Main Bronchus Research Articles

A rare case of endobronchial tuberculosis with left main bronchial stenosis in a patient with pulmonary tuberculosis

Endobronchial tuberculosis (EBTB) is a condition that occurs as a result of pulmonary tuberculosis (TB), where the infection spreads to the inner walls of the bronchial tubes or the trachea. This causes the inner lining and the layer underneath to become inflamed, swollen, ulcerated, or to develop granulated tissue or scar. We discuss a 19-year-old lady with active pulmonary TB who was receiving anti-TB drug treatment. Despite being on anti-TB medications, she had persistent cough, loss of weight and increasing dyspnea. She was diagnosed with EBTB with left main bronchus (LMB) stenosis, based upon a strong clinical suspicion, followed by using a variety of techniques, including lung function testing, a chest and neck CT scan, and a bronchoscopy. Given that EBTB is a rare consequence of TB, it is crucial for clinicians to take it into account when patients present with symptoms that are comparable. This will enable prompt and effective treatment.

Primary Pulmonary Sarcoma Coinfected with Pulmonary Tuberculosis: A Case Report

Introduction: Pulmonary tuberculosis (TB) and malignancy are conditions with similar respiratory diseases and they are even known to coexist simultaneously. Therefore, accurate diagnosis of each disease is crucial to ensure precise treatment. This case study showed the coexistence of pulmonary TB and primary pulmonary sarcoma.Case Presentation: A 62-year-old male presented with a 3-month history of dyspnea, which worsened within 3 days. Before hospitalization, there were complaints of left chest pain, fatigue, loss of appetite, weight loss within 5 months, and night sweats. The patient who was a heavy smoker had experienced hemoptysis in the past 5 months. Upon physical examination, an increased respiratory rate and decreased oxygen saturation level. Furthermore, there were asymmetrical thorax movements, dull percussion on the left side, and decreased vesicular breathing sound on the left hemithorax, with no rhonchi or wheezing. A chest x-ray showed a destroyed left lung, while scanning confirmed left lung atelectasis and indicated a suspected mass within or around the left bronchus causing total obstruction in the main left bronchus. The bronchoscopy procedure identified a mass blocking the left main bronchus. However, a biopsy yielded inconclusive results. A rapid molecular test of TB detected Mycobacterium tuberculosis, which was discovered to be Rifampicin sensitive. As a result, the patient was treated daily with 4 fixed drug combinations for anti-TB. Despite the treatment, the complaint was not resolved within the next 3 months, as there was still a disease of cough in the form of mass-like phlegm, which uncovered a malignancy focus cell with differential diagnosis of pleomorphic sarcoma and sarcomatoid carcinoma.Conclusions: Lung malignancy not only overlapped with but also occurred simultaneously alongside lung TB. Therefore, it was crucial to establish a clear diagnosis in patients with chronic respiratory disease.

Central Lung Tumors Eligible for Stereotactic Ablative Radiotherapy (SABR) Trials: Analysis of a Cohort Treated Using MR-Guided SABR

SABR for central and ultracentral lung tumors results in increased toxicity. We implemented MR-guided SABR in patients meeting the IASLC classification for central tumors, namely a Gross Tumor Volume (GTV) ≤2cm from trachea, main bronchi, esophagus, heart, brachial plexus, main mediastinal vessels, phrenic or laryngeal nerves and spinal cord. As patient inclusion criteria for ongoing clinical trials varies, we studied the eligibility of MR-SABR patients for inclusion into 3 clinical trials for central tumors. An Ethics approved institutional database was accessed for details of patients treated using multifractionated lung MR-SABR between 2016 and 2022. GTV and Planning Target Volumes (PTV) had been delineated on a breath-hold planning MRI and CT scans. For each tumor meeting the IASLC classification, patient eligibility for HILUS (NCT04917224), STRICT/STARLUNG (NCT05354596) and SUNSET (NCT03306680) trials were examined. Multifraction MR-SABR was performed in 97 central lung lesions meeting IASLC criteria. Of these, 73 patients (75.3%) fulfilled inclusion criteria for at least 1 trial, but inclusion in all 3 trials was possible in just 18.6% of treated lesions. Inclusion in the HILUS, STRICT/STARLUNG and SUNSET trials were possible in 33.0%, 73.2% and 25.8% of MR-SABR patients, respectively. For HILUS-eligible patients, 11 met the HILUS group A classification (GTV ≤1cm from the trachea and main bronchi), and 21 in group B (GTV >1cm from the trachea and main bronchi but ≤1cm from the intermediate and lobar bronchi). Use of STRICT/STARLUNG trial criteria would have defined 13 tumors as ultracentral (GTV ≤0.5cm from the trachea, main bronchi or intermediary bronchus or esophagus), and 58 as central (GTV 0.5cm-2.5cm from previously described structures or ≤0.5cm from the heart, aorta, spinal cord or lobar bronchi). For the SUNSET study, 25 tumors fulfilled criteria for ultracentral location (PTV touching or overlapping the central bronchial tree, esophagus, pulmonary vein or pulmonary artery). Ongoing clinical trials in central or ultracentral lung SABR enroll considerably different patient populations than those selected using the IASLC definition of central tumors. Due to steep dose-fall off in SABR plans, detailed descriptions of the location of tumor and organs-at-risk, as well as dose-distributions achieved, are necessary in order to allow study results to be uniformly extrapolated to clinical practice.

Pulmonary vein perforation into the respiratory tract with systemic air embolism: a rare complication of left atrial appendage closure

BackgroundPulmonary vein perforation is an uncommon complication during cardiac intervention. We present a rare case of pulmonary vein perforation into the respiratory tract with systemic air embolism during left atrial appendage closure (LAAC).Case presentationA 77-year-old man with persistent nonvalvular atrial fibrillation was referred for percutaneous LAAC under local anaesthesia (CHA2DS2-VASc score of 4, HAS-BLED score of 3, and prior ischaemic stroke). During the procedure, after delivering a super-stiff guidewire into the left superior pulmonary vein (LSPV), the patient suddenly developed a severe cough with haemoptysis upon advancement of a delivery sheath along the guidewire. Fluoroscopy showed signs of blood entering the left main bronchus, and fast transthoracic echocardiography revealed bubbles in the left heart without pericardial effusion. The procedure was terminated because of a major complication indicated by the repeated haemoptysis and headache, and haemostatic drugs were immediately administered. Subsequent chest computed tomography angiography (CTA) revealed a filling defect in the LSPV branches and bubbles in the aorta. The patient was transferred to the critical care unit for haemostasis and antibacterial treatment. Transthoracic echocardiography later that day showed no bubbles in the heart. The headache and haemoptysis significantly abated the following day. The bubbles in the aorta disappeared on chest CTA 7 days later.ConclusionsInterventional cardiologists should pay attention to anatomical variations of the pulmonary vein, which are associated with a high risk of complications of pulmonary vein perforation during LAAC. Preoperative CTA examination and intraoperative transoesophageal echocardiography might be helpful to avoid this complication.

Management of Foreign Body Aspiration in Children: Insights From 664 Cases in the Operating Room

Tracheal or bronchial foreign body aspiration is an important emergency o childhood requiring bronchoscopy under general anesthesia. In this retrospective study, bronchoscopy were performed for foreign body aspiration; anesthesia methods, risks, and postoperative complications were evaluated. Children who underwent bronchoscopy with suspicion of a foreign body in the pediatric surgery operating room between January 2010 and December 2021 were included in the study. Six hundred and sixty four children were evaluated. General anesthesia was applied to all bronchoscopy. Demographic characteristics of the patients, type of foreign body, localization of foreign body, distribution of foreign body according to age groups, complications related to anesthesia and surgical process, length of stay in the postoperative intensive care unit, and duration of hospital stay were evaluated. The patients who aspirated foreign bodies most frequently were children aged 1-3 years (73.6%). During bronchoscopy, organic matter (seeds, hazelnuts, peanuts, chickpeas) was the most frequently removed foreign body in children (559 patients). It was observed that foreign bodies were mostly located in the right main bronchus at a rate of 52.4%, the left main bronchus at 28%. The most common anesthesia-related complications were desaturation in 400 patients, hypercarbia in 200 patients, bronchospasm in 108 patients, and respiratory arrest in 2 patients. Many problems may be encountered in foreign body inhalation, and bronchoscopy of these patients should be performed by an experienced anesthesiologist and surgeon at the right time and in the safest way in terms of anesthesia and surgery.

Primary Pulmonary Leiomyosarcoma : an Extremely Rare, Difficult-to-Manage Case of Lung Cancer

Background: Primary Pulmonary Leiomyosarcoma (PPL) known as <0.5% of total lung cancer. Histopathological examinations are the pillars of PPL diagnosis as clinical manifestations and radiological features are usually not specific. Treatments of PPL include surgical resection, radiotherapy, and chemotherapy.
 Case Illustration: A 51-year-old male, smoker, with a productive cough for 2 weeks, accompanied by chest pain, weight loss, and loss of appetite. Imaging studies showed a solid mass in the right lung, which was confirmed through bronchoscopy, cytology, histology, and immunohistochemistry evaluations. Bronchoscopy showed an intraluminal mass in the right main bronchus suggesting malignancy. Immunohistochemistry of Desmin and Smooth Muscle Actin, which were positive, confirmed the diagnosis of PPL of the right lung stage T4N1M1a IVA.
 Discussion: Surgical resection is the gold standard treatment for PPL whose clinical conditions and tumor spread still allowed for safe operation. Surgical resection did not undergo because already in stage IVA. Radiotherapy and chemotherapy can be added for patients who are unable to have surgery. There are no guidelines regarding chemotherapeutic regimens that are recommended for PPL. Cisplatin/carboplatin and etoposide are two chemotherapeutic agents that are commonly used in other variants of lung cancer. Cisplatin is successful in 5-23% of patients and etoposide is successful in 8%. Doxorubicin and ifosfamide are usually used for soft tissue sarcoma too. After administration of 4 cycles of carboplatin/etoposide, a chest CT scan with contrast recist shows the progression of PPL.
 Conclusion: Carboplatin and etoposide have been long used as therapy for lung cancer. Currently, available literature shows that their effectiveness in PPL is still considered low. Nevertheless, more studies are needed to further explore the possibilities of using carboplatin and etoposide in PPL patients.
 
 Keywords: chemotherapy, lung cancer, primary pulmonary leiomyosarcoma

A case of a thoracic duct cyst extending from the mediastinum to the cisterna chyli resected using bilateral thoracoscopic surgery in the prone position

BackgroundThoracic duct cysts are extremely rare mediastinal tumors. We report a case of a thoracic duct cyst extending from the caudal aspect of the left main bronchus to the left renal artery that was safely and completely resected via bilateral thoracoscopic surgery in the prone position.Case presentationA 77-year-old male was referred to our hospital for follow-up computed tomography (CT) of prostate cancer, which revealed a mediastinal tumor and fatty low-density along the posterior mediastinum of the para-aortic artery with a slightly high-density component. Magnetic resonance imaging revealed a T2-weighted image with high intensity. The preoperative radiological diagnosis was lipoma or well-differentiated liposarcoma. CT in the prone position suggested that the tumor could be resected from the thoracic cavity to the caudal side, and bilateral thoracoscopic surgery was performed in the prone position. Based on the surgical findings, the tumor was diagnosed as a thoracic duct cyst rather than a lipoma. Dissection around the thoracic duct cyst was performed using a vessel-sealing system to prevent leakage of the chyle, and reliable clipping was performed to resect the cisterna chyli. Histopathological examination revealed smooth muscle structures around the cyst, suggestive of a thoracic duct cyst. The diagnosis of a thoracic duct cyst was made based on a high triglyceride level of 1310 mg/dL on examination of the milky-white cyst fluid. The patient's postoperative course was uneventful, and he was discharged 4 days postoperatively. A CT scan performed 13 months after surgery showed no recurrence.ConclusionsA rare thoracic duct cyst extending from the mediastinum to the cisterna chyli was safely and completely resected using bilateral thoracoscopic surgery, with the patient in the prone position.

The Significance of Reconstructive Tracheal and Bronchial Surgery in the Context of Malignant Pulmonary Tumours

Lung cancer holds a prominent position in the malignant mortality rates. Despite the rapid advancement of pharmacological approaches to the lung malignancy treatment, surgical interventions remain relevant and pertinent in contemporary practice. The choice of an appropriate therapy for local lung cancer presents a particularly acute dilemma. This issue gives rise to contradictions as it necessitates a tailored approach for each individual case. In such instances, the only radical treatment methods for lung cancer involve surgical interventions, namely pneumonectomy and lobectomy/bilobectomy. The preference leans towards lobectomy, given that this choice mitigates disability, thereby enhancing the patient's quality of life. Organ-preserving surgery holds a distinct significance for patients with compromised functional reserves, where complete lung resection is intolerable. However, at the time of identifying centrally located lung neoplasms, tumors or metastatic lymph nodes often extend to the orifices of the segmental and main bronchi. A lobectomy is feasible only with the resection (wedge-shaped or circumferential one) of the main bronchus and subsequent bronchoplasty. Tumor invasion of the pulmonary artery presents a formidable obstacle to organ-preserving surgery.In cases where pneumonectomy is intolerable, bronchoangioplastic lobectomy/bilobectomy stands as the sole viable radical intervention. Pneumonectomy with wedge-shaped or circumferential resection of the trachea, followed by tracheobronchoplasty, represents one of the most intricate procedures in thoracic surgery. However, when the tumor extends to the tracheal bifurcation, only this operation allows for a radical surgical approach. Notably, in circumstances where the tumor (carcinoid) affects the main bronchus, partial circumferential bronchial resection with subsequent bronchoplasty becomes feasible. Thus, the entire pulmonary ventilation capacity is preserved. Clinical observations of such procedures have been documented in patients with diminished functional reserves.

Single-center review on safety of biodegradable airway stenting in pediatric population.

Tracheobronchomalacia (TBM) and airway stenosis are recognized etiologies of airway obstruction among children. Their management is often challenging, requiring multiple interventions and prolonged respiratory support with associated long-term morbidity. Metallic or silicone stents have been used with mixed success and high complication rates. More recently biodegradable Ella stents (BES) provided an attractive interventional option. We report our experience in the treatment of TBM and vascular airway compression using BES. We deliberately downsized them to minimize intraluminal granulation tissue formation. Retrospective study over an 8-year period between November 2012 and December 2020 of pediatric patients with severe airway obstruction requiring airway stenting for extubation failure, malacic death spells, recurrent chest infections, or lung collapse. Thirty-three patients (5 tracheal and 28 bronchial diseases) required 55 BES during the study period. The smallest patient weighed 1.8 kg. Median age of patient at first stent implantation was 13.1 months (IQR 4.9-58.3). The majority of the bronchial stents were in the left main bronchus (93%), of which 57% for vascular compression. Repeat stents were used in 19 patients (57.7%), with a range of two to four times. We did not experience erosion, infection, or obstructive granuloma needing removal by forceps or lasering. Three stent grid occluded with secretions needing bronchoscopic lavage. Stent migration occurred in three patients. BES holds promise as a treatment option with low rate of adverse effects for a specific subset of pediatric patients with airway malacia or vascular compression. Further studies are warranted.

Research and development of the sOLVe Tube™ dual lumen endobronchial tube: from concept to construct.

Dual lumen endobronchial tubes (DLTs) are frequently used for lung isolation and one lung ventilation in thoracic surgery and other specialized clinical scenarios. Modern DLTs are large and rigid, and account for half of all tracheobronchial injuries. Their 70 year old design has numerous flaws which limit their safety and clinical utility. Our research team set out to design a new and improved DLT to mitigate these shortcomings, and then test the proposed device to ensure proper function. Using published airway anatomy data and computed tomography imaging from 195 thoracic surgery patients, we designed a new DLT with a single size/configuration that would fit into adult surgery patients. This single "Universal design" was intended to replace both left and right sided 35Fr-41Fr DLTs (8 total products), while remaining small in diameter (35Fr). Other design goals included: 1) making intubation easier and safer, 2) allowing full sized therapeutic bronchoscopes to fit into this tube, 3) making the DLT more resistant to dislodgement. After design process completion the proposed dimensions were tested against 195 patients' left and right mainstem bronchi for radiographic fit. Once production prototypes were manufactured, they were tested in large adult Yorkshire pigs and fresh human cadavers for anatomic fit and performance. The proposed design passed the radiographic fit test in all 195 patients for both left and right mainstem endobronchial placement. Intubation was successful and deemed atraumatic in all pigs and cadavers, and the device appropriately fit in both the right and left mainstem bronchi. Lung isolation was successfully achieved and the device proved resistant to axial force dislodgement. We propose a new design for a novel DLT meant to replace 8 currently supplied adult configurations with a single, one size/configuration fits all product that allows for large bore bronchoscopy and resists axial force dislodgement.

Role of esophageal ultrasound with a bronchoscope (EUS-B) with fine needle aspiration in the diagnosis of mediastinal Bronchogenic cyst.

A 12-year-old adolescent boy presented with complaints of persisting dry cough and exertional dyspnea. A CT chest revealed a cystic lesion posterior to the trachea and a flexible bronchoscopy revealed extrinsic compression of the posterior trachea and partial obstruction of the left main bronchus. He underwent an Endoscopic Ultrasound with a Bronchoscope. A Hypoechoic cystic lesion was seen just in front of the esophagus. Fine needle aspiration yielded thick mucoid aspirate and cytology revealed ciliated columnar epithelium, confirming the diagnosis of a Bronchogenic cyst.

Bronchial collapse and bronchial stenting in 9 dogs.

Principal and lobar bronchial collapse is increasingly recognized as an isolated entity. Retrospectively describe the procedure and outcomes of dogs undergoing bronchial stenting at a single referral hospital. Nine client-owned dogs with variable degrees of collapse of the left principal bronchus (LPB), lobar bronchus 1 (LB1), and lobar bronchus 2 (LB2), and with clinically relevant signs of respiratory dysfunction. Data were collected from patient records. All dogs underwent stenting of the LPB and LB2. Anatomic and functional impairment grades were assigned to each case before and 4 weeks after stenting. Data regarding response to stenting and complications were evaluated. Bronchial stenting was considered successful in all cases, with all dogs experiencing improved quality of life (QOL), and decreased functional impairment grade at 4 weeks post-stenting. Follow-up of >6 months was available for 6 dogs and of these, 5 were alive at 12 months, 3 were alive at 18 months, and 1 was alive at 24 months. Stent-related complications occurred in 4 dogs, and were resolvable in 3. Two dogs developed pneumothorax, 1 developed recurrent pneumonia, and 1 developed new-onset coughing. All dogs had mild and manageable coughing post-stenting. Stenting of the LBP and LB2 might be an effective option for dogs with advanced collapse of these bronchi and associated signs. Although all included dogs had resolution or improvement of clinical signs considered life-threatening or as affecting QOL, ongoing coughing is expected. Patient selection appears important with regard to achieving successful outcomes.

Gene delivery followed by ex vivo lung perfusion using an adeno-associated viral vector in a rodent lung transplant model

ObjectiveEx vivo lung perfusion has emerged as a platform for organ preservation, evaluation, and restoration. Gene delivery using a clinically relevant adeno-associated vector during ex vivo lung perfusion may be useful in optimizing donor allografts while the graft is maintained physiologically active. We evaluated the feasibility of adeno-associated vector–mediated gene delivery during ex vivo lung perfusion in a rat transplant model. Additionally, we assessed off-target effects and explored different routes of delivery. MethodsRat heart-lung blocks were procured and underwent 1-hour ex vivo lung perfusion. Before ex vivo lung perfusion, 4e11 viral genome luciferase encoding adeno-associated vector 9 was administered via the left bronchus (Br group, n = 4), via the left pulmonary artery (PA group, n = 3), or directly into the circuit (Circuit group, n = 3). Donor lungs in the Control group (n = 3) underwent ex vivo lung perfusion without adeno-associated vector 9. Only the left lung was transplanted. Animals underwent bioluminescence imaging weekly before being killed at 2 weeks. Tissues were collected for luciferase activity measurement. ResultsAll recipients tolerated the transplant well. At 2 weeks post-transplant, luciferase activity in the transplanted lung was significantly higher among animals in the Br group compared with the other 3 groups (Br: 1.1 × 106 RLU/g, PA: 8.3 × 104 RLU/g, Circuit: 3.8 × 103 RLU/g, Control: 2.5 × 103 RLU/g, P = .0003). No off-target transgene expression was observed. ConclusionsIn this work, we demonstrate that a clinically relevant adeno-associated vector 9 vector mediates gene transduction during ex vivo lung perfusion in rat lung grafts when administered via the airway and potentially the pulmonary artery. Our preliminary results suggest a higher transduction efficiency when adeno-associated vector 9 was delivered via the airway, and delivery during ex vivo lung perfusion reduces off-target effects after graft implant.

СИНДРОМ СУАЙРА-ДЖЕЙМСА-МАКЛЕОДА: ПОСТВОСПАЛИТЕЛЬНЫЙ СТЕНОЗ ЛЕВОГО ВЕРХНЕДОЛЕВОГО БРОНХА, ЭМФИЗЕМА ВЕРХНЕЙ ДОЛИ ЛЕВОГО ЛЕГКОГО (КЛИНИЧЕСКИЙ СЛУЧАЙ)

A clinical case of observation of a patient with a rare case of the Swyer-James-McLeod syndrome: postinflammatory stenosis of the left upper lobe bronchus, emphysema of the upper lobe of the left lung is presented. The difficulties of making a diagnosis of this nosological form with the analysis of the X-ray archive are analyzed. Based on the given example of a clinical case the need for timely diagnosis of the Swyer-James-McLeod syndrome is demonstrated.

Anomalies in the development of the tracheobronchial tree (clinical case)

According to the International Classification of Diseases the trachebronchial tree (TBT) anomalies are grouped into class XVII “Congenital anomalies (malformations), deformities and chromosomal disorders” (Q30–Q34, namely Q32.1 – “Other malformations of the trachea”).This paper presents a clinical case of congenital anomaly of TBT. Patient M., 18 years old, diagnosis of ICD-10 J90 Pleural effusion, not classified elsewhere, was referred from the pulmonology department to perform bronchoscopy for differential diagnosis with pulmonary tuberculosis. When the device was passed through the trachea, in the lower third towards the right main bronchus, a diverticuloid protrusion of the tracheal wall with deformation of the cartilaginous ring was found.Results and discussions. After examination, the conclusion was formed: Anomaly in the development of the lower third of the trachea (reduced tracheal bronchus on the right). Anomalies in the development of TBT are an extremely rare pathology, the pathology we describe is called “tracheal bronchus”. The tracheal bronchus, the rarest malformation of TBT with a frequency of no more than 1–2 % of cases, is the result of dysontogenesis. It is usually located on the right side of the trachea and may end blindly in the form of a diverticulum. In our description, there is no other anomaly of the TBT, so it can be attributed to the supernumerary variant of the tracheal bronchus. When anomalies in the development of TBT are detected, it is necessary to carry out differential diagnostics with tracheal diverticula, in which only its membranous part suffers.Conclusions. The clinical case we are describing refers to a supernumerary variant of the tracheal bronchus and requires the additional use of high-tech verification methods. We do not exclude that the environmental factors in the city of Zheleznogorsk could be the cause of its development.

231. ROBOT-ASSISTED TRANSMEDIASTINAL (TRANSCERVICAL & TRANSHIATAL) ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background Esophagectomy is still main treatment mode for esophageal cancer, though it is known to be associated with severe surgical invasiveness resulting in high morbidity and mortality. Minimally invasive esophagectomy (MIE), which consisted of thoracoscopic and/or laparoscopic procedure, has been widely performed to diminish those disadvantages of open procedure. Recent reports, however, show insufficient effects of the conventional MIE. Therefore, additional improvements are needed to overcome those problems. Methods We developed the robot-assisted transmediastinal esophagectomy (RATME) in 2012 to prevent the postoperative complications. It is the combination of transcervical and transhiatal approach without one lung ventilation anesthesia and body change during surgery. Upper mediastinal lymphadenectomy along left recurrent laryngeal nerve (RLN) is perfomed by transcervical mediastinoscopic procedure under pneumo-mediastinum. Laparoscopic abdominal LN dissection is performed in parallel with the cervical procedure. Remnant lower and middle LN dissections, including subcarinal and main bronchus, are done using robotic procedure in which robotic arms are inserted through hiatus from abdomen. Finally, bilateral pleura can be preserved. Results To date, 275 RATMEs have been performed. Among them, post-operative pneumonia occurred in 33 cases (12%), and mortality is zero. Oncological outcomes, e.g., the numbers of harvested LNs, post-operative QOL, e.g., post-operative pulmonary function, were observed and reported to be better in RATME group as compared to open esophagectomy group. Survival after surgery is, also, not at all inferior. Conclusion RATME is a promising minimally invasive technique, overcoming the disadvantages of conventional procedures. For the patients with previous thoracic surgery, and/or impaired respiratory function who are unable to undergo transthoracic esophagectomy, RATME can offer a valuable alternative surgery as a radical treatment.

370. TRANSMEDIASTINAL ESOPHAGECTOMY IS USEFUL FOR ESOPHAGOGASTRIC JUNCTION CANCER

Abstract Background The extent of surgical resection and lymph node dissection in esophagogastric junction cancer depends on the localization of the tumor center and the length of esophageal invasion. We developed Robot assisted-transmediastinal esophagectomy (TME) and have been applied for thoracic esophageal cancer. Since 2018, we also applied TME for esophagogastric junction (EGJ) cancer with esophageal involvement according to our determined indications, and examined its safety and usefulness. Methods Our indication of esophagetomy for EGJ cancer is, i) squamous cell carcinoma, ii) differentiated adenocarcinoma with≧3 cm esophageal involvement, iii) poorly differentiated with≧2 cm. Since 2018, we applied TME for all of these cases. Our operation procedure is following; upper thoracic paraesophageal LNs and recurrent nerve LNs are dissected by left-side cervical mediastinoscopic approach. Lower mediastinal LN is dissected by laparoscopic approach. Subcarinal LNs and main bronchus LNs are dissected by transhiatal robotic approach. When robot is not used, these LNs are dissected mediastionscopically. Reconstruction is done by gastric tube through posterior mediastinal route. Results Between January 2018 and March 2023, 36 patients was performed TME for EGJ cancer. In these, robot was used in 24 patients. Median operation time and amount of blood loss were 429 minutes and 170 mL. Pathological metastasis of thoracic paratracheal LNs; right recurrent nerve LNs, left recurrent nerve LNs and tracheobronchial LNs was detected in 2(5.5%), 1(2.7%) and 1(2.7%) patients, respectively. Anastomotic leakage was occurred in 2(5.5%) patients, but recovered conservatively. Recurrent laryngeal nerve (RLN) palsy severe more than Clavien-Dindo (CD) grade III was not occurred. Postoperative complications≧C-D IIIb was occurred in 1(2.7%) patient. Conclusion TME for EGJ cancer seems to be safe, especially can avoid intra-mediastinal anastomosis and severe complication associated with leakage. It might be more widely accepted when RLN palsy could be reduced. Recuurent nerve LNs dissection is main cause of RLN palsy, and not recommended in the algorism of LN dissection for EGJ cancer because the frequency of metastasis is low, so TME without recurrent nerve LNs dissection could be the option for EGJ cancer.

245. CONVERSION SURGERY AFTER DEINITIVE CHEMORADIOTHERAPY FOR THORACIC ESOPHAGEAL CANCER

Abstract Background Definitive chemoradiotherapy (dCRT) is an important treatment option for cStage III/IVa esophageal cancer. In our hospital, dCRT is the treatment of choice for cT4b. In this study, we investigated the technique, prognosis, and postoperative complications of salvage surgery after dCRT, with the aim of gaining knowledge to achieve both cure and safety. Methods The study included 36 patients who underwent conversion surgery after dCRT for thoracic esophageal cancer with suspected invasion of other organs between April 2012 and June 2021. The median age was 68 years (38–80 years). cT4b invasive organs were trachea and left main bronchus in 21 cases, aorta in 11 cases, and other organs in 4 cases. Thoracoscopic esophagectomy was performed in 13 patients. Reconstruction of the gastrointestinal tract via the posterior sternal route was the basic procedure. Resluts There was one case of death in hospital (3%). Postoperative complications (Clavien-Dindo Grade II or higher) were observed in 17 patients (47%), including pneumonia in 9 patients (25%) and suture failure in 5 patients (14%). The median postoperative hospital stay was 17 days. The incidence of postoperative pneumonia was lower in patients with higher preoperative serum Alb and preoperative PNI. The median recurrence-free survival was 14 months. Histopathologically, 7 patients (19%) showed cancerous remnants, and the prognosis was poor in patients with remnant disease, aortic invasion, or preoperative lymph node metastasis. Conclusion Perioperative outcomes were considered acceptable. Down staging is likely to be achieved after dCRT, but preoperative nutritional status should be improved. The prognosis is poor in patients with aortic invasion or lymph node metastasis, and the indication for chemoradiation should be carefully considered. Postoperative adjuvant therapy is an issue for the future.

Systematic literature study of trachea and bronchus morphology in children and adults.

Understanding the dimensions of the lower airway is critical for performing respiratory surgery, selecting and designing appropriate airway equipment, and removing aspirated foreign bodies via bronchoscopy, anaesthesia, and radiography. The purpose of this study was to analyse the trachea and bronchus morphologically in children and adults, as well as to standardise the data for these structures' measurements. Various databases were reviewed for studies on lower airway dimensions. The criteria for inclusion and exclusion were established. Finally, it was agreed to look into 28 studies that took place between 1984 and 2021. The length of the trachea, its anterior-posterior (AP) and transverse dimensions, the lengths and transverse diameters of the right and left major bronchus, and the subcarinal angle were also investigated in the study. In studies where measurements were performed with different methods and procedures. It was revealed that age and gender were effective in the difference in lower respiratory tract dimensions. The mean values of all parameters were greater in adults than in children, the AP diameter of the trachea in adults was greater than the transverse diameter. In children, it was observed that the transverse diameter was larger than the AP diameter on average, the left main bronchus was longer than the right main bronchus, and the transverse diameter was smaller than the right main bronchus in most of the studies. The articles reviewed for this study revealed that measurements were done using a variety of different procedures and approaches, and the resulting data were inconsistent and could not be standardized. The data collected will be beneficial both conceptually and clinically; we believe that additional comparison research involving children and adults in bigger groups are necessary.

Bilateral living-related lobar lung transplantation avoiding bronchial stenosis associated with scoliosis by modified anastomosis: a case report

BackgroundSevere thoracic deformity caused by scoliosis often hampers lung transplantation (LTx) due to its underlying restrictive ventilatory dysfunction. Postoperative stenosis of the reconstructed bronchus due to spinal compression is also a complication after LTx in patients with scoliosis. Previous reports on LTx with scoliosis and its outcomes have not discussed the technical aspect of bronchial anastomosis. This report describes a case in which bronchial stenosis was avoided by modifying the angle of the right bronchial anastomosis.Case presentationA 26-year-old woman with atrial septal defect (ASD), pulmonary hypertension, Eisenmenger’s syndrome, and severe right scoliosis underwent bilateral living-related lobar LTx with her parents as donors followed by ASD closure. Left pneumonectomy and anastomosis preceded. On the right side, after pneumonectomy, the recipient’s right main bronchus was trimmed to rotate the bronchial anastomosis clockwise by 45°. This resulted in clockwise rotation of the graft (the lower lobe of the mother’s right lung), making axes of the graft and deformed vertebrae parallel. Postoperative bronchoscopy 2 months after surgery showed no evidence of compression or stenosis of the basal bronchial branch.ConclusionBy obliquely trimming the recipient’s right main bronchus to make the angle of the pulmonary graft and deformed thorax parallel, postoperative bronchial stenosis owing to severe scoliosis was successfully avoided.