Interlobar Fissure Research Articles

CT fluoroscopy-guided biopsy of pulmonary lesions contacting the interlobar fissure: An analysis of 72 biopsies

PurposeThe purpose of this study was to evaluate retrospectively the safety and diagnostic yield of computed tomography (CT) fluoroscopy-guided biopsy for pulmonary lesions with interlobar fissure contact. Materials and methodsSeventy-two lesions showing interlobar fissure contact (mean size, 15.2 ± 5.3 [SD] mm [range: 5.3–27.0 mm]; mean length of interlobar fissure contact, 8.9 ± 3.6 [SD] mm [range: 2.6–17.5 mm] in 72 patients (33 men, 39 women; mean age, 69.7 ± 10.3 [SD] years; age range: 37–91 years) were evaluated. Multiple variables were assessed to determine the risk factors for diagnostic failure and pneumothorax. Additionally, these variables were compared between these 72 lesions and randomly selected controls (i.e., non-contact lesions). ResultsAll biopsies were technically successful using the transfissural (n = 14) or conventional routes (the route into the lung lobe with the target) with (n = 35) or without (n = 23) possible risk of needle insertion into the interlobar fissure after penetrating the target lesion. Sixty-eight (94.4%) procedures succeeded diagnostically and four (5.6%) failed. There were 27 grade I pneumothorax (37.5%), one (1.4%) grade II bleeding, and five (6.9%) grade IIIa pneumothorax requiring chest tube placement. Groups with and without pneumothorax did not differ significantly in patient-, lesion-, or procedure-related variables. Diagnostic yields and pneumothorax occurrence showed no significant differences between lesions with interlobar fissure contact and controls. ConclusionCT fluoroscopy-guided biopsy of pulmonary lesions with interlobar fissure contact is a safe procedure with a high diagnostic yield. Furthermore, because of potential complications, the transfissural route should be used only when a safer route is not possible.

Comparison of CT-Guided Core Needle Biopsy in Pulmonary Ground-Glass and Solid Nodules Based on Propensity Score Matching Analysis.

Purpose: To compare the diagnostic accuracy and safety of computed tomography (CT)-guided core needle biopsy (CNB) between pulmonary ground-glass and solid nodules using propensity score matching (PSM) method and determine the relevant risk factors. Methods: This was a single-center retrospective cohort study using data from 665 patients who underwent CT-guided CNB of pulmonary nodules in our hospital between May 2019 and May 2021, including 39 ground-glass nodules (GGNs) and 626 solid nodules. We used a 1:4 PSM analysis to compared the diagnostic yields and complications rates of CT-guided CNB between 2 groups. Results: After PSM, 170 cases involved in the comparison (34 GGNs vs 136 solid nodules) were randomly matched (1:4) by patient demographics, clinical history, lesion characteristics, and procedure-related factors. There was no statistically significant difference in the diagnostic yields and complications rates between 2 groups. Significant pneumothorax incidence increase was noted at small lesion size, deep lesion location, and traversing interlobar fissure (P < .05). Post-biopsy hemorrhage was a protective factor for pneumothorax (P < .05). The size/proportion of consolidation of GGN did not influence the diagnostic accuracy and complication incidence (P > .05). Conclusions: The accuracy and safety of CT-guided CNB were comparable for ground-glass and solid nodules and the size/proportion of consolidation of GGN may be not a relevant risk factor. The biopsy should avoid traversing interlobar fissure as far as possible. Smaller lesion size and deeper lesion location may lead to higher pneumothorax rate and post-biopsy hemorrhage may be a protective factor for pneumothorax.

Localized malignant pleural mesothelioma of the interlobar fissure mimicking a lung cancer

We report a case of localized malignant pleural mesothelioma (LMPM) of the interlobar fissure mimicking lung cancer. A 74-year-old woman presented with dyspnoea and a left pleural effusion. Chest computed tomography revealed a bulky mass, arising from the left lower lobe with intense uptake at the 18F-FDG PET. A left lower lobectomy was performed after thoracoscopic pleural biopsies. The final histology revealed an LMPM epithelioid like. We describe the diagnostic and curative path of the disease, speculating on the differential diagnosis and treatment of LMPM.

A Rare Case of Interlobar Pneumothorax

BACKGROUND: Pneumothorax is a severe medical condition characterized by the collection of air in one or several spaces of the pleura. A rare subtype of pneumothorax where air is restricted in interlobar pleural space, mostly due to the previous fibrous pleural adhesions, is known as interlobar pneumothorax. CASE PRESENTATION: We present a rare case of a 58-year-old female admitted to the emergency department due to difficulty on breathing, hemoptysis, and discomfort in the right anterior axillary line, which worsened with inspiration and was associated with breathlessness during physical activity. The diagnosis was confirmed by thoracic multi slice computed tomography (MSCT), showing that air was located between the middle and lower lobes of the right lung , measuring 7 × 5 × 2.5 cm (transversal × oblique cranio-caudal × antero-posterior), representing interlobar pneumothorax. DISCUSSION: Cases of interlobar pneumothorax need to be carefully differentiated and evaluated, while skin folds, overlapping breast margin, interlobar fissure, bullae in the apices, pneumomediastinum, pneumopericardium, inferior pulmonary ligament air collection, pneumatocele, and air collection in the intrathoracic extrapleural space, can mimic pneumothorax and make diagnosing very challenging.

This video demonstrates, step by step, a right thoracoscopic S9+10 segmentectomy through a subxiphoid approach combining both interlobar fissure and inferior pulmonary ligament approaches, on the basis of 3D-CT reconstruction and fluorescence imaging

This video demonstrates, step by step, a right thoracoscopic S9+10 segmentectomy through a subxiphoid approach combining both interlobar fissure and inferior pulmonary ligament approaches, on the basis of 3D-CT reconstruction and fluorescence imaging

Evaluation of HRCT for the Differential Diagnosis of Pneumonia-Like Consolidation Pattern of Pulmonary MALT Lymphoma from Lobar Pneumonia.

PurposeTo assess the performance of high-resolution computed tomography (HRCT) in discriminating the consolidation pattern of pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma from lobar pneumonia.Patients and MethodsThis retrospective study comprised 26 patients with pathologically confirmed consolidation pattern of pulmonary MALT lymphoma (12 men and 14 women; mean age, 59.4±12.1 years) and 36 patients with lobar pneumonia confirmed by body fluids or respiratory secretion culture (16 men and 20 women; mean age, 41.8±26.3 years). Two radiologists independently evaluated the CT images. The effectiveness of these variables in distinguishing lobar pneumonia from MALT lymphoma was analyzed using logistic regression analysis.ResultsThe average age of lobar pneumonia patients was younger than that of MALT lymphoma patients (p=0.002). The respiratory symptom was more common in lobar pneumonia than MALT lymphoma (p=0.002). Signs of bronchiectasis within the consolidation and bulging of interlobar fissure occurred significantly more often in MALT lymphoma than pneumonia (69.2% vs 11.1%, p<0.0001; 46.2% vs 19.4%, p=0.024). We used the predictors with p<0.05 (age, respiratory symptoms, bronchiectasis, and bulging of interlobar fissure) to construct a logistic regression model. The area under curve (AUC), negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity, and accuracy were 0.891, 84.21%, 83.33%, 88.89%, 76.92%, and 83.87% for discriminating lobar pneumonia from MALT lymphoma.ConclusionMiddle-aged, presence of mild clinical symptoms, bronchiectasis and bulging of the interlobar fissure on chest CT images are potential markers to distinguish pulmonary MALT lymphoma from lobar pneumonia.

Robot-assisted thoracoscopic lobectomy for severe incomplete interlober fissure.

An incomplete interlobar fissure makes thoracoscopic lobectomy difficult and is predictive of morbidity after thoracoscopic lobectomy. This report demonstrates the robot-assisted thoracoscopic (RATS) lobectomy technique for patients with severe incomplete interlobar fissures. A fissureless approach was chosen for pulmonary resection. Near-infrared fluorescence imaging with intravenous indocyanine green (ICG) was used to detect the interlobar line after transection of the bronchus, pulmonary artery and vein. Interlobar fissure was identified and divided by robotic staplers. This combined technique using ICG and fissureless lobectomy made RATS lobectomy safe for patients with severe incomplete interlobar fissures.

A rare case report: left-sided gall bladder without situs inversus viscerum

Left-sided gall bladder without situs inversus viscerum is a rare clinical entity. A left-sided gall bladder is a rare congenital anomaly defined as a gall bladder attached to the lower surface of the left lateral segment of the liver, to the left of the inter-lobar fissure and round ligament. We reported our experience of one cases of left-sided gall bladder in a woman aged 45 years who underwent laparoscopic cholecystectomy for acute calculous cholecystitis. Left-sided gall bladder may provide an unusual surprise to the surgeons during laparoscopy as routine pre-operative studies may not always detect the anomaly. Awareness of the unpredictable confluence of the cystic duct into the common bile duct (CBD) and selective use of intraoperative cholangiography aid in the safe laparoscopic management of this unusual entity. One previous case reported had shown cystic duct opened into the common hepatic duct on its right side in a patient with left sided gall bladder.

Correlation between pleural tags on CT and visceral pleural invasion of peripheral lung cancer that does not appear touching the pleural surface.

To evaluate the association between a sign and visceral pleural invasion (VPI) of peripheral non-small-cell lung cancer (NSCLC) that does not appear touching the pleural surface. A total of 221 consecutive patients with NSCLC that did not appear touching the pleural surface, ≤ 3 cm in solid tumor diameter, and was surgically resected between January 2009 and December 2015 were included. We focused on the flat distortion of the tumor caused by an arch-shaped linear tag between the tumor and the pleura on CT and named it a bridge tag sign. We evaluated the associations between the clinicopathological features of the tumor, including the bridge tag sign, and VPI. We also evaluated the associations between histopathological findings and the bridge tag sign. The utility of the bridge tag sign in the diagnosis of VPI was statistically assessed. The bridge tag sign was observed in 48 (20.8%) patients. VPI was positive in 9 (4.1%) patients; among these, the bridge tag sign was positive in 8 patients. In multivariate analysis, a bridge tag sign was significantly associated with VPI. The bridge tag sign was associated with longer contact length of the pleura with the tumor and trapezoid type pleural retraction. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the bridge tag sign in the diagnosis of VPI were 88.9%, 83.5%, 83.7%, 18.6%, and 99.4%, respectively. A bridge tag sign on CT might improve the accuracy of the prediction of VPI. • We present the bridge tag sign which is defined as a flat distortion of an NSCLC tumor by an arch-shaped linear tag between the tumor and chest wall or interlobar fissure. • The bridge tag sign was an independent predictive factor for visceral pleural invasion. • The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the bridge tag sign in the diagnosis of visceral pleural invasion were 88.9%, 83.5%, 83.7%, 18.6%, and 99.4%, respectively.

A randomized trial of who is better at treating the incomplete pulmonary fissure between stapler and thulium laser.

The role of thulium laser in the treatment of interlobar fissures in lobectomy is not clear. We aimed to evaluate the safety, effectiveness and economy of thulium laser in the treatment of incomplete interlobar fissure during lobectomy. A total of 76 patients were randomly divided into two groups: laser group and stapler group. The laser group was treated with thulium laser and the stapler group with stapler. Compared with stapler group, the laser group had a longer operation time, more postoperative drainage and lower operation cost, while there was no significant difference in hospitalization time, postoperative air leakage time and chest tube duration. Thulium laser is safe and effective in the treatment of incomplete interlobar fissure during lobectomy and can reduce the cost.

Thoracoscopic lobectomy through the pulmonary hilum approach for the treatment of congenital lung malformation.

Thoracoscopic lobectomy is widely accepted for the treatment of congenital lung malformations (CLM), owing to its advantages. However, severe incomplete interlobar fissure may lead to a high rate of conversion to thoracotomy and postoperational complications. Thoracoscopic lobectomy utilizing the pulmonary hilum approach may be an effective and safe method to resolve these problems. This retrospective study was conducted to estimate the safety and efficiency of this approach. A retrospective review of medical records was performed in our institution, from January 2014 to December 2019, and 432 patients with CLM who underwent thoracoscopic lobectomy through the pulmonary hilum approach were included in this study. Patients were divided into the incomplete fissure (IF) group and complete fissure (CF) group according to the level of fissure, which was proposed by an anatomical classification of pulmonary fissures. Patients in the IF and CF groups were 131 and 301, respectively. In univariate analysis, there were statistical significances between the two groups in terms of intraoperative blood loss (P = 0.04), surgical time (P = 0.01), the number of chest tube drainages (P < 0.01), and the total length of hospital stay (P = 0.03). However, no patients experienced bronchopleural fistula, postoperative pneumonia, or conversion to thoracotomy in either group. Five patients experienced prolonged air leakage in the IF group, and no prolonged air leakage occurred in the CF group. An IF would certainly increase the difficulty of CLM surgery, and thoracoscopic lobectomy using the pulmonary hilum approach is an effective and safe method for CLM patients.

Clinical characteristics of Chlamydia psittaci pneumonia.

Clinical characteristics of Chlamydia psittaci pneumonia.

Lobectomy for lung cancer with a displaced left B1 + 2 and an anomalous pulmonary vein: a case report

BackgroundA displaced left B1 + 2 accompanied by an anomalous pulmonary vein is a rare condition involving complex structures. There is a risk of unexpected injuries to bronchi and blood vessels when patients with such anomalies undergo surgery for lung cancer.Case presentationA 59-year-old male with suspected lung cancer in the left lower lobe was scheduled to undergo surgery. Chest computed tomography revealed a displaced B1 + 2 and hyperlobulation between S1 + 2 and S3, while the interlobar fissure between S1 + 2 and S6 was completely fused. Three-dimensional computed tomography (3D-CT) revealed an anomalous V1 + 2 joining the left inferior pulmonary vein and a branch of the V1 + 2 running between S1 + 2 and S6. We performed left lower lobectomy via video-assisted thoracic surgery, while taking care with the abovementioned anatomical structures. The strategy employed in this operation was to preserve V1 + 2 and confirm the locations of B1 + 2 and B6 when dividing the fissure.ConclusionThe aim of the surgical procedure performed in this case was to divide the fissure between S1 + 2 and the inferior lobe to reduce the risk of an unexpected bronchial injury. 3D-CT helps surgeons to understand the stereoscopic positional relationships among anatomical structures.

Fissureless trans-pericardial left upper lobectomy of the lung: a technique to avoid pneumonectomy

Fissureless lobectomy of the lung is an operative technique in which hilar vessels and bronchus are divided before the interlobar fissure is separated. When hilar vessels and bronchus cannot be exposed because of tumor progression, this procedure cannot be used. As an alternative, we propose here trans-pericardial fissureless left upper lobectomy, in which the left upper bronchus is exposed by dividing the posterior wall of the pericardium after the left upper pulmonary vein is divided in the pericardial cavity. This technique enables us to perform fissureless left upper lobectomy even when hilar vessels cannot be accessed outside the pericardium.

Development of a Predictive Model of Intraoperative Conversion to Thoracotomy for Lung Cancer Patients Undergoing Video-Assisted Thoracoscopic Surgery Lobectomy

Background: The predictors of intraoperative conversion to thoracotomy (ICT) remained inadequately understood. This multicenter trial aimed to develop a predictive model based on logistic regression model and other machine learning algorithms, thus to evaluate the risk of ICT for lung cancer patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy. Methods: We retrospectively collected data of lung cancer patients undergoing VATS lobectomy from three centers from September 2005 to August 2019. Predictors were selected based on stepwise selection, least absolute shrinkage and selection operator regression. Modelling approach included logistic regression, artificial neural network and random forest. Models was compared with area under the curve (AUC) of receiver operating characteristic (ROC), brier score and Logarithmic-loss in internal validation (10-fold cross validation) and external validation (200 bootstraps). Findings: Finally, 6546 patients were included, and 251 (3.8%) patients experienced ICT. Logistic regression-based model with nine predictors consisting of age, sex, peak expiratory flow, tumor size, clinical TNM stages, VATS ports, resection lobes, with/without pleural adhesion and with/without well-developed interlobar lung fissure, were selected based on the best discrimination and calibration in internal (AUC of ROC: 0.709, 95% CI: 0.560-0.806; Brier score: 0.036, 95%CI: 0.017-0.078; Logarithmic-loss: 0.154, 95%CI: 0.087-0.307) and external validation (AUC of ROC: 0.759, 95% CI: 0.519-0.968; Brier score: 0.037, 95% CI: 0.033-0.041; Logarithmic-loss: 0.152, 95% CI: 0.124-0.179). Interpretation: Logistic-regression based predictive model with nine selected predictors had the capability to evaluate the risk of ICT for lung cancer patients undergoing VATS lobectomy. Larger prospective study was needed to validate model performance. Funding Information: This work was supported by 1.3.5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (ZYGD18021, ZYJC18009), and Post-Doctor Research Project, West China Hospital, Sichuan University (2020HXBH109). Declaration of Interests: The authors declare no potential conflicts of interest. Ethics Approval Statement: The Ethics Committee of West China Hospital of Sichuan University (No. 2020-1034) and Affiliated Hospital of Zunyi Medical University (No. KLL-2020-278) approved this study and waived the requirement of informed consent.

Predictors of pneumothorax and chest drainage after percutaneous CT-guided lung biopsy: A prospective study.

We present an analysis of predictors of pneumothorax, and pneumothorax requiring chest drainage after CT-guided lung biopsy, in one of the largest Scandinavian dataset presented. We prospectively registered 875 biopsy procedures from 786 patients in one institution from January 27, 2012, to March 1, 2017, and recorded complications including pneumothorax with or without chest drainage, and multiple variables we assumed could be associated with complications. We performed multivariable logistic regression analysis to identify predictors of pneumothorax and pneumothorax requiring chest drainage. Of the biopsied lesions, 65% were malignant, 29% benign, and 6% inconclusive. Pneumothorax occurred in 39% of the procedures and chest drainage was performed in 10%. In multivariable analysis, significant predictors of pneumothorax were emphysema (OR 1.92), smaller lesion size (OR 0.83, per 1 cm increase in lesion size), lateral body position during procedure (OR 2.00), longer needle time (OR 1.09, per minute), repositioning of coaxial needle with new insertion through pleura (OR 3.04), insertion through interlobar fissure (OR 5.21), and shorter distance to pleura (OR 0.79, per 1 cm increase in distance). Predictors of chest drainage were emphysema (OR 4.01), lateral body position (OR 2.61), and needle insertion through interlobar fissure (OR 4.17). Predictors of pneumothorax were emphysema, lateral body position, needle insertion through interlobar fissure, repositioning of coaxial needle with new insertion through pleura, and shorter distance to pleura. The finding of lateral body position as a predictor of pneumothorax is not earlier described. Emphysema, lateral body position, and needle insertion through interlobar fissure were also predictors of chest drainage. • Pneumothorax is a frequent complication to CT-guided lung biopsy; a smaller fraction of these complications needs chest drainage. • Predictors for pneumothorax are emphysema, smaller lesion size, lateral body position, longer needle time, repositioning of coaxial needle with new insertion through pleura, needle insertion through the interlobar fissure, and shorter distance to pleura. • Predictors for requirement for chest drainage post CT-guided lung biopsy are emphysema, lateral body position, and needle insertion through the interlobar fissure.

The left main bronchus transected incorrectly during video-assisted thoracoscopic lobectomy: a case report

BackgroundSeveral severe intraoperative complications of lung cancer surgery have been reported, but the incorrect transection of the main bronchus is a very rare and serious complication. We report a surgical case of a patient with left lower lobe lung cancer invading the inferior segment of the lingula, with fused interlobar fissure and dense pleural adhesion, in which the left main bronchus was mistaken for the left lower lobe bronchus and was transected.Case presentationA 64-year-old woman with lung adenocarcinoma was referred to our hospital for surgical treatment. Chest computed tomography (CT) scan showed a 30-mm nodule with a clear border and irregular margins in the center of the anterior (S8) segment of the lower lobe of the left lung and another similar 30-mm nodule in the lateral (S9) segment of the same lobe. Metastasis within the same lobe was suspected. A thoracoscopic left lower lobectomy was scheduled for the patient. As the patient had a moderately, fused fissure, dense pleural adhesion, and suspicious tumor invasion from the left S8 segment to the left S5 segment, and the interlobar node tightly adhered to the main PA at the site of basilar artery origin of the LLL, we performed left lower lobectomy and a left S5 segmentectomy using the fissureless fissure-last technique. During surgery, the left main bronchus was mistaken for the left lower lobe bronchus and was transected. After transecting the left main bronchus, we performed a sleeve bronchoplasty to prevent pneumonectomy.ConclusionsWe experienced the rare and serious intraoperative complication of the incorrect transection of the main bronchus. There are few reports of this intraoperative complication, and it should not be overlooked by surgeons.

PNEUMONIA OR LYMPHOMA? DO NOT BE FOOLED!

SESSION TITLE: Medical Student/Resident Lung Pathology SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Mucosa-associated lymphoid tissue (MALT) Lymphoma, also known as Extranodal Marginal Zone B cell lymphoma (EMZL), is a rare type of non-Hodgkin’s lymphoma with an incidence rate of 18.3 cases per 1 million in the United States. The objective of this case is to describe a challenging case of EMZL presenting as persistent localized lung consolidation that was mistaken for pneumonia. CASE PRESENTATION: 77-year-old male, former smoker who presented with complains of nonproductive cough for several weeks, chest-x-ray (CXR) showed a 4.3 cm rounded hazy right parahilar mass. A follow up computed tomography (CT) of the chest revealed 4.7 x2.8 cm consolidative opacity along the interlobar fissure in the right upper lobe (RUL). Reviewing back a year ago, CT scan done for nonspecific chest pain, showed the mass size was unchanged but appeared to be less solid compared to the current scan. Patient underwent a Fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan which showed elevated FDG activity SUV 3.0 associated with a consolidative pulmonary opacity in the posterior portion of the right upper lobe silhouetting the major fissure. The patient subsequently underwent a CT guided percutaneous biopsy of the right upper lobe airspace consolidation. Histologic sections showed interstitial expansion and bronchial epithelium involvement by small monocytoid- appearing lymphocytes and significant amount of plasma cells (Figure 1). Immunohistochemistry was positive for CD20 and BCL-2 and negative for BCL-6 and CD10. CD138 which highlights plasma cell component was positive. Immunostaining for kappa and lambda showed findings most suggestive of monotypic lambda expression. Fluorescence in situ hybridization (FISH) studies for MALT1 (18q21) rearrangement identified a MALT1 gene rearrangement and B cell clonality studies done by PCR were positive for a clonal rearrangement. Therefore, the final diagnosis was small B-cell non-hodgkin lymphoma consistent with extranodal MALT. In retrospect the lymphoma was likely present a year ago however mistaken as a pneumonia. Given the lack of symptoms and minimal progression of over one year, was consistent with the indolent clinical behavior of the tumor. Decision was made not to treat at this point by the physician and patient. Till date patient remain asymptomatic. DISCUSSION: EMZL has been associated with persistent inflammatory state, either infectious or autoimmune in nature. EMZL can present in various ways from an incidental finding on imaging to ambiguous symptoms such as dyspnea, chest pain, cough, and rarely hemoptysis. Prognosis in MALT-type lymphomas is generally good with mean survival of more than 10 years. CONCLUSIONS: In conclusion, EMZL of the lung is uncommon and unique therefore a collaborative effort addressing early diagnosis and less invasive diagnostic testing for these high-risk EMZL patients are needed. Reference #1: Khalil MO, Morton LM, Devesa SS, et al. Incidence of marginal zone lymphoma in the United States, 2001 to 2009 with a focus on primary anatomic stie. Br J Haematol 2014; 165:67 Reference #2: Santos IG, Marchiori E, Zanetti G, Mano CM, SarcielliLuz B, Vianna FG. Primary pulmonary mucosaasociated lymphoid tissue lymphoma computed tomography findings: A case report. Cases J. 2009;2:6329. [PMCID:PMC2740136] [PubMed: 19829788] DISCLOSURES: No relevant relationships by Hussein Hussein, source=Web Response No relevant relationships by Ahmad JABRI, source=Web Response No relevant relationships by Sonya Joshi, source=Web Response No relevant relationships by Sujith Modugula, source=Web Response No relevant relationships by Elizabeth Verghese, source=Web Response

THORACOSCOPIC SURGICAL STAPLING AND ENDOBRONCHIAL VALVE PLACEMENT FOR LUNG VOLUME REDUCTION WITH INCOMPLETE LOBAR FISSURES: INITIAL EXPERIENCE

SESSION TITLE: Fellows Obstructive Lung Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Emphysema affects more than 4 million cases diagnosed in the US. Recently, bronchial valves were approved for selected patients with complete lobar fissure and severe hyperinflation. Unfortunately, most patients have collateral ventilation (CV) and thus are not candidates for bronchoscopic lung volume reduction alone. Combined minimally invasive thoracoscopic intervention to complete lung fissure along with bronchial valves (BVs) to achieve lung volume reduction is an appealing treatment for the majority of patients with CV. Our group has recently described the use of this combined procedure in animal models, but this is the first description in clinical practice. CASE PRESENTATION: A 58-year-old woman with severe heterogeneous emphysema and hyperinflation underwent endobronchial bronchial valves placement without significant improvement in her symptoms or pulmonary function tests at her 6 months follow-up visit. Following a multidisciplinary discussion with thoracic surgery, the patient underwent major fissure completion via VATS. The patient tolerated the procedure well and was discharged from the hospital on postoperative day 3. At 1-month follow up, patient-reported progressive improvement in her dyspnea. Her chest radiography showed atelectasis of the target lobe. Her lung function test showed an improvement of 0.1L (4%) in her FEV1, a decrease of 0.5L (27%) in her RV, and an increase of 1.4mL/min/mmHg (18%) in her DLCO. Another 59-year-old woman with severe homogeneous emphysema with hyperinflation. She underwent bronchial valve placement without significant improvement in her symptoms or pulmonary function tests at 12 months follow up visit. Following a multidisciplinary discussion with thoracic surgery, the patient underwent major fissure completion via VATS along with the removal of abundant pleural adhesions. She had an air leak for 3 days that resolved and was discharged home at postoperative day 4. At one month follow up, the patient had no improvement in her dyspnea. Her chest radiography showed hyperinflation without improvement in the lung function test. DISCUSSION: As emphysema remains an irreversible disease, treatment goals are primarily aimed to slow and stabilize disease progression, relieve symptoms, and improve quality of life. The most important factor that may prevent the development of desired lung volume reduction following bronchial valve treatment is CV. We present the first 2 cases in which a thoracoscopic approach was used to complete the interlobar fissures to address CV. The refinement of the technique along with appropriate patient selection is still under progress. CONCLUSIONS: Lobar fissure completion along with bronchial valves is a promising management alternative for patients with CV. Reference #1: Majid A, Kheir F, Alape D, Chee A, Parikh M, DeVore L, et al. Combined Thoracoscopic Surgical Stapling and Endobronchial Valve Placement For Lung Volume Reduction With Incomplete Lobar Fissures: An Experimental Pilot Animal Study. J Bronchol Interv Pulmonol. 2019 Aug;1. Reference #2: Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global Strategy for the Diagnosis, Management, and Prevention of COPD 2020. Reference #3: Koster D, Slebos D-J. The fissure: interlobar collateral ventilation and implications for endoscopic therapy in emphysema. Int J Chron Obstruct Pulmon Dis. 2016 Apr;765. DISCLOSURES: No relevant relationships by Sidhu Gangadharan, source=Web Response No relevant relationships by Fayez Kheir, source=Web Response Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with olympus Please note: $5001 - $20000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with pinacle biologics Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee Consultant relationship with cook medical Please note: $1001 - $5000 by Adnan Majid, source=Web Response, value=Consulting fee No relevant relationships by Daniel Ospina-Delgado, source=Web Response

Morphological features of lower respiratory tract of nine-banded armadillo (Dasypus novemcinctus, Linnaeus, 1758).

The nine-banded armadillo (Dasypus novemcinctus) is a mammal of the Xenarthra Superorder, which inhabits Central, South and North America. Few morphological descriptions are observed in this species, including the respiratory tract; therefore, the objective of this study was to describe morphologically the lower respiratory tract of the nine-banded armadillo. Five animals were dissected, and the macroscopic and microscopic aspects were analysed. In the anatomical analysis, the perfusion technique was performed with vinyl acetate and the fragments of tissue from respiratory organs (trachea, bronchi, bronchioles and pulmonary lobes) were stained with haematoxylin-eosin for visualization under optical microscopy. Containing about 30 cartilage rings, the trachea is lined internally with ciliated pseudostratified epithelial tissue. The lungs are subdivided into lobes by deep interlobar fissures, with two lobes in the right lung and three lobes in the left lung. Microscopically, the primary, secondary and tertiary bronchi have non-ciliated pseudostratified epithelium with goblet cells. It was found that macro- and microscopically the respiratory tract of this species is similar to existing xenarthras and other excavator animals. These data provide subsidies for the clinic and preservation of this species.