Incomplete Fissures Research Articles

Fissureless fissure-last video-assisted thoracoscopic lobectomy for all lung lobes: a better alternative to decrease the incidence of prolonged air leak?

Prolonged air leak (PAL) after major lung resections is a common postoperative complication that leads to extended length of hospital stay (LOS) and increased hospital costs. Dissection of the lung tissue through the fissure may increase the incidence of PAL especially in the patients with incomplete fissures. The objective of this study was to evaluate the impact of the fissureless fissure-last technique in VATS lobectomy on immediate outcome, especially relating to air leak and LOS. This is an observational analysis on prospectively collected data of a single thoracic surgery unit. A total of 54 consecutive patients underwent VATS lobectomy and mediastinal lymphadenectomy-in 24 patients conventional VATS lobectomy (Group 1), in 30 patients fissureless VATS lobectomy (Group 2) was performed. The two groups were compared according to preoperative, operative and postoperative parameters. No differences were found when comparing patient characteristics, operation time (M1 = 185 min; M2 = 176 min; P = 0.52) and number of staplers used (M1 = 6.2; M2 = 7.7; P = 0.088). The presence of air leak (P = 0.004; RR = 3.5), PAL (P = 0.003; RR = 10), in days with chest tube (M1 = 7.2; M2 = 4.2; P = 0.028) and LOS (M1 = 12.7; M2 = 8.9; P = 0.020) was significantly more frequent in patients that underwent conventional VATS lobectomy. Focusing on the air leak, significance was present in male gender (P = 0.034; RR = 2.41), higher ASA (M1 = 3.04; M2 = 2.67; P = 0.012), postoperative complications other than air leak (P = 0.001; RR = 5.78) and age between groups with and without air leak (M1 = 63.9; M2 = 74.1; P < 0.001). Fissureless fissure-last VATS lobectomy is a feasible and equivalent to conventional VATS lobectomy in terms of operation time, stapler use and complications. Fissureless fissure-last VATS lobectomy, however, appears to be a superior technique to conventional VATS lobectomy in terms of preventing PAL and reducing the LOS.

Unexpected Intraoperative Resecting of Common Trunk of Pulmonary Vein Resulted in an Incidental Pneumonectomy from Left Upper Lobectomy

There is a wide range of anatomical variations in the pulmonary vessels. Some of these variations may cause surgical morbidity during general thoracic surgery. We intended to perform a left upper lobectomy for a 73-year-old male with suspected left lung cancer (lt.U, S3, 20 × 20 mm, P0, E0, D0, PM0, N0, T1aN0M0, c-stage IA). Preoperatively, we did not recognize the existence of the common trunk of the left pulmonary vein. After the open thoracotomy, due to a severe intrathoracic adhesion, we omitted releasing the adhesion of the lower lobe. We did not exactly confirm the location of the inferior pulmonary vein (IPV). After cutting the interlobular pulmonary arterial branchies, we resected the superior pulmonary vein (SPV) using auto sutures. After division of the lung parenchyma and incomplete fissures using auto sutures, we intended to resect the upper bronchus. However, we could not find an IPV at the normal IPV site. A thin IPV was found to be returned to the peripheral site of the resected SPV. The SPV and IPV formed a common trunk at the normal site of the SPV. Although we considered reconstructing the resected common trunk, we finally made a decision of performing an incidental pneumonectomy in order to prevent any postoperative complications on the reconstruction of the IPV such as thrombus occlusion at the anastomosis site and venous return congestion. Retrospectively, we confirmed the preoperative images of the computed tomographic scanning, which showed a narrow IPV that returned to the peripheral site of the SPV. It is important to confirm both accurate locations of the SPV and IPV when performing a lobectomy.

Volumetric thin-section CT: evaluation of pulmonaryinterlobar fissures.

We aimed to perform an imaging analysis of interlobar fissures and their variations using thin-section computed tomography (CT). Volumetric thin-section CT scanning was performed in 208 subjects. Interlobar fissures were observed on axial images, and reconstructed coronal and sagittal images were observed by multiplanar reformatting (MPR). The vessel distributions were verified by maximal intensity projection (MIP). On the axial images, the interlobar fissures were characterized by lines of hyperattenuation, bands of hyperattenuation, avascular zones, and mixed imaging. The interlobar fissures were divided into seven grades according to the percentage of defects over the entire fissure. On the axial images, of all interlobar fissures without avascular zones, 70.2% of the right oblique fissures (ROFs) and 94.2% of the left oblique fissures (LOFs) appeared as lines, and 83.2% of the horizontal fissures (HFs) appeared as bands. All of the interlobar fissures appeared as lines on the coronal and sagittal images. Of all cases, 17.8% showed fully complete interlobar fissures for all three fissures. Incomplete fissures included 41.3% of ROFs, 58.2% of HFs, and 45.2% of LOFs. In ROFs and LOFs, discontinuity was most frequently below 20%, while in HFs discontinuity was most frequently 41%-60%. The most common classification of incomplete interlobar fissures was a discontinuous avascular zone. Incomplete interlobar fissures are common variations of interlobar fissures. Techniques including volumetric thin-section CT, MPR, and MIP can assist in the diagnosis of incomplete interlobar fissures.

Endoscopic bronchial valve treatment: patient selection and special considerations.

As well as lung volume reduction surgery, different minimally invasive endoscopic techniques are available to achieve lung volume reduction in patients with severe emphysema and significant hyperinflation. Lung function parameters and comorbidities of the patient, as well as the extent and distribution of the emphysema are factors to be considered when choosing the patient and the intervention. Endoscopic bronchial valve placement with complete occlusion of one lobe in patients with heterogeneous emphysema is the preferred technique because of its reversibility. The presence of high interlobar collateral ventilation will hinder successful treatment; therefore, endoscopic coil placement, polymeric lung volume reduction, or bronchoscopic thermal vapor ablation as well as lung volume reduction surgery can be used for treating patients with incomplete fissures. The effect of endoscopic lung volume reduction in patients with a homogeneous distribution of emphysema is still unclear and this subgroup should be treated only in clinical trials. Precise patient selection is necessary for interventions and to improve the outcome and reduce the risk and possible complications. Therefore, the patients should be discussed in a multidisciplinary approach prior to determining the most appropriate treatment for lung volume reduction.

Lung Volume Reduction in Pulmonary Emphysema from the Radiologist's Perspective.

Pulmonary emphysema causes decrease in lung function due to irreversible dilatation of intrapulmonary air spaces, which is linked to high morbidity and mortality. Lung volume reduction (LVR) is an invasive therapeutical option for pulmonary emphysema in order to improve ventilation mechanics. LVR can be carried out by lung resection surgery or different minimally invasive endoscopical procedures. All LVR-options require mandatory preinterventional evaluation to detect hyperinflated dysfunctional lung areas as target structures for treatment. Quantitative computed tomography can determine the volume percentage of emphysematous lung and its topographical distribution based on the lung's radiodensity. Modern techniques allow for lobebased quantification that facilitates treatment planning. Clinical tests still play the most important role in post-interventional therapy monitoring, but CT is crucial in the detection of postoperative complications and foreshadows the method's high potential in sophisticated experimental studies. Within the last ten years, LVR with endobronchial valves has become an extensively researched minimally-invasive treatment option. However, this therapy is considerably complicated by the frequent occurrence of functional interlobar shunts. The presence of "collateral ventilation" has to be ruled out prior to valve implantations, as the presence of these extraanatomical connections between different lobes may jeopardize the success of therapy. Recent experimental studies evaluated the automatic detection of incomplete lobar fissures from CT scans, because they are considered to be a predictor for the existence of shunts. To date, these methods are yet to show acceptable results. Today, surgical and various minimal invasive methods of lung volume reduction are in use. Radiological and nuclear medical examinations are helpful in the evaluation of an appropriate lung area. Imaging can detect periinterventional complications. Reduction of lung volume has not yet been conclusively proven to be effective and is a therapeutical option with little scientific evidence.

Development of a prediction model and risk score for procedure-related complications in patients undergoing percutaneous computed tomography-guided lung biopsy.

To propose a risk score predicting the potential occurrence of procedure-related complications in patients undergoing computed tomography (CT)-guided lung biopsy. Institution review board approval was obtained. A total of 342 CT-guided lung biopsies were retrospectively evaluated taking into account procedure-related complications and associated risk factors, including patient gender and age, previous radiation therapy (RT) and/or chemotherapy (CHT), lesion size, depth and location, incomplete pulmonary fissures, associated diffuse lung diseases, previous pneumothorax (PNX), lung volumes, punctured fissures, thoracic access, needle size and operator experience. Complications were assessed on chest X-ray and/or CT scans. Stepwise logistic regression was used to identify risk factors, to evaluate their correlation with procedure-related complications and to calculate models of risk (MoRs). PNX requiring chest tube placement occurred in 39 patients (11.4%), high-grade pulmonary parenchymal haemorrhage occurred in 62 patients (18.1%) and haemothorax occurred in 12 patients (3.5%). Risk factors increasing the incidence of complications were lesion size (P = 0.01), lesion depth (P = 0.01) and incomplete pulmonary fissures (P = 0.01); previous chemo-radiation therapy was correlated to a lower incidence of complications (P = 0.01). MoR for PNX was as follows: risk base line = 60%; age = +0.15%/year; punctured fissures = +20%; incomplete fissures = +9%; previous CHT/RT = -10%. MoR for parenchymal haemorrhage was as follows: risk base line = 20%, lesion depth = +0.8%/mm; age = +0.25%/year; incomplete fissures = +15%. MoR for haemothorax was as follows: risk base line = 1%; previous PNX = +20%; incomplete fissures = 7%; both previous PNX and incomplete fissures = +67%. This study provides MoRs to predict the risk of complications in patients undergoing CT-guided percutaneous lung biopsies.

Emphysema: Imaging for Endoscopic Lung VolumeReduction.

Chronic obstructive pulmonary disease (COPD) is characterized by two entities, the more airway-predominant type ("bronchitis") on the one hand, and emphysema-predominant type on the other. Imaging via high-resolution computed tomography plays an important role in phenotyping COPD. For patients with advanced lung emphysema, new endoscopic lung volume reduction therapies (ELVR) have been developed. Proper selection of suitable patients requires thin-section reconstruction of volumetric CT image data sets also in coronal and sagittal orientation are required. In the current manuscript we will describe emphysema subtypes (centrilobular, paraseptal, panlobular), options for quantifying emphysema and this importance of regional distribution (homogeneous or heterogeneous, target area) as this is crucial for patient selection. Analysis of the interlobular fissures is obligatory despite the lack of standardization, as incomplete fissures indicate collateral ventilation (CV) via parenchymal bridges, which is an important criterion in choosing endoscopic methods of LVR. Every radiologist should be familiar with modern LVR therapies such as valves and coils, and furthermore should know what a lung doctor expects from radiologic evaluation (before and after ELVR). Finally we present a checklist as a quick reference for all steps concerning imaging for ELVR. • High-resolution computed tomography with 3 D reconstructions becomes increasingly important in phenotyping COPD and diagnosing emphysema. • Patient selection is crucial for modern techniques of lung volume reduction, such as valves or coils. • Radiology plays a key role for fissural analysis and identifying a target area. • Success of this therapy depends on experience and multidisciplinary cooperation.

EMD Based Curve Evolution Method for Segmentation of Lungs on CT Scan Images

Medical imaging is the technique that is used to produce images of the human body or parts for clinical purpose. The CT image provides thorough information of structure of lungs, which could be used for better surgical preparation for treating Lung Cancer features. This work proposes a method for segmentation of lungs from the given CT images. Here a curve evolutional framework for segmentation is used. The flow fields driving the curves are based on the distributions of features in the inner and outer regions bounded by the curves. The segmentation method is automatic and shows good result. Computer Tomography (CT) is one of the most efficient medical diagnostic methods and has currently a widespread usage. Multi-slice CT scanning technology has revolutionized screening of the lungs and inspires necessitate for pulmonary image analysis. Segmentation of the lungs and lobes is a prerequisite for such image analysis in chest CT scans. CT scan is more appropriate for showing the detailed information of the parts of human body and it is used for various applications such as detection, classification etc. The analysis of lungs in CT image is used to detect the airway and the vessel present in the lungs [6]. The human lungs are subdivided into distinct pulmonary lobes separated by thin barriers, called fissures. Each lobe contains separate supply branches for both vessels and airways. The segmentation of anatomical parts is important in the detection of pathological abnormalities present in the lungs. Segmentation of the pulmonary lobes is relevant in many clinical applications. Accurate lung segmentation allows for the detection and quantification of abnormalities within the lungs. The lobes are separately supplied by the first subdivisions of the bronchial tree after the main bronchi. The lobes function independently within the lungs. Segmentation of the pulmonary lobes is relevant in clinical practice and particularly challenging for cases with severe diseases or incomplete fissures. Pulmonary fissure is a boundary between the lobes in the lungs. Its segmentation is of clinical interest as it facilitates the assessment of lung disease on a lobar level. A new approach has been made for segmenting the major fissures in both lungs on thin-section computed tomography (CT) [5]. An image transformation called “ridge map” is proposed for enhancing the appearance of fissures on CT. A curve-growing process, modeled by a Bayesian network, is described that is influenced by both the features of the ridge map and prior knowledge of the shape of the fissure. The process is implemented in an adaptive regularization framework that balances these influences and reflects the causal dependencies in the Bayesian network using an entropy measure. This method effectively alleviates the problem of inappropriate weights of

Effectiveness of Endobronchial Coil Treatment for Lung Volume Reduction in Patients with Severe Heterogeneous Emphysema and Bilateral Incomplete Fissures: A Six-Month Follow-Up

Background: Treatment with lung volume reduction coils (LVRC) may be effective in patients with severe heterogeneous emphysema and incomplete fissures. Objective: We hypothesized that LVRC placement improves pulmonary function, exercise tolerance and quality of life in these patients. Methods: Twenty-six patients with chronic obstructive pulmonary disease (COPD), 13 males and 13 females, aged 66 ± 8 years with heterogeneous emphysema and incomplete fissures were included in this retrospective analysis. The coils were implanted unilaterally in the upper or lower lobe. Patients were followed up at 30, 90 and 180 days after treatment and changes in pulmonary function test and 6-minute-walk-test (6MWT) values as well as scores for the modified Medical Research Council (mMRC) dyspnea scale and the St. George's Respiratory Questionnaire (SGRQ) were recorded. Results: FEV₁ improved significantly at 90 days and tended to decrease at the 180-day follow-up (0.67 ± 0.17 vs. 0.78 ± 0.25 vs. 0.73 ± 0.21 liters, respectively, p < 0.001). The 6MWT score had improved significantly at 90 days and had tended to decrease at the 180-day follow-up (216 ± 107 vs. 262 ± 97 vs. 262 ± 112 m, respectively, p = 0.001). SGRQ was significantly improved at 90 days. Multivariate analysis showed that worse 6MWT performance at baseline was independently associated with a greater improvement in 6MWT at the 90-day follow-up. The total complication rate was 54% (n = 14) and included light hemorrhage in 6 patients, COPD exacerbation in 6, pneumothorax in 1 and both COPD exacerbation and pneumothorax in 1 patient. Conclusions: This is the first study to show that LVRC in patients with heterogeneous emphysema and incomplete fissures improves exercise capacity, quality of life and lung function up to 90 days after the intervention. Further studies are needed to assess the long-term effects of LVRC in these patients.

Pulmonary fissure integrity and collateral ventilation in COPD patients.

PurposeTo investigate whether the integrity (completeness) of pulmonary fissures affects pulmonary function in patients with chronic obstructive pulmonary disease (COPD).Materials and MethodsA dataset consisting of 573 CT exams acquired on different subjects was collected from a COPD study. According to the global initiative for chronic obstructive lung disease (GOLD) criteria, these subjects (examinations) were classified into five different subgroups, namely non-COPD (222 subjects), GOLD-I (83 subjects), GOLD-II (141 subjects), GOLD-III (63 subjects), and GOLD-IV (64 subjects), in terms of disease severity. An available computer tool was used to aid in an objective and efficient quantification of fissure integrity. The correlations between fissure integrity, and pulmonary functions (e.g., FEV1, and FEV1/FVC) and COPD severity were assessed using Pearson and Spearman's correlation coefficients, respectively.ResultsFor the five sub-groups ranging from non-COPD to GOLD-IV, the average integrities of the right oblique fissure (ROF) were 81.8%, 82.4%, 81.8%, 82.8%, and 80.2%, respectively; the average integrities of the right horizontal fissure (RHF) were 62.6%, 61.8%, 62.1%, 62.2%, and 62.3%, respectively; the average integrities of the left oblique fissure (LOF) were 82.0%, 83.2%, 81.7%, 82.0%, and 78.4%, respectively; and the average integrities of all fissures in the entire lung were 78.0%, 78.6%, 78.1%, 78.5%, and 76.4%, respectively. Their Pearson correlation coefficients with FEV1 and FE1/FVC range from 0.027 to 0.248 with p values larger than 0.05. Their Spearman correlation coefficients with COPD severity except GOLD-IV range from −0.013 to −0.073 with p values larger than 0.08.ConclusionThere is no significant difference in fissure integrity for patients with different levels of disease severity, suggesting that the development of COPD does not change the completeness of pulmonary fissures and incomplete fissures alone may not contribute to the collateral ventilation.

A cadaveric study of anatomical variations of fissures and lobes of lung

Abstract Background and aim: The anatomical variations of fissures and lobes of lungs have been described by many research workers on CT scans, whereas, there were fewer studies done on gross anatomical specimens. Materials and methods: In the present study, 30 embalmed cadavers have been dissected and lungs were examined for fissures and lobes. Results: Nine out of 30 left lungs showed incomplete oblique fissures. Eight out of 30 right lungs showed incomplete transverse fissure but oblique fissure was complete, and in two right lungs, incomplete oblique and transverse fissures were found. In one cadaver one accessory lobe and one accessory fissure was present, on right side. Comparative analysis of present work with data in literature suggest that different studies performed on radiological images reported greater prevalence of incomplete or absence of pulmonary fissures as compared to present cadaveric study. Therefore our findings with regard to fissures and lobes are different from many studies but are approximately similar to two. Conclusion: Variation of lung anatomy is important for cardio-thoracic surgeons, radiologists for interpreting x-rays, CT scans and MRI and also it is of academic interest to all medical persons.

(814) - The Impact of Incomplete Pulmonary Fissures of Living Lobar Lung Transplant Donors on Bronchial Stenosis of Lung Recipients

Bronchial complications are among the most challenging problems after living-donor lobar lung transplantation (LDLLT), although the ischemic time of living-donor lungs can be minimized compared to cadaveric lung transplantation. To prevent bronchial complications, maintaining the pulmonary blood flow is critical for the bronchial healing. However, in the donor lobectomy of LDLLT, the inadequate dissection of interlobar fissures could cause unexpected obstruction of the pulmonary vessels and decreased blood flow to the bronchial anastomosis. The purpose of this study was to examine the relationships between incomplete pulmonary fissures of living-donor lungs and bronchial stenosis of LDLLT recipients. We retrospectively analyzed 127 donors and 69 recipients of bilateral and unilateral LDLLT at our institution between October 1998 and October 2013. According to Craig’s classification of pulmonary fissures, interlobar fissures of donor lungs were Grade 1 in 43, Grade 2 in 73, Grade 3 in 11 and Grade 4 in no donor. Postoperative lung perfusion scintigraphy was available in 119 of 127 transplanted lungs after LDLLT. Lung perfusion scintigraphy showed segmental defect or reduced blood flow in the lobar apex in 12 transplanted lungs (Group A), and homogenous distribution of blood flow in 107 transplanted lungs (Group B). Grade of interlobar fissures in Group A was significantly higher than that in Group B (2.1 ± 0.15 v.s. 1.7 ± 0.059; p < 0.05). While 3 of 12 (25 %) transplanted lungs in Group A revealed bronchial stenosis after LDLLT, no bronchial stenosis was encountered in 107 transplanted lungs of Group B. Our experience suggests that the incomplete pulmonary fissure of living-donors is a possible risk factor for bronchial stenosis of lung recipients in LDLLT. Careful dissection of incomplete pulmonary fissures should be required to maintain the pulmonary blood flow in the living-donor lobectomy.

(815) - Traffic Density Does Not Affect Lung Function in the First Year After Double Lung Transplant

s S295 anastomosis. The purpose of this study was to examine the relationships between incomplete pulmonary fissures of living-donor lungs and bronchial stenosis of LDLLT recipients. Methods: We retrospectively analyzed 127 donors and 69 recipients of bilateral and unilateral LDLLT at our institution between October 1998 and October 2013. Results: According to Craig’s classification of pulmonary fissures, interlobar fissures of donor lungs were Grade 1 in 43, Grade 2 in 73, Grade 3 in 11 and Grade 4 in no donor. Postoperative lung perfusion scintigraphy was available in 119 of 127 transplanted lungs after LDLLT. Lung perfusion scintigraphy showed segmental defect or reduced blood flow in the lobar apex in 12 transplanted lungs (Group A), and homogenous distribution of blood flow in 107 transplanted lungs (Group B). Grade of interlobar fissures in Group A was significantly higher than that in Group B (2.1 ± 0.15 v.s. 1.7 ± 0.059; p < 0.05). While 3 of 12 (25 %) transplanted lungs in Group A revealed bronchial stenosis after LDLLT, no bronchial stenosis was encountered in 107 transplanted lungs of Group B. Conclusion: Our experience suggests that the incomplete pulmonary fissure of living-donors is a possible risk factor for bronchial stenosis of lung recipients in LDLLT. Careful dissection of incomplete pulmonary fissures should be required to maintain the pulmonary blood flow in the living-donor lobectomy.

Incomplete and accessory fissures of the lung evaluated by high-resolution computed tomography

PurposeThe aim of our study was to assess incomplete and accessory interlobar fissures using volumetric thin-section high-resolution computed tomography (HRCT). Materials and methodsRetrospective assessment of HRCT examinations of 250 patients was performed. We assessed the localization, extension, and type of the incompleteness of fissures as well as the presence and localization of accessory fissures. We searched for possible correlation among the localization of interlobar fissures, the presence of incompleteness, and accessory fissures. ResultsOn the left side, an incomplete oblique fissure was found in 24%. The discontinuity was present in the parahilar region and the area of the incompleteness was most frequently between 21% and 40%. The right oblique fissure was incomplete in 35%, mostly parahilarly, with the most frequent discontinuity below 20%. An incomplete horizontal fissure was found in 74%. Accessory fissures were identified in 16% of patients, with the same frequency on both sides. The most frequent finding was accessory horizontal fissure with 8.0% on the left side, superior accessory fissure (7.2%) and inferior accessory fissure (5.2%) on the right side. No correlation was found among the localization of interlobar fissures, the presence of incompleteness, and accessory fissures. ConclusionIncomplete and accessory fissures are frequent anatomic variations of interlobar fissures.

Pulmonary lobe segmentation based on ridge surface sampling and shape model fitting

Performing lobe-based quantitative analysis of the lung in computed tomography (CT) scans can assist in efforts to better characterize complex diseases such as chronic obstructive pulmonary disease (COPD). While airways and vessels can help to indicate the location of lobe boundaries, segmentations of these structures are not always available, so methods to define the lobes in the absence of these structures are desirable. The authors present a fully automatic lung lobe segmentation algorithm that is effective in volumetric inspiratory and expiratory computed tomography (CT) datasets. The authors rely on ridge surface image features indicating fissure locations and a novel approach to modeling shape variation in the surfaces defining the lobe boundaries. The authors employ a particle system that efficiently samples ridge surfaces in the image domain and provides a set of candidate fissure locations based on the Hessian matrix. Following this, lobe boundary shape models generated from principal component analysis (PCA) are fit to the particles data to discriminate between fissure and nonfissure candidates. The resulting set of particle points are used to fit thin plate spline (TPS) interpolating surfaces to form the final boundaries between the lung lobes. The authors tested algorithm performance on 50 inspiratory and 50 expiratory CT scans taken from the COPDGene study. Results indicate that the authors' algorithm performs comparably to pulmonologist-generated lung lobe segmentations and can produce good results in cases with accessory fissures, incomplete fissures, advanced emphysema, and low dose acquisition protocols. Dice scores indicate that only 29 out of 500 (5.85%) lobes showed Dice scores lower than 0.9. Two different approaches for evaluating lobe boundary surface discrepancies were applied and indicate that algorithm boundary identification is most accurate in the vicinity of fissures detectable on CT. The proposed algorithm is effective for lung lobe segmentation in absence of auxiliary structures such as vessels and airways. The most challenging cases are those with mostly incomplete, absent, or near-absent fissures and in cases with poorly revealed fissures due to high image noise. However, the authors observe good performance even in the majority of these cases.

Incomplete pulmonary fissures evaluated by volumetric thin-section CT: Semi-quantitative evaluation for small fissure gaps identification, description of prevalence and severity of fissural defects

ObjectiveTo assess the interobserver agreement for a semi-quantitative evaluation of the interlobar fissures integrity in volumetric thin-section CT images, looking for more detailed information regarding fissural defects; and describe prevalence and severity of fissural defects between the different functional groups of subjects. Materials and methodsVolumetric scans of 247 individuals exposed to tobacco with different functional status (normal to severe COPD), were retrospectively and independently evaluated by 2 chest radiologists, with a consensual reading additionally with a third reader in disagreement cases. Right oblique (RO), right horizontal (RH) and left oblique fissures (LO) integrity was estimated using a 5% scale. GOLD classification was available for all subjects. ResultsInterobserver agreement (weighted Kappa-index) for fissural categorization was 0.76, 0.70 and 0.75, for RO, RH and LO, respectively. Final evaluation found 81%, 89% and 50% of RO, RH and LO to be incomplete, with respective mean integrity of 80%, 58% and 80%. Small fissure gaps (<10%) were present in 30% of patients. Prevalence and severity of fissural defects were not different between the GOLD categories. ConclusionsA substantial agreement between readers was found in the analysis of interlobar fissures integrity. The semi-quantitative method allowed a detailed description of the fissural defects, information that can be important, for example, in endoscopic lung volume reduction therapies for emphysema. Small fissure gaps, overlooked in previous studies, were found in almost a third of the patients. A higher than previously described prevalence of fissural defects was described, but without significant differences among the distinct functional groups.

Endobronchial valves in severe emphysematous patients: CT evaluation of lung fissures completeness, treatment radiological response and quantitative emphysema analysis

OBJECTIVE: To evaluate lung fissures completeness, post-treatment radiological response and quantitative CT analysis (QCTA) in a population of severe emphysematous patients submitted to endobronchial valves (EBV) implantation. MATERIALS AND METHODS: Multi-detectors CT exams of 29 patients were studied, using thin-section low dose protocol without contrast. Two radiologists retrospectively reviewed all images in consensus; fissures completeness was estimated in 5% increments and post-EBV radiological response (target lobe atelectasis/volume loss) was evaluated. QCTA was performed in pre and post-treatment scans using a fully automated software. RESULTS: CT response was present in 16/29 patients. In the negative CT response group, all 13 patients presented incomplete fissures, and mean oblique fissures completeness was 72.8%, against 88.3% in the other group. QCTA most significant results showed a reduced post-treatment total lung volume (LV) (mean 542 ml), reduced EBV-submitted LV (700 ml) and reduced emphysema volume (331.4 ml) in the positive response group, which also showed improved functional tests. CONCLUSION: EBV benefit is most likely in patients who have complete interlobar fissures and develop lobar atelectasis. In patients with no radiological response we observed a higher prevalence of incomplete fissures and a greater degree of incompleteness. The fully automated QCTA detected the post-treatment alterations, especially in the treated lung analysis.

A Malformed Staple Causing Cardiac Tamponade After Lobectomy

We present a patient with cardiac tamponade caused by a malformed staple after lobectomy. The patient was successfully rescued by an urgent reoperation. Although rare, acute cardiac tamponade should be taken into account after lobectomy, and proper measures should be taken against the potential harm caused by a malformed staple.

Automatic Segmentation of the Pulmonary Lobes From Chest CT Scans Based on Fissures, Vessels, and Bronchi

Segmentation of the pulmonary lobes is relevant in clinical practice and particularly challenging for cases with severe diseases or incomplete fissures. In this work, an automated segmentation approach is presented that performs a marker-based watershed transformation on computed tomography (CT) scans to subdivide the lungs into lobes. A cost image for the watershed transformation is computed by combining information from fissures, bronchi, and pulmonary vessels. The lobar markers are calculated by an analysis of the automatically labeled bronchial tree. By integration of information from several anatomical structures the segmentation is made robust against incomplete fissures. For evaluation the method was compared to a recently published method on 20 CT scans with no or mild disease. The average distances to the reference segmentation were 0.69, 0.67, and 1.21 mm for the left major, right major, and right minor fissure, respectively. In addition the results were submitted to LOLA11, an international lung lobe segmentation challenge with publically available data including cases with severe diseases. The average distances to the reference for the 55 CT scans provided by LOLA11 were 0.98, 3.97, and 3.09 mm for the left major, right major, and right minor fissure. Moreover, an analysis of the relation between segmentation quality and fissure completeness showed that the method is robust against incomplete fissures.

Incomplete fissures in severe emphysematous patients evaluated with MDCT: Incidence and interobserver agreement among radiologists and pneumologists

ObjectivePulmonary fissures completeness predicts efficacy in endobronchial valves (EBV) implantation, a new lobar volume reduction therapy for severe emphysematous patients. We assessed the incidence of incomplete fissures and the interobserver agreement in its evaluation with MDCT, in severe emphysematous patients prior to EBV implantation. Materials and MethodsVolumetric thin-section CT scans of 35 patients (CODP GOLD 3/4, heterogeneous emphysema) were retrospectively reviewed by 2 pneumologists, 1 general and 2 experienced chest radiologists, independently and blinded for treatment outcome, and the pulmonary fissures were classified as either complete or incomplete. Interobserver agreement was assessed with Kappa index (KI). ResultsAgreement between all readers for the left oblique, right oblique and horizontal fissure was, respectively, moderate (KI=0.53), fair (KI=0.37) and moderate (KI=0.42). Highest agreement (99/105 fissures) was observed among experienced radiologists, being for left oblique, right oblique and horizontal, respectively, almost perfect (KI=0.79), perfect (KI=1.0) and moderate (KI=0.52). These 2 reviewers found that all of 35 patients had at least one incomplete fissure, with a proportion of incomplete fissures assigned as 74/65%, 85/85% and 91/88%, respectively for the left oblique, right oblique and horizontal fissures. ConclusionsPneumologists and radiologists agreed fairly to moderately in fissures analysis, while the experienced chest radiologists reached the highest clinically adequate agreement of 94%. We believe that clinical routine visual analysis of the fissures integrity can be done with a good degree of confidence in MDCT images, and experienced readers might be required. Also, a higher than expected incidence of incomplete fissures was described in our studied population.