Endoscopic Occlusion of Tracheoesophageal Fistula in Ventilated Patients Using an Amplatzer Septal Occluder.

Acquired tracheoesophageal fistula (TEF) is a challenging, life threatening condition. It most commonly appears in critically ill patients requiring prolonged mechanical ventilation, who cannot withstand open neck or chest surgery. An endoscopic technique could be better tolerated by these patients. We present our experience using a cardiac Amplatzer ASD septal occluder for an endoscopic TEF repair in ventilation-dependent patients. Two high risk patients underwent the procedure under general anesthesia and close respiratory monitoring. In one patient the device was inserted through the trachea and in the other through the esophagus. In both cases fistula closure was achieved for different periods of time allowing the patients a temporary relief of symptoms. The procedure was well tolerated by the patients, and no significant adverse effect documented. The technique was successful as a temporary solution for unstable patients with TEFs and should be considered as a treatment modality for similar patients.

Morbidity and mortality after major pulmonary resections in patients with locally advanced stage IIIA non-small cell lung carcinoma who underwent induction therapy.

BACKGROUND: The optimal treatment for patients with locally advanced stage IIIA non-small cell lung carcinoma (NSCLC) remains controversial, but induction therapy is increasingly used. The aim of this study was to evaluate mortality, morbidity, hospital stay and frequency of postoperative complications in stage IIIA NSCLC patients that underwent major pulmonary resections after neoadjuvant chemotherapy or chemoradiation. METHODS: We conducted a retrospective analysis of all patients who underwent major pulmonary resections after induction therapy for locally advanced NSCLC from October 2009 to February 2014. Forty-one patients were included in the study. RESULTS: Complete resection was achieved in 40 patients (97.5%). A complete pathologic response was seen in 10 patients (24.4%). Mean hospital stay was 17.7 days (ranged 5-129 days). Early (in-hospital) mortality occurred in 2.4% (one patient after bilobectomy), late (six months) mortality in 4.9% (two patients after right pneumonectomy and bilobectomy), and overall morbidity in 58.5% (24 patients). Postoperative complications included: bronchopleural fistula (BPF) with empyema - three patients, empyema without BPF - five patients, air leak - eight patients, atrial fibrillation - eight patients, pneumonia - eight patients, and lobar atelectasis - four patients. CONCLUSION: Following neoadjuvant therapy for stage IIIA NSCLC, pneumonectomy can be performed with low early and late mortality (0% and 5.8%, respectively), bilobectomy is a high risk operation (16.7% early and 16.7% late mortality); and lobectomy a low risk operation (0% early and late mortality). The need for major pulmonary resections should not be a reason to exclude patients from a potentially curative procedure if it can be performed with acceptable morbidity and mortality rates at an experienced medical centre.

Video-assisted thoracic surgery lobectomy versus lobectomy by thoracotomy for lung cancer: pilot study.

OBJECTIVE: Video-assisted thoracic surgery lobectomy (VATS-L) has become accepted as a safe and effective procedure to treat early-stage non-small cell lung carcinoma (NSCLC). However, the advantages of VATS-L compared with lobectomy by thoracotomy (TL) remain controversial. The aim of this study was to compare the outcomes of patients who underwent VATS-L with those who underwent TL. METHODS: We studied 103 patients who underwent surgery for operable NSCLC between October 2009 and March 2012. All operations were performed by a single surgeon. The inclusion and exclusion criteria for VATS-L and TL were formulated before the study was initiated. Data on age, sex, preoperative comorbidities, intraoperative and postoperative complications, hospital stay, morbidity, mortality, and other characteristics were recorded preoperatively, in real time intraoperatively, and during hospitalization and were statistically compared. Comorbidities were scaled according to the Charlson Comorbidity Index, and propensity scores between the patients who underwent TL and VATS-L were compared. RESULTS: Sixty-three VATS-L operations and 40 TL operations were performed. There were no postoperative complications in 39 patients (61.9%) who underwent VATS-L compared with 25 patients (62.5%) who underwent TL. The patients who underwent TL were significantly younger than the patients who underwent VATS-L (mean ± SD, 64.7 ± 12.6 vs 70.9 ± 8.4; P = 0.003). Hospital stay was not found to be related to the type of surgery (mean ± SD, 8.43 ± 3.15 days vs 8.32 ± 4.13 days; P = 0.888). There were no significant differences when comparing postoperative complications. CONCLUSIONS: Our initial data suggest that VATS-L is a safe procedure in patients with resectable IA/IB NSCLC and may be the preferred strategy for treatment of the older patient population.

Endobronchial closure of recurrent bronchopleural and tracheopleural fistulae by two amplatzer devices.

We present a case of right pneumonectomy after induction chemotherapy complicated by a large bronchopleural fistula and empyema two weeks after surgery. The patient was treated surgically by transsternal transpericardial bronchopleural fistula closure and open window thoracoplasty. Thereafter, two new fistulae developed, one in the right main bronchial stump and one in the accessory tracheal bronchus. The two Amplatzer devices that were originally designed for transcatheter closure of cardiac defects were successfully used for closure of the bronchopleural fistulae.

Hydrogen peroxide in exhaled breath condensate (EBC) vs eosinophil count in induced sputum (IS) in parenchymal vs airways lung diseases.

We compared exhaled breath condensate (EBC) and induced sputum (IS) for assessing inflammation in pulmonary diseases in patients with obstructive lung disease (n = 20), persistent cough >6 months (n = 20), interstitial lung disease (n = 25) and controls (n = 10). EBC was collected by suspending a Teflon perfluoroalkoxy tube installed in an ice-filled container and connected to a polypropylene test tube. IS was recovered after 20' inhalation of 3% saline with an ultrasonic nebulizer, and 300 cells were differentially counted in cytospin Giemsa-stained slides. H(2)0(2) was measured by a method based on oxidation of phenolsulfonphthalein (phenol red) mediated by horseradish peroxidases and H(2)0(2). Pulmonary function tests were performed by conventional methods. H(2)0(2) levels in EBC and % eosinophils in IS were significantly different between groups. A positive and significant correlation was found between % eosinophils in IS and the levels of H(2)0(2) in EBC for each group and for all patients combined.

The role of induced sputum in amiodarone-associated interstitial lung diseases.

Amiodarone, a highly effective medication for suppressing cardiac rhythm disturbances, may cause pulmonary injury, such as chronic interstitial lung diseases, in 5-15% of the patients who take it. We applied induced sputum (IS), a non-invasive technique, for diagnosing amiodarone-induced pulmonary toxicity. Four patients with interstitial lung disease who were treated by amiodarone for ischemic heart diseases were evaluated by a conventional clinical workup. All four patients showed marked interstitial pattern on computerized tomography and decreased diffusion capacity (DLCO-SB 51-76%). IS showed lymphocytosis, a high CD4 or CD8 count, eosinophilia and amiodarone in 3 of 4 patients. IS may be a useful tool for assessing amiodarone toxicity in patients with ischemic heart diseases and concomitant pulmonary side effects.

Combined CD4/CD8 ratio in induced sputum and pulmonary function testing for non-invasive identification of sarcoidosis.

UNLABELLED: Induced sputum is a useful noninvasive method for assessing parenchymal diseases. This retrospective study investigated its potential application in combination with functional parameters to differentiate sarcoidosis from non-sarcoid interstitial lung disease (NSA-ILD), especially when bronchoscopy is clinically contraindicated. All 120 study patients (67 sarcoidosis and 53 NSA-ILD) underwent both bronchoalveolar lavage (flexible fiberoptic video bronchoscope; Pentax, Japan) and induced sputum testing (3% NaCl, selecting plugs method, 300 cells differentially counted in Giemsa stained cytopreps). CD4/CD8 subsets were identified by a fluorescence-activator cell sorter. All patients underwent high-resolution computerized tomography and 103 of 120 underwent transbronchial biopsy. Multivariate logistic regression models were applied to the data to predict the probability of having the sarcoidosis as a function of the explanatory variables: Model I contained demographic and induced sputum data, and Model II included demographic data and combined sputum and pulmonary function test results. The area under the curve was 0.899 for induced sputum parameters alone and 0.914 for induced sputum and pulmonary function parameters. CONCLUSION: The results derived from the combination of noninvasive induced sputum approach can be used as predictors with high specificity and sensitivity in the differential diagnosis of sarcoidosis.

Use of the Rapiscope vs chest auscultation for detection of accidental bronchial intubation in non-obese patients undergoing laparoscopic cholecystectomy.

STUDY OBJECTIVE: Main stem bronchial intubation is not always detected by routine means and may occur more frequently during laparoscopic procedures. Tracheal tube positional changes in non-obese patients undergoing laparoscopic cholecystectomy were detected by either the Rapiscope (Cook Critical Care, Bloomington, Ind) or chest auscultation. DESIGN: Prospective, double-blind, crossover study. SETTING: University hospital. PATIENTS: Forty non-obese patients (BMI <28 kg.m(-2)), aged 18 to 80 years, American Society of Anesthesiologists risk class I-III, who underwent elective laparoscopic cholecystectomy were enrolled in this double-blind, prospective study. INTERVENTIONS: After endotracheal intubation by one anesthesiologist, two other anesthesiologists assessed the tracheal tube's positioning by either the Rapiscope or chest auscultation; the results of one anesthesiologist's measurement were concealed from the other. MEASUREMENTS: Assessments of the endotracheal tube tip's position were performed after intubation, head-down, and head-up positioning, after maximal abdominal insufflation and before extubation. At the same time points, Sp(O2), ET(CO2), and peak inspiratory pressures were also recorded. MAIN RESULTS: Postintubation Rapiscope assessment revealed normal tracheal positioning of the tube's tip in all patients. Changes in tube's position were subsequently detected by the Rapiscope in 16 patients. In 8 cases, the tip moved endobronchially. Half of the endobronchial intubations occurred after maximal abdominal insufflation and the other half after changing the table position from neutral to 30 degrees head-down. Chest auscultation detected bronchial intubation in two cases only (P = .01). There were 4 additional events of downward movements and 4 events of cephalad migration of the tube's tip identified by the Rapiscope only. ET(CO2), Sp(O2), and peak inspiratory pressures did not change in patients who did experience bronchial intubation. CONCLUSION: The Rapiscope detected significantly more events of endobronchial intubation as compared with chest auscultation; it could be considered useful during procedures where tracheal tube movements are potential.

Chronic beryllium disease among dental technicians in Israel.

BACKGROUND AND AIM: The potential risks of beryllium use in the dental industry have been recognized for some time. This is the first case series that focuses on the effect of a number of potentially harmful effects of substances that induce lung disease among dental technicians with emphasis on beryllium as a major risk factor in the work environment of dental technicians. METHODS: All the dental technicians consecutively recruited to this study had past occupational exposure to beryllium. They were evaluated in order to confirm immunological evidence of beryllium exposure for differential diagnosis between sarcoidosis and chronic beryllium disease (CBD). They were tested for beryllium sensitization by the beryllium lymphocyte proliferation test (BeLPT), and underwent lung function and induced sputum (IS) studies. Each had earlier undergone a comprehensive evaluation that included high-resolution computerized tomography, bronchoscopy and transbronchial biopsy to establish the final diagnosis of their condition. RESULTS: There were 24 enrollees (mean age 49.7 +/- 13.7 years, 17 males, 7 females) of whom 12 (50%) had positive BeLPT findings and were finally diagnosed as suffering from CBD, 7 (29%) had negative BeLPT findings and were diagnosed as suffering from another pulmonary pathology (sarcoidosis, chronic obstructive pulmonary disease, rejection of transplanted lung), and 5 (20.8%) had negative BeLPT findings and were diagnosed as being free of pulmonary disease. CONCLUSION: This case series study demonstrates that dental technicians are exposed to beryllium and various other occupational dusts and chemicals and are at high risk of developing CBD and other lung diseases. Our findings emphasize the need for awareness of the medical community to detect occupation related diseases in this profession.

Misdiagnosis of sarcoidosis in patients with chronic beryllium disease.

BACKGROUND AND AIM: Sarcoidosis (SA) is a chronic systemic disorder characterized by infiltration of inflammatory cells in affected organs, resulting in the formation of granulomas. Granulomas are observed in numerous infectious diseases and hypersensitivity reactions (e.g., beryllium). Chronic beryllium disease (CBD) is a multisystem entity caused by dust, fumes or mists of beryllium metal or its salts. Although beryllium has been used for years by several industries in Israel, no case of CBD had ever been reported until recently when we described a 21-year-old female dental technician with CBD who was originally diagnosed as having SA. We launched the current investigation to test the hypothesis that other cases of CBD in Israel were not previously reported because these patients were misdiagnosed as having SA. METHODS: Forty-seven patients with confirmed-SA from our outpatient clinic were recalled in order to reevaluate their occupational exposure history. We performed the beryllium lymphocyte transformation test (BeLTT) on each patient with a potentially positive environmental exposure anamnesis to beryllium (14/47). RESULTS: Two of the 14 patients with evidence of granulomas in lung tissue (pulmonary involvement) and 1/14 with extrapulmonary involvement who all had a positive occupational exposure to beryllium and a positive BeLTT test had been erroneously diagnosed as having SA instead of CBD. CONCLUSION: Our findings emphasize the vital importance of taking a comprehensive occupational history in the clinical evaluation of patients suspected of having SA.

Nebulized 3% hypertonic saline solution treatment in hospitalized infants with viral bronchiolitis.

OBJECTIVE: To determine the utility of inhaled hypertonic saline solution to treat infants hospitalized with viral bronchiolitis. DESIGN: Randomized, double-blind, controlled trial. Fifty-two hospitalized infants (mean +/- SD age, 2.9 +/- 2.1 months) with viral bronchiolitis received either inhalation of epinephrine, 1.5 mg, in 4 mL of 0.9% saline solution (group 1; n = 25) or inhalation of epinephrine, 1.5 mg, in 4 mL of 3% saline solution (group 2; n = 27). This therapy was repeated three times every hospitalization day until discharge. RESULTS: The percentage improvement in the clinical severity scores after inhalation therapy was not significant in group 1 on the first, second, and third days after hospital admission (3.5%, 2%, and 4%, respectively). In group 2, significant improvement was observed on these days (7.3%, 8.9%, and 10%, respectively; p < 0.001). Also, the improvement in clinical severity scores differed significantly on each of these days between the two groups. Using 3% saline solution decreased the hospitalization stay by 25%: from 4 +/- 1.9 days in group 1 to 3 +/- 1.2 days in group 2 (p < 0.05). CONCLUSIONS: We conclude that in nonasthmatic, nonseverely ill infants hospitalized with viral bronchiolitis, aerosolized 3% saline solution/1.5 mg epinephrine decreases symptoms and length of hospitalization as compared to 0.9% saline solution/1.5 mg epinephrine.