Multi-institutional retrospective analysis of adverse events following rigid tracheobronchoscopy.

BACKGROUND AND OBJECTIVE: Rigid tracheobronchoscopy (RTB) has seen an increasing interest over the last decades with the development of the field of IPM but no benchmark exists for complication rates in RTB. We aimed to establish benchmarks for complication rates in RTB. METHODS: A multicentric retrospective analysis of RTB performed between 2009 and 2015 in eight participating centres was performed. RESULTS: A total of 1546 RTB were performed over the study period. One hundred and thirty-one non-lethal complications occurred in 103 procedures (6.7%, 95% CI: 5.5-8.0%). The periprocedural mortality rate was 1.2% (95% CI: 0.6-1.8%). The 30-day mortality rate was 5.6% (95% CI: 4.5-6.8%). Complication rate increases further when procedures were performed in an emergency setting. Procedures in patients with MAO are associated with a higher 30-day mortality (8.1% vs 2.7%, P < 0.01) and a different complication profile when compared to procedures performed for BAS. CONCLUSION: RTB is associated with a 6.7% non-lethal complication rate, a 1.2% periprocedural mortality rate and a 5.6% 30-day mortality in a large multicentre cohort of patients with benign and malignant airway disease.

Standardized Definitions of Bleeding After Transbronchial Lung Biopsy: A Delphi Consensus Statement From the Nashville Working Group.

BACKGROUND: Transbronchial lung biopsies are commonly performed for a variety of indications. Although generally well tolerated, complications such as bleeding do occur. Description of bleeding severity is crucial both clinically and in research trials; to date, there is no validated scale that is widely accepted for this purpose. Can a simple, reproducible tool for categorizing the severity of bleeding after transbronchial biopsy be created? METHODS: Using the modified Delphi method, an international group of bronchoscopists sought to create a new scale tailored to assess bleeding severity among patients undergoing flexible bronchoscopy with transbronchial lung biopsies. Cessation criteria were specified a priori and included reaching > 80% consensus among the experts or three rounds, whichever occurred first. RESULTS: Thirty-six expert bronchoscopists from eight countries, both in academic and community practice settings, participated in the creation of the scale. After the live meeting, two iterations were made. The second and final scale was vetted by all 36 participants, with a weighted average of 4.47/5; 53% were satisfied, and 47% were very satisfied. The panel reached a consensus and proposes the Nashville Bleeding Scale. CONCLUSIONS: The use of a simplified airway bleeding scale that can be applied at bedside is an important, necessary tool for categorizing the severity of bleeding. Uniformity in reporting clinically significant airway bleeding during bronchoscopic procedures will improve the quality of the information derived and could lead to standardization of management. In addition to transbronchial biopsies, this scale could also be applied to other bronchoscopic procedures, such as endobronchial biopsy or endobronchial ultrasound-guided needle aspiration.

Predictors of Intraprocedural Respiratory Bronchoscopy Complications.

PURPOSE: Sleep apnea can increase adverse outcomes during ambulatory surgery but not during gastrointestinal endoscopy. We hypothesize that STOP-BANG is associated with intraprocedural bronchoscopy respiratory complications. METHODS: Consecutive patients undergoing bronchoscopy under moderate sedation were prospectively administered the STOP-BANG questionnaire. Participants were assessed for intraprocedural complications including hypoxemia (oxygen saturation≤85%), bradypnea (respiratory rate<8), premature procedure cessation as well as the use of nonrebreather mask, bag-mask ventilation, jaw lift/chin tilt, nasal/oral airway, and naloxone administration. Associations were assessed via logistic regression. Least absolute shrinkage and selection operator was used for multivariable model variable selection. RESULTS: The 223 participants-mean age 61.1±15.5 years, body mass index 25.4kg/m (interquartile range: 22.4 to 30.7), 50.7% female, and 45.3% inpatient-had a high rate of respiratory complications (37.7%). There were no associations between STOP-BANG score and respiratory complications [odds ratio (OR)=1.07, 95% confidence interval (CI): 0.92-1.25]. Asthma was protective in univariable models (OR=0.26, 95% CI: 0.04-0.98), whereas endobronchial ultrasound (OR=2.34, 95% CI: 1.35-4.10) and the number of procedure types (OR=1.24, 95% CI: 1.01-1.51) was associated with increased complications. The following factors were associated with respiratory complications in both multivariable and univariate analyses: increasing age (OR=1.28/decade, 95% CI: 1.03-1.61), baseline oxygen use per each liters per minute (OR=1.57, 95% CI: 1.21-2.09), and bronchoscopy duration (OR=1.20/10 min, 95% CI: 1.08-1.33). CONCLUSION: Bronchoscopy respiratory complications are common. STOP-BANG was not associated with increased immediate bronchoscopy complication risk. Increasing age, oxygen use, and bronchoscopy duration were associated with respiratory complications; increased vigilance in these circumstances may prevent complications.

Immune checkpoint inhibitor-induced sarcoidosis-like granulomas.

Immune checkpoint inhibitors targeting the cytotoxic T lymphocyte-associated antigen-4 and programmed cell death-1 receptors have transformed the treatment of melanoma and other cancers. These therapies are associated with a number of side effects, including immune-related adverse events. Sarcoidosis-like granulomas (SLGs) are important immune checkpoint inhibitor-related reactions to recognize as SLGs can mimic disease progression and accordingly impact treatment decisions. We systematically review reports of immune checkpoint inhibitor-induced SLGs in cancer patients and discuss potential underlying pathophysiological mechanisms.

Fiducial marker placement with electromagnetic navigation bronchoscopy: a subgroup analysis of the prospective, multicenter NAVIGATE study.

BACKGROUND: Fiducial markers (FMs) help direct stereotactic body radiation therapy (SBRT) and localization for surgical resection in lung cancer management. We report the safety, accuracy, and practice patterns of FM placement utilizing electromagnetic navigation bronchoscopy (ENB). METHODS: NAVIGATE is a global, prospective, multicenter, observational cohort study of ENB using the superDimension™ navigation system. This prospectively collected subgroup analysis presents the patient demographics, procedural characteristics, and 1-month outcomes in patients undergoing ENB-guided FM placement. Follow up through 24 months is ongoing. RESULTS: Two-hundred fifty-eight patients from 21 centers in the United States were included. General anesthesia was used in 68.2%. Lesion location was confirmed by radial endobronchial ultrasound in 34.5% of procedures. The median ENB procedure time was 31.0 min. Concurrent lung lesion biopsy was conducted in 82.6% (213/258) of patients. A mean of 2.2 ± 1.7 FMs (median 1.0 FMs) were placed per patient and 99.2% were accurately positioned based on subjective operator assessment. Follow-up imaging showed that 94.1% (239/254) of markers remained in place. The procedure-related pneumothorax rate was 5.4% (14/258) overall and 3.1% (8/258) grade ⩾ 2 based on the Common Terminology Criteria for Adverse Events scale. The procedure-related grade ⩾ 4 respiratory failure rate was 1.6% (4/258). There were no bronchopulmonary hemorrhages. CONCLUSION: ENB is an accurate and versatile tool to place FMs for SBRT and localization for surgical resection with low complication rates. The ability to perform a biopsy safely in the same procedure can also increase efficiency. The impact of practice pattern variations on therapeutic effectiveness requires further study. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02410837.

Diagnostic Accuracy of Mediastinal Lymph Node Staging Techniques in the Preoperative Assessment of Nonsmall Cell Lung Cancer Patients.

BACKGROUND: Nonsmall cell lung cancer (NSCLC) treatment is based on an accurate staging. Mediastinal lymph nodes staging has a critical impact on treatment management. METHODS: The objective was to assess the current accuracy of preoperative tools for predicting mediastinal and hilar lymph nodes staging with NSCLC. Retrospective analysis of 997 biopsy-proven NSCLC patients treated at a single academic medical center between January 2006 and April 2012. Mediastinal lymph nodes were evaluated with preoperatively with: computed tomography (CT), positron emission tomography (PET), endobronchial ultrasound-guided fine needle aspiration, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Results are compared with pathologic surgical biopsy. RESULTS: A total of 217 cervical mediastinoscopies, 15 anterior mediastinotomies, and 952 surgical lymphadenectomies were performed. The sensitivity of CT scan for mediastinal lymph nodes detection was 18.9% and PET-CT scan was 33.8%. Specificities were 94.9% and 93.8%, respectively. For hilar lymph nodes detection, CT was less sensitive (17.0% vs. 39.7%); however, more specific (94.7% vs. 80.3%) than PET-CT. Endobronchial ultrasound-guided fine needle aspiration (72.7% sensitivity and 100% specificity) and endoscopic ultrasound-guided fine needle aspiration (51.9% sensitivity and 100% specificity) both demonstrated superior results. CONCLUSIONS: The majority of biopsy-proven mediastinal lymph nodes metastases are not associated with positive results on preoperative CT or PET. CT and PET have low positive predictive value for mediastinal lymph node. This study supports the routine utilization of invasive mediastinal lymph nodes staging in NSCLC, especially for patients with tumors of >4 cm diameter, regardless of CT or PET-CT results.

Pulmonary Hemorrhage following Edge-to-Edge Mitral Valve Repair.

Mitral valve repair with the MitraClip device has emerged as an effective treatment option for patients with severe mitral regurgitation and contraindications for surgical interventions. While the procedure is not known to cause pulmonary complications, we describe two cases of pulmonary hemorrhage following percutaneous mitral valve repair. The patients did well with supportive care and reinitiation of anticlotting agents was well tolerated after resolution of bleeding.

Severe Chronic Obstructive Pulmonary Disease Is Not Associated With Complications After Navigational Bronchoscopy Procedures.

BACKGROUND: Electromagnetic navigational bronchoscopy (ENB) is a commonly used technique to obtain biopsies of peripheral pulmonary lesions. Little is known about risk factors for complications with this procedure. The aim of this study was to assess the complication rate associated with ENB and the relationship of complications to patient- and procedure-related factors. METHODS: Consecutive ENB procedures at an academic medical center between May 11, 2011, and September 11, 2015, were reviewed retrospectively. Preoperative characteristics, including pulmonary function, procedure characteristics, and the occurrence of complications, were recorded. RESULTS: In all, 361 procedures were performed on 341 patients. Complications occurred in 30 of 361 (8.3%), the most common of which was pneumothorax (27, 7.5%). Complications were not related to age, sex, American Society of Anesthesiologists grade, or pulmonary function test result. Patients with complications had longer procedure times (50 versus 73 minutes, p = 0.03), and had more interventional modalities used (2.4 versus 3.2, p = 0.001). Multiple logistic regression demonstrated that bronchoalveolar lavage was significantly associated with complications (odds ratio 6.40; 95% confidence interval: 1.68 to 24.3, p = 0.006). CONCLUSIONS: Electromagnetic navigational bronchoscopy is safe, and the rate of complications is not elevated among patients with poor lung function. Bronchoalveolar lavage performed during ENB was associated with elevated risk of complications and should be studied further.

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

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.

Committee I: Indications for pulmonary cytology sampling methods.

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. © 2016 Wiley Periodicals, Inc.

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

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.

Endoscopic Mediastinal Staging in Lung Cancer Is Superior to "Gold Standard" Surgical Staging.

BACKGROUND: The objective was to evaluate whether endobronchial ultrasonography (EBUS) or endoscopic ultrasonography (EUS) staging techniques of the mediastinum for lung cancer can change the treatment plan compared with the "gold standard" of surgical staging. METHODS: Patients were retrospectively identified from a prospectively collected database. Endoscopic staging was compared with the "gold standard" cervical mediastinoscopy (CM). In cases where mediastinoscopy was not performed, EBUS/EUS was compared with "ideal" CM, a virtual procedure, which was assumed to have 100% rates of sensitivity and specificity. RESULTS: EBUS was performed in 324 patients (99%), EUS in 295 patients (90%), and CM in 101 patients (31%); 226 patients (69%) were assumed to have undergone a virtual ideal CM and a virtual surgical mediastinal staging; 108 positive biopsies (33.0%) with endosonography had sampling of targets that were out of the scope of CM. Distant metastatic disease was diagnosed by EBUS/EUS in 7 patients (2.1%); 22 patients (6.7%) had positive targets outside the reach of the CM or virtual CM. If the 14 patients who had positive stations 5, 6, 10, and 11 are excluded (accessible with anterior mediastinotomy or extended cervical mediastinoscopy), there were 6 patients (1.8%) in whom endosonography upstaged the patient over ideal surgical mediastinal staging. In 20 patients (6.1%), ultrasound-guided biopsy made the diagnoses, which changed the treatment plan over CM and ideal CM. CONCLUSIONS: Combined EBUS- and EUS-guided biopsies can access more targets, including lung and distant metastasis, and thus have the potential to upstage patients compared with mediastinoscopy and change the treatment plan.

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.

Transesophageal pulmonary nodule biopsy using endoscopic ultrasonography.

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.

Neurocysticercosis in the infant of a pregnant mother with a tapeworm.

Taeniasis occurs after ingestion of undercooked pork infected with cysticerci. Most Taenia solium infections are mild; proglottids are rarely noticed in the feces. Cysticercosis develops with ingestion of eggs from a tapeworm carrier. Cysticercosis affects approximately 50 million people worldwide, and is seen mostly in Central and South America, sub-Saharan Africa, India, and Asia. We present a case of an 18-month-old child living in New York, who presented with seizures caused by neurocysticercosis. A family study found a 22-year-old mother, 7 months pregnant, positive for T. solium, which presented a management dilemma.