infection in the allograft, technical challenges imposed by viral-mediated injury to the native lung, and the potential risk for allograft infection by pathogens causing ventilator-associated pneumonia in the native lung. Additionally, the native lung might recover, resulting in long-term outcomes preferable to those of transplant. Here, we report the results of lung transplantation in three patients with nonresolving COVID-19-associated respiratory failure. We performed single-molecule fluorescence in situ hybridization (smFISH) to detect both positive and negative strands of SARS-CoV-2 RNA in explanted lung tissue from the three patients and in additional control lung tissue samples. We conducted extracellular matrix imaging and single-cell RNA sequencing on explanted lung tissue from the three patients who underwent transplantation and on warm postmortem lung biopsies from two patients who had died from COVID-19-associated pneumonia. Lungs from these five patients with prolonged COVID-19 disease were free of SARS-CoV-2 as detected by smFISH, but pathology showed extensive evidence of injury and fibrosis that resembled end-stage pulmonary fibrosis. Using machine learning, we compared single-cell RNA sequencing data from the lungs of patients with late-stage COVID-19 to that from the lungs of patients with pulmonary fibrosis and identified similarities in gene expression across cell lineages. Our findings suggest that some patients with severe COVID-19 develop fibrotic lung disease for which lung transplantation is their only option for survival.

Elective lung resection after treatment for COVID-19 pneumonia.

A 65-year-old man with coronavirus disease 2019 (COVID-19) was admitted to our hospital. Computed tomography detected bilateral pneumonia with a lung nodule suspicious for lung cancer. Lobectomy was performed 3 months after the treatment for COVID-19 without any complications. The surgical specimen revealed fibrosis below the pleura with a small collection of lymphocytes and intravascular hemorrhagic thrombosis, and no residual RNA was detected. This is the first report describing a surgical specimen after recovery from COVID-19 pneumonia, and suggests that elective thoracic surgery can be performed safely, depending on the patient's respiratory function, without infectious risk.

Pulmonary Pathology of COVID-19 Following 8 Weeks to 4 Months of Severe Disease: A Report of Three Cases, Including One With Bilateral Lung Transplantation.

OBJECTIVES: Current knowledge of the pulmonary pathology of coronavirus disease 2019 (COVID-19) is based largely on postmortem studies. In most, the interval between disease onset and death is relatively short (<1 month). Information regarding lung pathology in patients who survive for longer periods is scant. We describe the pathology in three patients with severe COVID-19 who underwent antemortem examination of lung tissue at least 8 weeks after initial diagnosis. METHODS: We conducted a retrospective case series. RESULTS: The first patient developed acute respiratory failure and was started on extracorporeal membrane oxygenation (ECMO) on day 21, with subsequent hemothorax. Debridement (day 38) showed extensive lung infarction with diffuse alveolar damage and Candida overgrowth. The second patient developed acute respiratory failure requiring mechanical ventilation that did not improve despite ECMO. Surgical lung biopsy on day 74 showed diffuse interstitial fibrosis with focal microscopic honeycomb change. The third patient also required ECMO and underwent bilateral lung transplantation on day 126. The explanted lungs showed diffuse interstitial fibrosis with focal microscopic honeycomb change. CONCLUSIONS: This series provides histologic confirmation that complications of COVID-19 after 8 weeks to 4 months of severe disease include lung infarction and diffuse interstitial fibrosis.

Salvage Lobectomy to Treat Necrotizing SARS-CoV-2 Pneumonia Complicated by a Bronchopleural Fistula.

We report a case of necrotizing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia complicated by a bronchopleural fistula and treated by decortication and salvage lobectomy. Owing to the unknown characteristics of the underlying SARS-CoV-2 infection, treatment of the abscess and bronchopleural fistula was delayed. This may have resulted in further deterioration of the patient, with ensuing multiple organ dysfunction. Complications of SARS-CoV-2 pneumonia, such as a bacterial abscess and a bronchopleural fistula, should be treated as if the patient were not infected with SARS-CoV-2.

Postoperative COVID-19 Pneumonia in an Asymptomatic Patient: A Case Report.

BACKGROUND: The recent outbreak of the coronavirus disease (COVID-19) in China has rapidly spread throughout the world and there are many reports of symptoms ranging from malaise to acute respiratory distress syndrome (ARDS) caused by this infection. However, few reports have been discussed surgical outcomes in COVID-19 patients. CASE PRESENTATION: In this report, we described a case of an elderly female developed with postoperative pulmonary complications after uneventful elective minor surgery. The patient was asymptomatic before the operation with no history of cough or fever. After surgery, the patient developed respiratory distress and chest radiological imaging revealed bilateral ground-glass opacities. It seems any type of surgeries requiring local anesthesia or general anesthesia may contribute to worsening outcomes in patients with covid19.

Lobectomy for Hemorrhagic Lobar Infarction in a Patient With COVID-19.

Patients with severe coronavirus disease 2019 from infection with severe acute respiratory syndrome coronavirus 2 mount a profound inflammatory response and are predisposed to thrombotic complications. Pulmonary vein thrombosis is a rare disease process resulting in pulmonary congestion, infarction, and potential mortality. This report describes a patient with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation for hypoxic respiratory failure who developed hemorrhagic infarction of the right lower lobe. During emergency exploration the patient was found to have a right inferior vein thrombosis and marked lobar hemorrhage mandating lobectomy.

Late histological findings in symptomatic COVID-19 patients: A case report.

RATIONALE: Although there have been several studies describing clinical and radiographic features about the novel coronavirus (COVID-19) infection, there is a lack of pathologic data conducted on biopsies or autopsies. PATIENT CONCERNS: A 56-year-old and a 70-year-old men with fever, cough, and respiratory fatigue were admitted to the intensive care unit and intubated for respiratory distress. DIAGNOSIS: The nasopharyngeal swab was positive for COVID-19 and the chest Computed Tomography (CT) scan showed the presence of peripheral and bilateral ground-glass opacities. INTERVENTIONS: Both patients developed pneumothoraces after intubation and was managed with chest tube. Due to persistent air leak, thoracoscopies with blebs resection and pleurectomies were performed on 23rd and 16th days from symptoms onset. OUTCOMES: The procedures were successful with no evidence of postoperative air-leak, with respiratory improvement. Pathological specimens were analyzed with evidence of diffuse alveolar septum disruption, interstitium thickness, and infiltration of inflammatory cells with diffuse endothelial dysfunction and hemorrhagic thrombosis. LESSONS: Despite well-known pulmonary damages induced by the COVID-19, the late-phase histological changes include diffused peripheral vessels endothelial hyperplasia, in toto muscular wall thickening, and intravascular hemorrhagic thrombosis.