Thoracic surgery in United Arab Emirates.

The United Arab Emirates (UAE) has undergone a significant change in its population and economy in the last decades and in parallel its healthcare system has evolved rapidly to provide advanced, innovative and world-leading care. At the forefront of this revolution in healthcare is the development of a multidisciplinary multimodality thoracic service provision, offered at quaternary referral hospitals amalgamating academics, training, research and innovation. Previously, thoracic service care was limited to single providers at various public and private hospitals, usually performing lower complexity cases. Most complex thoracic cases were repatriated outside the UAE. This practice was replaced with the opening of Cleveland Clinic Abu Dhabi (CCAD), in 2015, which created a multidisciplinary thoracic program. This included the start of a mini-invasive surgical and lung transplantation program. Since that time other public and private hospitals have emerged providing care in a similar model. The impact of these programs has been a decreased transfer of patients abroad for treatment. Under the umbrella of the Emirates Thoracic Society (ETS) a platform for greater collaboration aimed at improving patient care, potential research and physician education has been created. Direct links have been established with world-leading Thoracic surgery and Respiratory Medicine Centers facilitating this development and offering support and guidance. This article charts these changes in thoracic care in the recent past, present, and delineates plans for the future in the UAE.

The Journey for Lung Cancer Screening where we Stand Today.

Background: Lung cancer remains a leading cause of cancer mortality worldwide with many patients presenting with advanced disease. Objective: We reviewed the available literature for lung cancer screening using low dose computed tomography (LDCT). We reviewed the National Lung Screening Trial (NLST), Early Lung Cancer Action Program (ELCAP) and the (Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) trials. We also look at different lung cancer risk prediction models that may aid in identifying target populations and also discuss the cost-effectiveness of LDCT screening in different groups of smokers and ex-smokers. Lastly, we discuss recent guideline changes that have occurred in line with new and emerging evidence on lung cancer screening. Conclusion: LDCT has been shown reduce lung cancer mortality in certain groups of current and former smokers and should be considered to help in the early diagnosis of lung cancer.

Outcomes of a Newly Established Electromagnetic Navigation Bronchoscopy Service in the Middle East.

Aims: Electromagnetic Navigation Bronchoscopy (EMNB) is a useful tool for the bronchoscopist to target peripheral pulmonary lesions. It has a well-established efficacy and safety profile; however, there are no studies describing its utility in a Middle Eastern population. In this paper, we describe the efficacy and safety outcomes of a newly established EMNB service. Background: The diagnosis of peripheral pulmonary lesions presents a significant challenge to the bronchoscopist, especially in the era of increased thoracic imaging with computerized tomography (CT) scans. EMNB is a relatively novel technique that utilizes an image-guided localization system akin to Global Positioning Satellite (GPS) technology, offering the bronchoscopist an accurate navigational pathway to sample peripheral pulmonary targets. Objective: We present our initial experience of performing EMNB and report our diagnostic and safety outcomes with EMN bronchoscopy. Methods: We conducted a retrospective review of the medical notes of all patients booked for EMNB from May 2015 to December 2019 at our tertiary care center using the electronic medical record system. Results and Discussion: Fifty-five patients were scheduled for EMNB, and 47 patients (24 males, 23 females) had EMNB-guided sampling between May 2015 and December 2019. The median age of the patients was 61 years (IQR 49.5-74.3). A bronchus sign was present on the CT chest in 29 (61.7%) cases. Thirty-one (66%) patients had positive EMNB guided samples. There was a weak correlation between the lesion size and the positive EMNB guided sampling (r: 0.34). Twenty-one of 29 (72%) patients with positive bronchus signs had positive EMNB guided samples, compared to 10/18 (56%) patients without bronchus signs; however, the difference was not statistically significant (p-value 0.335). When the presence or absence of rapid onsite examination of cytopathological specimens (ROSE) was compared during the procedure, a trend favoring the presence of ROSE could be seen, but this was statistically non-significant (p-value 0.078). In this series, one patient with pre-existing triple vessel coronary artery disease developed an inferior wall ST-segment elevation myocardial infarction (STEMI), likely secondary to spasm. This patient recovered completely and was discharged from the hospital. Conclusion: This study demonstrates that EMNB can be safely performed in a Middle Eastern population with results similar to those reported in major international studies. The highest diagnostic yield was in patients with a bronchus sign on a CT scan, and combining EMNB with ROSE can increase the chances of having a positive diagnostic bronchoscopy. However, patients and physicians need to be aware of the need to follow up with the patients with negative biopsies to ensure that false negatives are not missed.

Complications of surgical and percutaneous tracheostomies, and factors leading to decannulation success in a unique Middle Eastern population.

INTRODUCTION: Surgical and percutaneous tracheostomy remains a commonly performed procedure in the intensive care unit (ICU). Given the unique patient population in the Middle East we decided to perform a review of the procedures performed in our hospital over a two-year period. METHODS: Single centre, retrospective observational study. All tracheostomies performed between January 2016 and January 2018 were included in the study. The primary outcome was the rate of tracheostomy complications. Multivariate logistic regression analysis was used to identify the independent factors associated with complications and decannulations. RESULTS: One hundred sixty-four patients were included in the study. Percutaneous tracheostomy was performed in 99 patients (60.4%). Complications occurred in thirty-eight patients (23%). Higher Left ventricular ejection fraction (OR = 0.94, 95%CI: [0.898-0.985]) and percutaneous tracheostomy (OR = 0.107, 95%CI: [0.029-0.401]) were associated with lower complications. Good Eastern Cooperative Oncology Group (ECOG) performance status (OR = 4.1, 95%CI: [1.3-13.3]) and downsized tracheostomy tube (OR = 6.5, 95%CI: [2.0-21.0]) were associated with successful decannulations. Successful decannulation was associated with lower hospital mortality when compated to those who could not be decannulated (3.2% vs 33.3% p < 0.0001). CONCLUSION: In our older population with high comorbidities, percutaneous tracheostomies were associated with less complications than surgical tracheostomies. Patients with poor premorbid functional status and those who could not have their tracheostomy tube sucessfuly downsized were less likely to be decannulated, and had a higher mortality. This data enables physicians to inform the families of the added risks involved with tracheostomy in this patient group.

Procedimientos híbridos para la resección de nódulos pulmonares: el comienzo de una nueva era / Hybrid Procedures for Pulmonary Nodule Resection: The Beginning of a New Era

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Unexpected Intraoperative Finding of Azygos Vein Aneurysm Mimicking a Metastatic Lymph Node / Hallazgo intraoperatorio inesperado de un aneurisma de la vena ácigos en forma de nódulo linfático metastásico

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Ex vivo lung graft perfusion.

This review proposes an update of the state of the art and the ongoing clinical trials of ex vivo lung perfusion for lung transplantation in patients. Ex vivo lung perfusion techniques (EVLP) can be used to evaluate a lung graft outside of the body. The goal of EVLP is to study the functional status of lung grafts that were first rejected for transplantation because they did not match all criteria for a conventional transplantation. After an EVLP evaluation, some of these lungs may be requalified for a possible transplantation in patients. This article proposes an overview of the developments of EVLP techniques. During EVLP, the perfusion and ventilation of the isolated lung preparation are very progressive in order to avoid oedema due to ischaemia-reperfusion injuries. Lung evaluation is mainly based on gasometric (PaO2/FiO2) and rheological criteria (low pulmonary arterial resistance). Several series of patients transplanted with EVLP evaluated lungs have been recently published with promising results. EVLP preparations also allow a better understanding of the physiopathology and treatments of ischaemia-reperfusion injuries. Organ procurements from "non-heart-beating" donors will probably require a wider application of these ex vivo techniques. The development of semi-automated systems might facilitate the clinical use of EVLP techniques.

Effects of cyclosporine a in ex vivo reperfused pig lungs.

OBJECTIVE: Several works highlight the role of CsA in the prevention of IRI, but none focus on isolated lungs. Our objective was to evaluate the effects of CsA on IRI on ex vivo reperfused pig lungs. METHODS: Thirty-two pairs of pig lungs were collected and stored for 30 minutes at 4 °C. The study was performed in four groups. First, a control group and then three groups receiving different concentrations of CsA (1, 10, and 30 µM) at two different times: once at the moment of lung procurement and another during the reperfusion procedure. The ex vivo lung preparation was set up using an extracorporeal perfusion circuit. Gas exchange parameters, pulmonary hemodynamics, and biological markers of lung injury were collected for the evaluation. RESULTS: CsA improved the PaO2 /FiO2 ratio, but it also increased PAP, Pcap, and pulmonary vascular resistances with dose-dependent effects. Lungs treated with high doses of CsA displayed higher capillary-alveolar permeability to proteins, lower AFC capacities, and elevated concentrations of pro-inflammatory cytokines. CONCLUSIONS: These data suggest a possible deleterious imbalance between the beneficial cell properties of CsA in IRI and its hemodynamic effects on microvascularization.

Pulmonary resection after lung transplantation in cystic fibrosis patients.

Pulmonary resection after lung transplantation in end-stage cystic fibrosis presents unique challenges, and scant literature exists to guide physicians. We retrospectively reviewed 78 transplants for cystic fibrosis performed between 2003 and 2008. Fourteen patients underwent posttransplantation pulmonary resection. We analyzed the indications, surgical procedures, outcomes, and survival. Three pneumonectomies, 4 lobectomies, and 11 wedge resections were carried out. We identified 2 groups based on indication: a diagnostic group, and a therapeutic group of patients in whom the indications were septic native lung in 2, allograft infection in 2, lobar torsion in 2, pulmonary infarction in 2, and size mismatch in 4. The mean intensive care unit and hospital stays were 29 and 50 days, respectively. Four (28.57%) patients died during follow-up, including 2 who underwent pneumonectomy; 10 (71.43%) are still alive. Survival was 43.43 ± 8.06 months, and it was not significantly different from that in cystic fibrosis patients who had lung transplantation without pulmonary resection. Pulmonary resection following lung transplantation in cystic fibrosis patients showed acceptable survival and surgical risk, but metachronous pneumonectomy was associated with higher mortality.

Urgent lung transplantation in cystic fibrosis patients: experience of a French center.

OBJECTIVE: We report preliminary results obtained with urgent lung transplantation (ULTx) in cystic fibrosis (CF) patients, based on a French high emergency lung allocation (HELA) system, and the impact of this system on waiting-list death. METHODS: The medical records of the first 15 CF patients receiving ULTx between June 2007 and May 2010 at Hôpital Européen Georges Pompidou, France, were retrospectively reviewed. ULTx patients (URG group, n=15) were compared with our entire cohort of CF patients receiving elective lung transplants (LTx) (ELT group, n=118). RESULTS: Both groups were similar in terms of use of cardiopulmonary bypass (CPB), length of stay in the intensive care unit (ICU), and intubation > 72 h. Incidence of primary graft dysfunction (PGD) and perioperative mortality was also similar in both groups, but graft ischemic time and severity of PGD were higher in the URG group. One-year and 2.5-year survival rates were, respectively, 73% and 54.5% for the URG group. Death on the waiting list and time to LTx (including all pulmonary diagnoses) decreased by 67% and 64%, respectively. CONCLUSIONS: Although still preliminary and with a short follow-up period, our results suggest that the allocation of LTx to CF patients based on the HELA criteria yielded acceptable outcomes and improved waiting-list death rate and time to LTx.

Risk factors for post-transplant lymphoproliferative disease in patients with cystic fibrosis.

The objective of this study was to retrospectively analyze risk factors associated with post-transplant lymphoproliferative disease (PTLD) in a cohort of 112 lung transplant recipients with cystic fibrosis (CF). Prior to transplantation, patients were tested for Epstein-Barr virus (EBV), human herpesvirus (HHV types 1, 2, 3, 6, and 8), herpes zoster virus, and cytomegalovirus (CMV) serologies. PTLD diagnosis was established based on increased EBV viral charge plus clinical/radiographic findings and confirmed by biopsy. Negative EBV and HHV serologies at the time of lung transplantation (LTx) were significant risk factors associated with development of PTLD in patients with CF in the univariate logistic regression analysis (p < 0.05) and also in the multivariate analysis (odds ratio of 77.5 and 12.5, respectively). CMV serology, CMV mismatch, acute rejection in the first three months following LTx, HLA-A3 antigen expression, and female gender did not affect PTLD. Our study confirmed the presence of a strong association between negative EBV serology at the time of LTx and PTLD and suggested an independent effect of negative HHV serology on PTLD.

Extra corporal membrane oxygenation in general thoracic surgery: a new single veno-venous cannulation.

Extracorporeal membrane oxygenation (ECMO) is used in severe respiratory failure to maintain adequate gas exchange. So far, this technique has not been commonly used in general thoracic surgery. We present a case using ECMO for peri-operative airway management for pulmonary resection, using a novel single-site, internal jugular, veno-venous ECMO cannula.

Early unilateral laryngeal paralysis after pulmonary resection with mediastinal dissection for cancer.

BACKGROUND: The purpose of this study was to document the symptoms, evolution, management, and outcome in a large series of patients with an early unilateral laryngeal paralysis after mediastinal lymph node dissection and pulmonary resection for cancer. METHODS: In this retrospective series of 69 patients, treatment relied on isolated speech therapy in 18 patients and surgical medialization of the paralyzed vocal cord in 51 patients. Duration of follow-up varied from 2 to 109 months, with a mean duration of 15 months. Treatment included isolated speech therapy and laryngeal medialization in 18 patients and 51 patients, respectively. RESULTS: Symptoms included swallowing impairment and dysphonia noted in 63.7% and 98.5% of patients, respectively. Recovery of motion of the paralyzed larynx varied from 2.8% in patients in whom the operative report mentioned that the inferior laryngeal or Xth cranial nerve had been transected, to 23.5% in patients in whom the operative report did not mention nerve transection. Recovery of motion did not occur past the ninth month that followed thoracic surgery. When performed, medialization of the paralyzed larynx resulted in an overall 95.4% and 96% improvement rate for swallowing impairment and dysphonia, respectively, but 1 patient also died of aspiration-related pneumonia. CONCLUSIONS: In patients with an early unilateral laryngeal paralysis after pulmonary resection with mediastinal lymph node dissection for cancer, laryngeal medialization has a beneficial impact on swallowing, speech, and voice, resulting in a better quality of life. Persistent swallowing impairment after laryngeal medialization must be managed aggressively, given the risk for delayed pneumonia and even death from aspiration.

Management of lobar torsion following lung transplantation.

We report 4 cases of acute lobar torsion in patients who had undergone bilateral lung transplantation. Bronchoscopy showed complete obstruction in only 2 of them. Torsion was confirmed by computed tomography in coronal minimal and maximal intensity projections with reconstruction. At operation, 1 detorsion and 3 lobectomies were carried out. Early diagnosis and rapid surgical intervention can save the affected lobe.

[Donor lung availability in the 21st century]. / Quels types de greffons et de donneurs en transplantation pulmonaire au XXIe siècle.

Lung transplantation has become an established treatment for end-stage pulmonary failure refractory to medical management. However, the scarcity of lung grafts and the growing number of candidates has led to an increase in deaths among patients on waiting lists. Despite improvements in donor management, organ preservation, and the use of marginal and cardiac-death donors, only about 20% of candidate lungs are currently being transplanted. A new ex vivo "reconditioning" technique is opening up new perspectives. Indeed, a significant number of rejected lungs can now be retrieved and transplanted with acceptable results. Given the longer storage times provided by this technique, transplantation can be programmed, with better surgical efficiency. In the near future, a new mobile organ-care machine should become available, along with laboratories dedicated to ex vivo reconditioning of all lung grafts before their transplantation.

Prognostic factors and surgical indications of pulmonary epithelioid hemangioendothelioma: a review of the literature.

BACKGROUND: Pulmonary epithelioid hemangioendothelioma is a rare vascular tumor of low-grade malignancy, the prognosis of which remains unpredictable. The purpose of this analysis based on 80 patients was to determine prognostic factors and to evaluate results of surgery. METHODS: We recorded data of 75 patients from reports published in the English and French literature using the terms "intravascular bronchoalveolar tumor" or "pulmonary epithelioid hemangioendothelioma" or a combination of both. We added to this database 5 more cases of pulmonary epithelioid hemangioendothelioma operated on in our thoracic surgery department from 1989 to 2005. Univariate and multivariate analyses of prognostic factors were performed using the log rank test and the Cox model. The factors we tested were age, sex, clinical symptoms, biologic and radiologic findings, and surgical treatment. RESULTS: There were 49 women and 31 men with a mean age of 39.7 years (range, 7 to 72 years). The 5-year survival probability was 60% (range, 47% to 71%). Univariate analysis showed that loss of weight, anemia, pulmonary symptoms, and more particularly pleural hemorrhagic effusions were significant factors of poor prognosis, with a median survival of less than 1 year. Multivariate analysis showed a statistically worse survival in patients with hemorrhagic symptoms (hemoptysis, p < 0.0001; pleural effusion, p < 0.0001). CONCLUSIONS: Pulmonary epithelioid hemangioendothelioma typically occurs among young patients. Surgery can be proposed in cases of unilateral single or multiple nodules. There is no single effective treatment in cases of bilateral multiple nodules. Lung transplantation should be evaluated in patients with vascular aggressivity with pleural hemorrhagic effusion and anemia.