Lower Bronchus Research Articles

Tobacco use, self-reported professional dental cleaning habits, and lung adenocarcinoma diagnosis are associated with bronchial and lung microbiome alpha diversity

RationaleThe lung microbiome is an inflammatory stimulus whose role in the development of lung malignancies is incompletely understood. We hypothesized that the lung microbiome associates with multiple clinical factors, including the presence of a lung malignancy.ObjectivesTo assess associations between the upper and lower airway microbiome and multiple clinical factors including lung malignancy.MethodsWe conducted a prospective cohort study of upper and lower airway microbiome samples from 44 subjects undergoing lung lobectomy for suspected or confirmed lung cancer. Subjects provided oral (2), induced sputum, nasopharyngeal, bronchial, and lung tissue (3) samples. Pathologic diagnosis, age, tobacco use, dental care history, lung function, and inhaled corticosteroid use were associated with upper and lower airway microbiome findings.Measurements and Main ResultsOlder age was associated with greater Simpson diversity in the oral and nasopharyngeal sites (p = 0.022 and p = 0.019, respectively). Current tobacco use was associated with greater lung and bronchus Simpson diversity (p < 0.0001). Self-reported last profession dental cleaning more than 6 months prior (vs. 6 or fewer months prior) was associated with lower lung and bronchus Simpson diversity (p < 0.0001). Diagnosis of a lung adenocarcinoma (vs. other pathologic findings) was associated with lower bronchus and lung Simpson diversity (p = 0.024). Last professional dental cleaning, dichotomized as ≤ 6 months vs. >6 months prior, was associated with clustering among lung samples (p = 0.027, R2 = 0.016). Current tobacco use was associated with greater abundance of pulmonary pathogens Mycoplasmoides and Haemophilus in lower airway samples. Self-reported professional dental cleaning ≤ 6 months prior (vs. >6 months prior) was associated with greater bronchial Actinomyces and lung Streptococcus abundance. Lung adenocarcinoma (vs. no lung adenocarcinoma) was associated with lower Lawsonella abundance in lung samples. Inhaled corticosteroid use was associated with greater abundance of Haemophilus among oral samples and greater Staphylococcus among lung samples.ConclusionsCurrent tobacco use, recent dental cleaning, and a diagnosis of adenocarcinoma are associated with lung and bronchial microbiome α-diversity, composition (β-diversity), and the abundance of several respiratory pathogens. These findings suggest that modifiable habits (tobacco use and dental care) may influence the lower airway microbiome. Larger controlled studies to investigate these potential associations are warranted.

Comparison of rigid bronchoscopy and flexible bronchoscopy for the management of foreign body aspiration in children

ObjectiveTo compare clinical outcomes of flexible and rigid bronchoscopies for the management of foreign body aspiration (FBA) in different airway locations, especially in unilateral main bronchus, in children, so as to provide some suggestions to assist clinical decisions. MethodsThe medical records of children diagnosed with FBA in Qingdao Women and Children's Hospital Affiliated to Qingdao University from January 2020 to June 2022 were retrospectively reviewed. The following information was collected: demographics, radiological findings, endoscopic findings, foreign body locations, duration of operation, operation cost, and intraoperative and postoperative complications. Results182 children were included in the study with the median age of 1.3 years (interquatile range, 1.0–1.8). Among whom, 124 cases (68.1 %) were male and 58 cases (31.9 %) were female. 11 cases (6.0 %) had the foreign bodies located in the trachea (larynx to carina), 3 cases (1.6 %) located in the trachea and lower bronchus, 1 case (0.5 %) located in bilateral main bronchus, 135 cases (74.2 %) located in unilateral main bronchus, 4 cases (2.2 %) located in main and lobar bronchus, and 28 cases (15.4 %) located in the lobar or segmental bronchus. Among all the included children, 84 cases (46.2 %) received rigid bronchoscopy (RB) and 98 cases (53.8 %) received flexible bronchoscopy (FB). 131 cases with the foreign bodies located in unilateral main bronchus received one type of bronchoscopy (RB or FB). They were divided into two groups according to the location of foreign body relative to the midpoint of main bronchus, the proximal bronchus group and the distal bronchus group. In the proximal bronchus group, duration of operation using RB and FB was 15 (12.5–27.5) min and 15 (14.5–30.0) min, respectively (Z = 0.000, P = 1.000). The intraoperative and postoperative complication rate using RB and FB was 15.4 % and 9.1 %, respectively (χ2 = 0.008, P = 0.927). Operation cost of FB was significantly higher than that of RB (t = −13.396, P = 0.000). In the distal bronchus group, duration of operation using RB was 20 (13.5–25.0) min, which was drastically shorter than that of FB (25 (20.0–35.0) min) (Z = −2.947, P=0.003). Operation cost of FB was still found to be significantly higher than RB (t = −20.456, P=0.000). No significant difference was found in complication rate of RB (14.3%) compared to FB (8.3%) (χ2=0.251, P=0.616). ConclusionsWhen foreign bodies are lodged in unilateral main bronchus, RB could be chosen as the first-choice procedure with advantages in duration of operation and operation cost, especially for patients in China. Regardless of duration of operation and operation cost, FB is also a safe and efficient therapeutic procedure to remove inhaled foreign bodies in children, except for those located in the trachea and asphyxiating foreign bodies.

A rare case of migration of ballistic projectile from left to right main bronchus

A foreign body in the bronchus due to a ballistic projectile is very uncommon. A 45-year-old man presented to the hospital after being accidentally shot. The initial radiographic assessment found a bullet in his left thoracic cavity. With the help of an X-ray, an urgent left posterolateral thoracotomy was conducted, but no foreign body was found. The foreign body had migrated to the contralateral chest cavity, as determined by the C-arm. On the following day, a thorax computed tomography scan was conducted, and it was discovered that the foreign body had already migrated to the right lower bronchus. A right thoracotomy was then performed to remove the foreign body. He was moved to the intensive care unit and discharged with a stable condition. In conclusion, migration of a foreign body in the bronchus is rare. A thorough strategy is required to prevent the object from migrating even further.

ALL THAT WHEEZES IS NOT ASTHMA: BRONCHIAL PAPILLOMA

ALL THAT WHEEZES IS NOT ASTHMA: BRONCHIAL PAPILLOMA

Transvenous retrograde thoracic duct embolization for effective treatment of recurrent plastic bronchitis after Fontan palliation

Plastic bronchitis (PB) is a rare but potentially detrimental complication of the Fontan circulation. Retrograde transvenous thoracic duct embolization (TDE) has been proposed as a treatment strategy for lymphatic dysfunction. A 5.5-year-old patient (16 kg/105 cm) was referred to our institution for severe PB refractory to conservative treatment 3 months after completion of Fontan palliation. CT-scan showed multiple bilateral areas of patchy consolidation and ground-glass opacity with obstruction of the right main and right lower bronchi. Bi-inguinal transnodal fluoroscopy-guided lymphangiogram confirmed the diffuse and abnormal lymphatic leak originating from the thoracic duct into the chest, predominantly right-sided, and showed the TD ostium near the left venous angle. There was no opacification of any target central lymphatic vessel for direct transabdominal puncture. Retrograde approach from the femoral vein was adopted to catheterize the thoracic duct and selectively embolize its distal portion using intercalation of microcoils and liquid embolic adhesive. Recurrence of symptoms after 2 months indicated a redo catheterization that revealed the persistence of dilated peribronchial lymphatic network with a minimal residual leak across the previously embolized caudal section of the TD. Complete occlusion of the TD over its entire length was performed using the same technique. The procedure was technically successful and the patient was uneventfully discharged after 2 days. There was no cast recurrence or procedure-related complications and sustained clinical improvement at 18-month of postoperative follow-up. Fluoroscopy-guided lymphangiography was essential to understand the anatomy and flow pattern of the lymphatic system and to plan the lymphatic intervention. End-to-end TDE is an effective minimally invasive treatment in Fontan patients with PB and can be necessary in case of relapse after selectively embolizing the TD distal section.

Aberrant mediastinal mediobasal segmental pulmonary artery in a patient with lung cancer undergoing right lower lobectomy: a case report

BackgroundA mediastinal mediobasal segmental pulmonary artery (A7) from the right main pulmonary artery is extremely rare.Case presentationWe report the case of a 71-year-old woman with an aberrant mediastinal A7 who underwent right lower lobectomy for lung cancer (cT1bN0M0, stage IA2). Preoperative three-dimensional computed tomography (CT) angiography revealed an aberrant mediastinal A7 in the right main pulmonary artery. Right lower lobectomy and mediastinal lymph node dissection were performed. Intraoperatively, A7 was observed between the superior and inferior pulmonary veins and in the front of the lower bronchus near the anterior hilum. The artery was carefully dissected from the caudal side after inferior pulmonary vein dissection. The lung parenchyma, which was within the fissure due to poor lobulation between the middle and lower lobes, was safely divided.ConclusionsThoracic surgeons need to carefully evaluate CT angiography or enhanced multidetector CT findings at preoperative conferences and always keep this anomaly in mind.

Tracheobronchiale aspergillose: behandeling met isavuconazol

Tracheobronchial aspergillosis Tracheobronchial aspergillosis is a potential fatal form of pulmonal aspergillosis involving the trachea and lower bronchi. It is mostly seen in severely ill or immunocompromised patients. This article reports a clinical case of a 51-year-old man who was diagnosed with tracheobronchial aspergillosis while admitted to the intensive care unit for severe pancreatitis complicated by multiorgan failure. The diagnostic process, epidemiology and treatment of tracheobronchial aspergillosis with isavuconazole, a relatively new triazole, are discussed.

Stapling of an endobronchial suction tube with the bronchus during robot-assisted right lower lobectomy: a case report

BackgroundTroubleshooting intraoperative complications requires careful management, and the safest technique should be chosen. We recently experienced a unique intraoperative bronchial complication during pulmonary lobectomy in robot-assisted thoracic surgery (RATS). There is no consensus on whether to continue RATS or convert to a more familiar technique, such as video-assisted thoracic surgery (VATS) or thoracotomy, for intraoperative complications that occur during RATS, and the decision should be determined individually.Case presentationA 74-year-old woman with primary lung adenocarcinoma (clinical stage IA2) underwent robot-assisted right lower lobectomy under one-lung ventilation and CO2 insufflation. Intraoperatively, the anesthesiologist placed the endobronchial suction tube in the right bronchus with intention of maintaining the right lung collapse, which was simultaneously stapled with the right lower bronchus during the right lower lobe bronchial closure using a robotic stapler. During robot-assisted manipulation, we removed the staples involved with the suction tube, one by one, using robotic-arm forceps and sutured the partially opened stump. Subsequently, the bronchial stump was covered with a pedicled pericardial fat pad. The postoperative course was uneventful, and the patient developed no complications when followed up 8 months after discharge. Hence, we could rectify this intraoperative bronchial complication using a robot-assisted technique and avoid conversion to VATS or thoracotomy.ConclusionThe precise manipulation techniques in RATS contributed to facilitate the successful execution of surgical procedures, such as staple removal and re-suturing of the bronchial stump and may be a useful as a method for such troubleshooting such intraoperative complications.

A case report of aspergillosis accompanied by saccular bronchodilation after bronchial thermoplasty in a 19-year-old woman

BackgroundFungal infections are rarely reported as a complication of bronchial thermoplasty (BT) in patients without immunosuppressive comorbidity.Case presentationA 19-year-old woman college student was admitted to our hospital owing to uncontrolled severe asthma despite using the maximum dose of steroid inhalation. She experienced asthmatic attacks more frequently while cheerleading, which is an extracurricular activity. She received BT because she wanted to continue cheerleading. After the second BT session, she developed more sputum and cough. During the third session, white secretion and saccular bronchodilation appeared in the left lower bronchus. Aspergillus fumigatus was detected in the culture of the bronchial lavage sample, and saccular bronchodilation in the affected bronchus was observed on computed tomography (CT). Five months after the start of oral itraconazole, her subjective symptoms as well as her CT findings improved. Her asthma condition improved enough for the patient to continue cheerleading without exacerbation.ConclusionsIt is necessary to consider the possibility of respiratory tract infections including fungal infections after BT. Detailed observations of the entire bronchus and sample collection for microbial culture are highly recommended.

The clinical characteristics of 89 cases of non-tuberculous mycobacterium pulmonary disease complicated with tracheobronchial lesions

Objective: To explore the clinical characteristics of non-tuberculous mycobacterium(NTM) pulmonary disease complicated with tracheobronchial lesions. Methods: From January 2014 to December 2018, there were 1 006 patients who were admitted to Guangzhou Chest Hospital for the first time and received examination by bronchoscopy. A total of 89 patients with complete data were selected, including 40 males and 49 females, aged 20 to 85 years, with 46 patients (52%) aged 60 years or older. The clinical symptoms and signs of the patients were analyzed with chest imaging, bronchoscopy and pathological examination results. Comparisons between groups were made by Chi-square test and t test. Results: The number of patients with NTM complicated with tracheobronchial lesions accounted for 8.9%(89/1 006) of those hospitalized with NTM and received bronchoscopy during the same period. Clinical symptoms included cough and sputum (89/89), different degrees of hemoptysis or blood sputum (52/89), and shortness of breath (50/89). Chest CT showed that 72 cases (72/89, 81%) had lung lesions involving more than 3 lung fields, and 83 cases (93%) had bronchiectasis and 63 cases (63/89, 71%) with cavities. Pulmonary atelectasis was shown in 45 cases (45/89, 51%). By bronchoscopy, 39 cases (39/89, 44%) were diagnosed as tuberculous lesions involving bilateral upper bronchi, while lesions of the right lower bronchus was found in 27 cases (27/89, 30%).The percentage of patients with multilobar bronchial involvement was 50.6%(45/89). The morphological characteristics of the bronchial lesions included scar stenosis or atresia in 63 cases (63/89, 71%), hyperemia and edema in 46 cases (46/89, 52%), and multiple types of lesions in 48 cases (48/89, 54%). Conclusions: Patients with NTM lung disease complicated with tracheobronchial inflammatory lesions did not have specific manifestations clinically. Lung lesions are extensive, often accompanied by bronchiectasis and cavity formation. Endoscopic changes were mostly manifested as multilobar tracheobronchial involvement characterized by scar stenosis, congestion and edema, mainly involving bilateral upper bronchi and the right lower bronchus.

Multiple endo\xa0bronchial lipoma: a rare case report

BackgroundEndobronchial lipoma is an extremely rare benign tumor, which is generally located in the first three subdivisions of the tracheobronchial tree. According to the existing literature, all endobronchial lipomas are single (one per patient). Here, we report a rare case in which the patient presented with two endobronchial lipomas in the same patient, and underwent a bronchoscopic tumor resection in the left main bronchus and the left lower bronchus. Both tumors were pathologically confirmed as endobronchial lipoma.Case presentationA 52-year-old Chinese man presented at the clinic reporting a mild cough with yellow color sputum and exertional dyspnea for 2 weeks. He was a heavy smoker (45 pack-years). Chest auscultation demonstrated faint wheezing in left lower lobe. Computed tomography (CT) revealed two low-density endobronchial masses located in the middle segment of the left main bronchus and the posterior basilar segmental bronchus of the left lower lobe. The neoplasms measured a CT-attenuation value of -70HU, −98HU in density with air trapping and atelectasis in the segmental bronchus of the left lower lobe. The patient underwent interventional bronchoscopic management to remove the neoplasms by using an electrosurgical snare, cryotherapy, and electrocautery. The locations of the neoplasms were confirmed at the left main bronchus and the superior segment of the left lower lobe during bronchoscopic intervention. Histopathological examination confirmed that both tissues were consistent with lipomas. After 18 months of follow-up, the patient was free of symptoms and CT revealed that bronchiectasia remained in the superior segment of the left lower lobe; however, no mass lesion was present in the left bronchus.ConclusionsThis case suggests that an endobronchial lipoma can present as multiple lesions, and both proximal and distal types can simultaneously occur in the same patient. Thus, these findings help us further understand the biology of endobronchial lipomas.

A new pharmacological approach based on remdesivir aerosolized administration on SARS-CoV-2 pulmonary inflammation: A possible and rational therapeutic application

The new zoonotic coronavirus (SARS-CoV-2) responsible for coronavirus disease (COVID-19) is a new strain of coronavirus not previously seen in humans and which appears to come from bat species. It originated in Wuhan, Hubei Province, China, and spread rapidly throughout the world, causing over 5,569,679 global cases and 351,866 deaths in almost every country in the world, including Europe, particularly Italy. In general, based on existing data published to date, 80.9% of patients infected with the virus develop mild infection; 13.8% severe pneumonia; 4.7% respiratory failure, septic shock or multi-organ failure; 3% of these cases are fatal. Critical patients have been shown to develop acute respiratory distress syndrome (ARDS) and hospitalization in intensive care units. The average age of patients admitted to hospital is 57–79 years, with one third half with an underlying disease. Asymptomatic infections have also been described, but their frequency is not known. SARS-CoV-2 transmission is mainly airborne from one person to another via droplets. The data available so far seem to indicate that SARS-CoV-2 is capable of producing an excessive immune reaction in the host. The virus attacks type II pneumocytes in the lower bronchi through the binding of the Spike protein (S protein) to viral receptors, of which the angiotensin 2 conversion enzyme (ACE2) receptor is the most important. ACE2 receptor is widely expressed in numerous tissues, including the oropharynx and conjunctiva, but mostly distributed in ciliated bronchial epithelial cells and type II pneumocytes in the lower bronchi. The arrival of SARS-CoV-2 in the lungs causes severe primary interstitial viral pneumonia that can lead to the “cytokine storm syndrome”, a deadly uncontrolled systemic inflammatory response triggered by the activation of interleukin 6 (IL-6), whose effect is extensive lung tissue damage and disseminated intravascular coagulation (DIC), that are life-threatening for patients with COVID-19. In the absence of a therapy of proven efficacy, current management consists of off-label or compassionate use therapies based on antivirals, antiparasitic agents in both oral and parenteral formulation, anti-inflammatory drugs, oxygen therapy and heparin support and convalescent plasma. Like most respiratory viruses can function and replicate at low temperatures (i.e. 34–35 °C) and assuming viral thermolability of SARS-CoV-2, local instillation or aerosol of antiviral (i.e. remdesivir) in humid heat vaporization (40°–41 °C) in the first phase of infection (phenotype I, before admission), both in asymptomatic but nasopharyngeal swab positive patients, together with antiseptic-antiviral oral gargles and povidone-iodine eye drops for conjunctiva (0,8–5% conjunctival congestion), would attack the virus directly through the receptors to which it binds, significantly decreasing viral replication, risk of evolution to phenotypes IV and V, reducing hospitalization and therefore death.

Successful Treatment of Bronchobiliary Fistula After Living Donor Liver Transplantation: A Case Report

A bronchobiliary fistula (BBF), which is defined by abnormal communication between the biliary system and the bronchial tree, is usually regarded as a consequence of local infection, such as hydatid or amebic disease of the liver, hepatic abscess, trauma, neoplasm, and other causes of biliary obstruction. We present a 40-year-old female patient who received a living donor liver transplantation for autoimmune hepatitis and who suffered from biliary stricture at the anastomosis, bile leakage in the right subphrenic region, and development of a BBF 1 year later. Magnetic resonance cholangiography (MRC) and fistulography showed a fistula between the subphrenic biloma and right lower bronchus. The patient was treated successfully by the subphrenic drainage tube and percutaneous transhepatic cholangial drainage (PTCD) crossing the biliary stricture. In conclusion, the BBF is an extremely rare complication after liver transplantation; and minimal-invasive procedures, such as percutaneous drainage and PTCD, are useful for the closure of BBF. This case report is approved by the Institutional Review Board (IRB) of Kaohsiung Medical University Chung-Ho Memorial Hospital, certifying that no prisoners were used in the case and that participants were neither paid nor coerced.

Implantation of 125I radioactive seeds via c-TBNA combined with chemotherapy in an advanced non-small-cell lung carcinoma patient

BackgroundThe critical management of advanced non-small-cell lung carcinoma (NSCLC), especially when complicated by severe airway stenosis, is difficult and often leads to high clinical risks and medical costs.Case presentationA 51-year-old previously healthy male was admitted to the Department of Respiratory and Critical Care Medicine, Taizhou People’s Hospital, in November 2018 for haemoptysis and difficulty breathing during a 15-d period. Following admission, chest computed tomography (CT) showed a large mass in the left hilum with atelectasis in the left upper lobe and obstructive pneumonia in the left lower lobe. Bronchoscopy revealed that the lesions occurred in the distal segment of the left main trachea, with occlusion of the left upper bronchus and significant narrowing of the lower bronchus. A basal mucosal biopsy of the lump tissue was performed after haemostasis treatment with sub-plasma coagulation (APC), and squamous lung carcinoma was confirmed. Following the final diagnosis, the patient was successfully treated with implantation of 125I radioactive seeds via transbronchial needle aspiration (c-TBNA) combined with chemotherapy.ConclusionWe believe that implantation of 125I radioactive seeds via c-TBNA is an effective treatment for patients with advanced lung cancer and those presenting with severe and mixed main bronchus stenosis.

Wine cup stoma anastomosis after extended sleeve lobectomy for central-type squamous cell lung cancer

BackgroundExtended sleeve lobectomy is rarely applied to pulmonary surgery for primary lung cancer to avoid a pneumonectomy. As there is a size discrepancy between main bronchus and peripheral bronchus, ingenuity to improve anastomosis is required in the bronchoplasty. We report herein a case in which successful reconstruction of extended sleeve lobectomy with bronchial wall flap.Case presentationWe report on a 64-year-old man suffering from hemoptysis, cough, mild fever and dyspnea. His computed tomography (CT) scan showed solid tumor of 40 mm in diameter in left lower bronchus, which obstructed the lower bronchus and caused obstructive pneumonia of left lower lobe and expanded to second carina and pulmonary artery. His bronchoscopy showed that tumor was exposed in the bronchial lumen and infiltrated to left main bronchus and upper bronchus even though the scope could pass through the exposed tumor of upper bronchus. Transbronchial lung biopsy showed squamous cell carcinoma. He had undergone left sleeve lingular segmentectomy and left lower lobectomy. Reconstruction was performed with bronchial wall flap. Pathological findings revealed pT3N0M0 stage IIB according to UICC 8th edition. Postoperative bronchoscopic findings showed no troubles at the anastomotic site. He has been well for eighteen months without recurrence after surgery.ConclusionsWe experienced a successful case who was reconstructed with bronchial wall flap (wine cup stoma) after extended sleeve lobectomy. This technique might be also useful for other types of extended sleeve lobectomy and lung transplantation to adjust caliber changes of bronchi.

Scimitar Syndrome with Partial Left Pulmonary Artery Sling in a Neonate.

Scimitar syndrome is a rare condition including right lung hypoplasia, anomalous pulmonary venous drainage, dextroposition of the heart, and hypoplastic right pulmonary artery (RPA). The infantile form is sometimes associated with pulmonary hypertension, cardiac failure, and a poorer prognosis. We present a 1-day-old girl with a rare combination of partial left pulmonary artery (LPA) sling and scimitar syndrome, which was suspected in prenatal sonography and confirmed by echocardiography, computed tomography and cardiac catheterization. The patient received re-implantation of the aberrant left lower pulmonary artery and patch augmentation of the main-left upper pulmonary arteries at 4 months of age. Another operation was performed at 7 months of age with patch augmentation for stenosis of the left lower pulmonary artery and left pulmonary vein elevation to relieve its clenching of the left lower bronchus, with improvement of respiratory distress.

Extended sleeve lobectomy for centrally located non-small-cell lung cancer: a 20-year single-centre experience.

Extended sleeve lobectomy (ESL), an atypical bronchoplasty with resection of more than 1 lobe, might be technically demanding but has certain theoretical advantages, including the avoidance of pneumonectomy. However, clinical outcomes after ESL are not well known. Between March 1995 and December 2015, 540 patients with centrally located non-small-cell lung cancer underwent sleeve resection. Among them, 63 patients underwent an ESL procedure. We retrospectively analysed those patients in terms of hospital mortality, postoperative complications and local recurrence and compared clinical outcomes with patients who underwent simple sleeve lobectomy in the same period. The 63 patients were classified into 4 groups: anastomosis between the right main and lower bronchi (n = 14), anastomosis between the right main and upper bronchi (n = 37), anastomosis between the left main and basal segmental bronchi (n = 4) and anastomosis between the left main and upper divisional bronchi (n = 8). No operative deaths occurred within 30 days, but there were 2 in-hospital deaths from postoperative acute lung injury. Ten (16%) patients had anastomosis-related complications including 3 strictures, 5 bronchopleural fistulas and 2 pulmonary vein thromboses. There were no significant differences in in-hospital mortality (3% vs 3%, P = 0.67), anastomosis-related complications (16% vs 9%, P = 0.07) and loco-regional recurrence rate (8% vs 10%, P = 0.63) between ESL and simple sleeve lobectomy. According to our findings, ESL is a safe and feasible procedure that does not compromise oncological principles. It can be considered an appropriate alternative to pneumonectomy and should be considered in patients with centrally located tumours.

Right lower lobectomy: section of lower pulmonary arteries, lower pulmonary vein and lower bronchus

Right lower lobectomy: section of lower pulmonary arteries, lower pulmonary vein and lower bronchus

Left lower lobectomy: section of lower pulmonary arteries, lower pulmonary vein and lower bronchus

Left lower lobectomy: section of lower pulmonary arteries, lower pulmonary vein and lower bronchus

Endoscopic Repair of Tracheoesophageal Fistula Using an Amplatzer Septal Occluder Device: 2017 Presidential Poster Award

Benign tracheoesophageal fistulas (TEF) are usually caused by direct trauma, caustic ingestion, radiation and infection. Symptoms are mainly respiratory infections due to recurrent aspirations, excessive secretions and cough. The Amplatzer device has been used extensively to treat septal defects with the goal of inducing an endothelial response and closure of the defect. We present our experience using a cardiac septal occluder for an endoscopic TEF repair. A 49-year-old female presented with failure to thrive, dysphagia, and 40lb weight loss in 6 months. She had endoscopic PEG-J placement and noted to have a large esophageal diverticulum. One day later she had severe abdominal pain. A barium swallow noted a ruptured distal esophageal diverticulum with multiple fistula tracts communicating with the right lower lobe bronchial tree. A metal esophageal stent was subsequently placed. Three weeks later the esophageal stent was removed but a 15mm circular defect was found at 35cm from incisors on the anterior lateral wall of esophagus. This defect was approximated with 2 over the scope (OTS) clips and a 23mm x 10cm EndoMax covered metal stent was deployed across the esophageal defect. Two months later during stent removal, a tiny residual defect was noted near the previous OTS clip. Over the course of 3 months, she was admitted for respratory failure due to recurrent pneumonia necessitating antibiotics caused by reformation of TEF despite multiple endoscopic interventions of either stent placement or OTS clips. Eventually, it was decided to perform endoscopic repair of TEF using a septal occluder device. The distal esophageal fistula was cannulated using a 7Fr Wilson-Cook Omni cannula over a glidewire. A 8 mm fistula tract between the right lower bronchus and esophageal diverticulum was noted. The guide wire was manipulated up the trachea, grasped and pulled out the ETT using a snare. A 7 mm septal occluder device was advanced inside 6 Fr introducer sheath to the distal esophagus. The distal (esophageal) disc and the proximal (bronchial) disc was released inside the fistula tract. A postprocedure esophageal occlusion fistulogram showed no extravasation of contrast medium into the trachea or mainstem bronchi. We demonstrate the technical feasibility and efficacy of the cardiac septal occluder to close a TEF. This novel technique is an alternative to surgical repair, although the long term efficacy and potential for epithelialization or migration are unknown.Figure: Tracheoesophageal Fistula.Figure: Guidewire through Tracheoesophageal Fistula.Figure: Occlusion of Tracheoesophageal Fistula using Septal Occluder Device.