Segmental Bronchi Research Articles

Opening of the posterior part of the major fissure for better exposure of the segmental bronchi

Opening of the posterior part of the major fissure for better exposure of the segmental bronchi

Robotic sleeve resection for pulmonary disease

BackgroundFew studies have described robotic sleeve resection with pulmonary resection. Here, we report the successful implementation of a completely portal robotic sleeve resection with or without pulmonary resection using a modified suture mode.MethodsIn total, 339 patients underwent curative robotic pulmonary surgery at Ruijin Hospital between May 2015 and September 2017. Three of these patients underwent robotic sleeve resection (right upper lobe, one; left upper lobe, one; and lingular segmental bronchus, one). Five port incisions were utilized, and a simple continuous running suture combined with two interrupted sutures of the membranous and cartilaginous junction portion was preferred for the anastomosis.ResultsThe postoperative course was uneventful for two patients with squamous cell carcinoma. The lingular segmental bronchus patient without pulmonary resection (a salivary gland tumor) underwent short-term atelectasis. The median operation time was 155 (range 132–230) minutes. The median anastomosis time was 25 (range 23–32) minutes. The median length of postoperative hospital stay was 7 (range 6–10) days. There was no mortality or conversion to thoracotomy for any of the patients. All patients were followed for 3–6 months, and there is no tumour recurrence.ConclusionsOur limited experience suggested that robotic sleeve resection for pulmonary disease with or without pulmonary resection may be safe and effective. The anastomosis time can be shortened with more robotic surgery experiences and the modified suture mode.

Determination of the intersegmental plane using the slip-knot method.

Visualization of intersegmental planes in the lung is desirable for precise anatomical lung segmentectomy. We developed the slip-knot method for creating inflation-deflation lines. This study aimed to assess relevant data for thoracoscopic segmentectomy performed using this method. In the slip-knot method, the objective segmental bronchus is looped with a monofilament thread. One end of the thread is then pulled during temporary bilateral ventilation, causing the knot to slip toward the bronchus. Thereafter, bronchial ligation is tightened to block the outflow of segmental air, ensuring that the segment remains expanded while the other reserved segments collapse on resumption of unilateral ventilation. Data from 221 patients who underwent thoracoscopic pulmonary segmentectomy between 2010 and 2016 were analyzed. A total of 147 patients (67%) were indicated for the slip-knot method, and 74 cases (33%) were non-adaptive cases. Ninety six percent of 147 cases were well adapted to the slip-knot method, which allowed us to obtain good inflation-deflation line images to determine the intersegmental plane. The mean operative time was 171±51 min (range, 71-367 min). The mean duration of chest tube insertion was 1.5±1.2 days (range, 1-7 days). Three cases (2.0%) had prolonged air-leakage and one (0.7%) case had readmission for late air-leakage. Our method enables determination of anatomical intersegmental planes using only one monofilament thread, thus facilitating thoracoscopic pulmonary anatomical segmentectomy.

Results of Bronchoscopic Lung Volume Reduction with One-way Valve in Patients with Severe Emphysema in Vietnam

Background: Bronchoscopic lung volume reduction (BLVR) has been applied in COPD patients with heterogeneous emphysema. In this first clinical trial in Vietnam, we evaluated the safety and initial results of BLVR by one-way valve in COPD patients with severe emphysema. Methods: We performed a prospective, nonrandomized, single center longitudinal study in 30 stable COPD patients with heterogeneous severe emphysema on CT-scanner, the average age of 65.17 years old, FEV1≤35 %pred., TLC ≥ 100 %pred., RV ≥ 150 %pred. and 6MWT < 450 meters. The Zephyr one-way bronchial valves (PulmonX, Redwood City, CA, USA) with the size of 5.5 mm and 4mm were placed in lobar or segmental bronchi via flexible bronchoscopy. 28 patients were placed only one valve, 1 patient with two and 1 patient with three valves. 23 valves with the size 5.5 mm diameters and 10 valves with the size 4.0mm used. All patients received optimal medical treatment at the time of procedure and during the study period. Outcomes will be assessed at 3 months after treatment include the changes of clinic, and lung function, the occurrence of complications. Results: After 3 months, mean CAT scores decreased significantly compared with before procedure (17.73 ± 3.53 vs 20.10 ± 3.58) (p<0.05), with the median change of 2.73 points and the improvement more than 2 points in 76.67% of patients. 6 MWT increased at 3 months with mean 32.13 meters, 93.33% of the patients increased 6MWT, 46.67% of the patients increased 6MWT more than 26 meters. MRC decreased with the median change of 0.5 score. VC decreased by a mean 0.2 (L) (0.42 - 0.02), FEV1 increased by a mean 0.05 (L) (0.04 - 0.05) but not statistically significant (p>0.05); FVC increased by a mean 0.14 (L) (0.01 - 0.28), RV decreased by a mean 0.62 (L) (1.05 - 0.2), TLC decreased by a mean 0.52 (L) (0.77- 2.4) with statistically significant (P<0.05). The early complications were 13.33%, the later complications were 23.34% of the patients. Conclusions: The unilateral bronchoscopic lung volume reduction with one-way valve (mainly one valve) in treatment of heterogeneous severe emphysema in stable COPD patients in Viet Nam have shown that this procedure is safe with encouraging initial results.

Utility of the Histological Examination of the Bronchial Mucosa in the Diagnosis of Severe Equine Asthma Syndrome in Horses

The severe equine asthma syndrome is one of the most common respiratory problems in older horses. Although epithelial damage and basement membrane thickening are well-known features of airway remodeling in human asthma, pathological features of the bronchial mucosa and their value in the diagnosis of severe equine asthma syndrome are poorly characterized. Therefore, we wanted to determine if classic histologic features characterizing equine asthma are clinically useful. Thirty horses with severe equine asthma and 10 healthy animals were evaluated. A clinical examination, complete blood count, serum chemistry, endoscopic examination, and bronchoalveolar lavage were performed in all the horses. During the bronchoscopy of each horse, three or more biopsies were obtained from either the right or the left first segmental bronchus. The samples were assessed with respect to the surface epithelium, lamina propria, smooth muscle, glands, type of inflammation, and hyperemia. There was a significant difference (P < .05) in all clinical variables between the control and study groups. The horses included in the study group had a mean clinical score of 5.06, wherein the mean clinical score for the control group was 0.7. Cough, nostril flare, and abdominal lift were the components that had the most significant impact on the clinical score. The statistical analysis revealed no statistically significant differences for any histologic variables in the two groups. A classic histological assessment of an endobronchial biopsy is insufficient to differentiate horses with asthma from healthy horses and appears to be less sensitive than the clinical assessment.

Robotic Endoscopic Airway Challenge: REACH Assessment

Bronchoscopy for peripheral pulmonary lesions continues to present challenges to clinicians. One potential limitation may be the inability to advance conventional bronchoscopes into close proximity of peripheral lesions before biopsy. This study was performed to assess the reach of a robotic endoscopic system within human cadaveric lungs compared with conventional thin bronchoscopes. All segmental bronchi (RB1 to 10, LB1 to 10) were accessed in two human cadavers using a conventional thin bronchoscope and robotic endoscope of identical outer diameter. Bronchus generation count and insertion depth measured by electromagnetic navigation and external fluoroscopy were recorded. The robotic endoscope was advanced beyond the conventional thin bronchoscope in all segments, particularly in bronchi with increased angulation such as RB1 (mean generation count 8 versus 3.5, respectively) and LB1+2 (mean generation count 8 versus 4.5). The robotic endoscopic system was advanced beyond a conventional thin bronchoscope with identical outer diameter into the periphery of human cadaveric lungs. Improved reach within the lung periphery may address some limitations with contemporary bronchoscopic approaches for peripheral lesion biopsy.

Hyperinflation of bronchi in vitro impairs bronchodilation to simulated breathing and increases sensitivity to contractile activation.

Lung hyperinflation and reduced bronchodilation to deep inspiration (DI) are features of chronic obstructive pulmonary disease (COPD). Hyperinflation might impair the ability of a DI to stretch airway smooth muscle (ASM), as the bronchi operate at a stiff region of the pressure-volume curve. Bronchial segments from pig lungs were mounted in an organ bath and equilibrated at either 5 cm H2 O (control) or 20 cm H2 O (hyperinflated) transmural pressure (Ptm ). Cumulative dose-response curves to acetylcholine (ACh) were performed to determine maximal response (Emax ) and sensitivity under static conditions (fixed Ptm ) or during simulated breathing (Δ10 cm H2 O Ptm at 0.25 Hz). The effect of hyperinflation on ASM contraction was further examined in bronchial rings contracted at a short ASM length (reference length, Lref ) or stretched by an additional 30% (length 1.3 times the Lref , 1.3Lref ). Oscillatory loads halved Emax from 61.0 ± 3.8 to 29.7 ± 4.4 cm H2 O (P < 0.0001) in control bronchial segments, but only from 40.0 ± 2.5 to 31.2 ± 2.4 cm H2 O (P < 0.05) in hyperinflated segments. The percentage reduction in active pressure with oscillation was less in hyperinflated compared with control segments (P < 0.01). Sensitivity was not altered by oscillation in either hyperinflated or control segments; however, hyperinflated segments were more sensitive (P < 0.05). The effect of inflation on sensitivity was confirmed using bronchial rings where stretched rings were more sensitive than unstretched rings (P < 0.01). Hyperinflated bronchi exhibit reduced bronchodilation to breathing and increased sensitivity to bronchoconstrictor stimuli. Findings suggest that hyperinflation may directly alter airway function by reducing the protective effects of DI and initiating contraction at low doses of contractile stimuli.

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.

A cadaveric study on accessory lobes of lungs and their bronchial branching pattern

Background: An accessory lobe is a part of lung tissue separated off by an accessory fissure. It develops due to occasional monopodial branching of the stem bronchi. Different accessory lobes may be encountered in the human lungs e.g., azygos lobe, dorsal lobe, cardiac lobe and tracheal lobe. An accessory lobe may be confused with a lung abscess or bulla in x-ray and CT-scan, and its variable bronchial supply may cause difficulty during bronchoscopy. Hence, the present work has been carried out to study the accessory lobes and their bronchial branching pattern in human lungs. Materials and Methods: 92 adult human lungs (46 right and 46 left) were collected from the Department of Anatomy and Department of Forensic and State Medicine, Gauhati Medical College and Hospital, Guwahati, Assam and preserved in 10% formalin. The lungs were, then, examined for accessory lobes and their bronchial supply was noted following dissection from the hilum. Results: In the present study, the azygos lobes were present in 2.17% of cases and dorsal lobe was present in 1.08% of cases, all of which belonged to the right side. The azygos lobes were supplied by the apical segmental bronchus of the right superior lobe and dorsal lobe was supplied by the apical basal segmental bronchus and posterior basal segmental bronchus of the right inferior lobe. Conclusion: A detailed knowledge of the accessory lobes and their bronchial supply is important for correct radiological diagnosis and bronchoscopic examination of lungs.

Treatment of distal bronchial stenosis after bilateral lung transplantation

The effi ciency of lung transplantation is considerably limited by the complications associated with the bronchial pathologies. Despite the progress of the treatment methods, bronchial complications are still remaining as an actual problem in the postoperative period with frequency of occurrence from 7 to 29%. However, the bronchial stenosis are the most common bronchial complications after lung transplantation with mortality from 2 to 4%.Aim. To study an experience of our center of bronchial stenosis treatment in lung recipients. Materials and methods. 34 patients underwent lung transplantation from September 2014 to January 2017. 6 (16%) of them had a stenosis of lobar or segmental bronchi from 84 to 494 postoperative day. 5 (83%) of them have demonstrated multifocal lesions. In all of the cases there was performed an endoscopic bougienage, which involved a balloon dilatation and electrocoagulated incision of granular tissue under X-ray control. After that the patients were administrated by everolimus.Results. Restenosis was formed in 132,0 ± 94,2 postoperative day after primary treatment in all patients. In four cases (67%) we used nitinol stent placement under X-ray control. There were no complications. In 3 cases stents were dislocated distally, so we needed to use repeated endoscopic bougienage to replace the stent. Using of everolimus has allowed to decrease the rate of restenosis, but it need future research.Conclusion. Distal bronchial stenosis after lung transplantation can be managed with endoscopic bougienage and stent placement. Adding everolimus has not signifi cantly affected the risk of frequency of restenosis.

Clinical Success Stenting Distal Bronchi for "Lobar Salvage" in Bronchial Stenosis.

Airway stents are traditionally used in central airway obstructions to maintain airway patency. Historically, distal bronchial stenting within lobar and segmental bronchi has not been amenable to stenting. In addition, there are questionable benefits to stenting small airways. The Atrium iCast stent is a polytetrafluoroethylene covered stainless steel balloon deployed stent which can be deployed through a flexible bronchoscope under direct visualization. The purpose of this study was to assess the feasibility, complications, and long-term impact of using this stent in patients with lobar bronchial stenosis either secondary to malignancy or benign etiologies. All records of patients who had the placement of an iCast stent were reviewed over 3.5 years. For each patient the age, sex, location, histology, stent size, duration of stent placement, radiographic improvement, and complications were collected. A total of 122 iCast stents were deployed in 38 patients with lobar bronchial stenosis. The average age was 58 years with 50% male. The etiology included 45% malignant and 55% due to benign conditions. In total, 18.5% patients had stents placed in >1 segment. There was an average of 4 procedures per patient with a mean time to stent revision or removal of 85 days. All patients had symptomatic or radiographic improvement. Common complications included migration (10%), granulation tissue formation (5%), deployment malfunction (2%), stent dislodgement immediately after deployment (2%), mucous plugging (1%), and tumor occlusion (1%). Stenting small airways with lobar salvage is feasible and improves symptoms and radiographic outcomes.

The role of imaging in the diagnosis of bronchiectasis: The key is in the distribution

Diseases that involve the medium caliber airways (segmental and subsegmental bronchi) are common and present clinically with nonspecific respiratory symptoms such as cough, recurrent respiratory infections and occasionally, hemoptysis. The abnormal and irreversible dilation of bronchi is known as “bronchiectasis”. The diagnosis can be challenging and the analysis of the regional distribution of the bronchiectasis is the most useful diagnostic guide. The objective of this manuscript is to describe the main imaging findings of bronchiectasis and their classification, review the diseases that most commonly present with this abnormality, and provide an approach to the diagnosis based on their imaging appearance and anatomic distribution. Bronchiectasis is a frequent finding that may result from a broad range of disorders. Imaging plays a paramount role in diagnosis, both in the detection and classification, and in the diagnosis of the underlying pathology.

Association Between Airway Parameters and Abdominal Fat Measured via Computed Tomography in Asthmatic Patients.

PurposeWe aimed to investigate whether airway parameters, assessed via computed tomography (CT), are associated with abdominal fat areas and to compare the clinical characteristics of asthmatic patients with and without elevated visceral to subcutaneous fat area ratio (EV).MethodsAsthmatic patients (aged ≥40 years) were prospectively recruited. Chest (airway) and fat areas were assessed via CT. Airway parameters, including bronchial wall thickness (WT), lumen diameter (LD), lumen area (LA), wall area (WA), total area (TA), as well as WA/TA percentage (wall area %) were measured at the apical segmental bronchus in the right upper lobe. Visceral (VFA), subcutaneous (SFA) and total (TFA) fat areas (cm2) were also measured. The correlations between abdominal fat areas and airway parameters were assessed. EV was defined as VFA/SFA ≥ 0.4.ResultsFifty asthmatic patients were included (mean age 62.9 years; 52% female); 38% had severe asthma. Significant correlations were found between VFA and both LD and LA (r = −0.35, P = 0.01; r = −0.34, P = 0.02, respectively), and SFA and both WA and TA (r = 0.38, P = 0.007; r = 0.34, P = 0.02, respectively). Exacerbations, requiring corticosteroid therapy or ER visitation, were significantly more frequent in subjects without EV (83% vs. 34%, P = 0.05).ConclusionsAbdominal fat is associated with asthma, according to the location of fat accumulation. In asthmatic subjects, visceral fat seems to be attributable to the bronchial luminal narrowing, while subcutaneous fat may be related to thickening of bronchial wall.

Assessment of proximal and peripheral airway dysfunction by computed tomography and respiratory impedance in asthma and COPD patients with fixed airflow obstruction.

OBJECTIVE:To ascertain: (i) if elderly patients with fixed airflow obstruction (FAO) due to asthma and chronic obstructive pulmonary disease (COPD) have distinct airway morphologic and physiologic changes; (ii) the correlation between the morphology of proximal/peripheral airways and respiratory impedance.METHODS:Twenty-five asthma cases with FAO and 22 COPD patients were enrolled. High-resolution computed tomography was used to measure the wall area (WA) and lumen area (LA) of the proximal airway at the apical segmental bronchus of the right upper lobe (RB1) adjusted by body surface area (BSA) and bronchial wall thickening (BWTr) of the peripheral airways and extent of expiratory air trapping (ATexp). Respiratory impedance included resistance at 5 Hz (R5) and 20 Hz (R20) and resonant frequency (Fres). Total lung capacity (TLC) and residual volume (RV) were measured.RESULTS:Asthma patients had smaller RB1-LA/BSA than COPD patients (10.5 ± 3.4 vs. 13.3 ± 5.0 mm2/m2, P = 0.037). R5(5.5 ± 2.0 vs. 3.4 ± 1.0 cmH2O/L/s, P = 0.02) and R20(4.2 ± 1.7 vs. 2.6 ± 0.7 cmH2O/L/s, P = 0.001) were higher in asthma cases. ATexp and BWTr were similar in both groups. Regression analysis in asthma showed that forced expiratory volume in one second (FEV1) and Fres were associated with RB1-WA/BSA (R2= 0.34, P = 0.005) and BWTr (0.5, 0.012), whereas RV/TLC was associated with ATexp (0.38, 0.001).CONCLUSIONS:Asthma patients with FAO had a smaller LA and higher resistance of the proximal airways than COPD patients. FEV1 and respiratory impedance correlated with airway morphology.

Distinct clinicopathologic features, genomic characteristics and survival of central and peripheral pulmonary large cell neuroendocrine carcinoma: From different origin cells?

BackgroundPulmonary large cell neuroendocrine carcinoma (LCNEC) represents a rare entity in lung cancer with dismal prognosis. In the present study, we investigated whether there are significant differences between central and peripheral tumors of LCNEC, in terms of clinicopathologic features, genomic profiles, and survival. Methods and materialsA total of 126 cases of LCNEC were included. The tumors with invasion of the segmental and/or lobar bronchus were classified as central LCNEC and those without as peripheral LCNEC. EGFR/BRAF/Kras mutations and ALK/ROS1 translocations were detected. Overall survival (OS) was evaluated by the Kaplan-Meier plots. ResultsThe majority of LCNEC proved to be of the peripheral type (64.3%, 81/126). Central tumors were associated with smoking habit (p = 0.047), higher TNM-stage (p = 0.014) and larger tumor size (p < 0.001). Expression of neuroendocrine markers (CD56, CGA, and SYN) was not significantly different by tumor location but central tumors had higher serum levels of NSE (p = 0.004). Peripheral tumors had a higher incidence of EGFR mutations (18.8% vs. 0%, p = 0.023). ROS1 translocation was detected in 1 patient with peripheral LCNEC. RB1 protein was more frequently expressed in peripheral tumor than central tumor. The median OS was 3.71 years in the entire cohort. Peripheral tumors had better survival compared with central tumors (median OS: 4.04 vs. 1.51 years, p < 0.001). Multivariate analyses demonstrated tumor location (hazard ratio [HR], 6.07, 95% confidence interval [CI], 1.57-23.44, p = 0.009), resection status (HR, 6.58, 95% CI, 1.92-22.51, p = 0.003) and EGFR mutational status (HR, 0.18, 95% CI, 0.04-0.75, p = 0.018) were independent prognostic factors for OS. ConclusionPrimary tumor location of LCNEC, divided into central and peripheral type, has distinct clinicopathologic features, genomic characteristics and survival. These differences are likely due to differences in the origin cells and pathogenesis of these tumors.

A powered vascular staple for the application of segmental bronchial closure in thoracoscopic anatomic segmentectomy.

We used the powered vascular staple (PVS) instead of the conventional staple technique [the utilization of the powered linier cutter (PLC)] or ligation for total 23 segmental or subsegmental bronchi with less than 10 mm in the bronchial luminal size on computed tomography (CT) in thoracoscopic segmentectomy. Our results suggested that the availability of the PVS represents a novel advance in the armamentarium and may have a possibility of being pervasive widely however, more observative periods and further sample accumulation are needed.

Congenital bronchial atresia in adults: thoracoscopic resection.

Congenital bronchial atresia (CBA) is a rare congenital malformation consisting in an interruption of a lobar or-more frequently-of a segmental bronchus. It leads to mucus impaction and hyperinflation of the obstructed lung segment. It causes infectious complications and, in the long term, destruction of the adjacent lung parenchyma. Thus, a surgical resection is usually indicated, even in asymptomatic patients.

Non-Obstructive Middle Lobe Syndrome: An Unusual Cause of Recurrent Pneumonia in an Elderly Woman

An 84-year-old woman had five episodes of pneumonia in 4 months. Despite extensive comorbidities and advanced age, her health status was good and the recurrence seemed unjustified. Exhaustive background investigation revealed 14 episodes of right-sided pneumonias during the 3 previous years and an inconclusive investigation with CT of the thorax and bronchofibroscopy, despite some fibrotic and atelectasic alterations in the right middle lobe. A new right-sided x-ray showed a wedge-shaped density extending anteriorly and inferiorly from the hilum, and CT of the thorax revealed aggravated middle lobe abnormalities with thickening of the bronchial wall and segment atelectasis, without any visible airway obstruction. After extensive work-up had excluded other causes of recurrent pneumonia and immunodeficiency, a non-obstructive middle lobe syndrome (MLS) was deemed responsible for the repeated episodes of pneumonia. MLS is characterised by chronic hypoventilation and atelectasis of the middle lobe, facilitating secretion accumulation, chronic inflammation and repeated infection. After treatment with bronchodilators and immunostimulants was initiated, the patient experienced no recurrences for several months.LEARNING POINTSRecurrent pneumonia is common and has several possible causes. Investigation should be directed by whether or not the location of the episodes varies, suggesting a systemic condition or a local abnormality, respectively.Middle lobe syndrome (MLS) is characterised by chronic hypoventilation of the right middle lobe resulting in atelectasis and secretion accumulation, sometimes causing recurrent pneumonia, and should therefore be considered in the differential diagnosis.MLS is not unusual in children with asthma but is quite uncommon in the elderly despite age-related changes in the characteristics of airways with reduced elastic recoil and mucociliary clearance.

P3.16-052 Use of Decellularised Porcine Intestinal Submucosa Extracellular Matrix in Airway Reconstruction to Enable Lung-Sparing Oncological Surgery

Reconstruction of the airways following tracheal resection, tracheo-oesophageal complications and lung-sparing oncological surgery is challenging. Airway reconstruction materials ideally must possess balanced properties of rigidity, flexibility and have an intact surface of epithelium to maintain a functional airway. A novel approach is the use of bio-scaffolds which allow regeneration of respiratory epithelium and eliminate the need for immunosuppressive treatment. Initial experiences with decellularised porcine small intestine submucosa extracellular matrix (CorMatrix®) as a scaffold for vascular, cardiac and pericardial tissue repair and reconstruction has been encouraging. The properties of extracellular matrix are potentially suitable for airway reconstruction. We initially used the bio-scaffold for repairing tracheal defects and tracheo-oesophageal fistulae (n=6). We then extended its use to reconstruct distal airways to facilitate lung-sparing oncologic resections of intermediate grade lung tumours (n=3). These patients would otherwise have required pneumonectomy (Case 1 and 2) or bi-lobectomy in a patient with borderline lung function (Case 3). We describe our experience using extracellular matrix for airway reconstruction in lung-sparing oncological surgery. Three patients underwent complex sleeve resections with varying degrees of bronchial airway reconstruction using extracellular matrix. The lung tumours were: (1) muco-epidermoid tumour of the left upper lobe and left main bronchus; (2) typical carcinoid of the right main bronchus; (3) typical carcinoid of the intermediate bronchus and right middle lobe. All patients underwent frozen section pathology examination at the time of surgery and formal histology confirmed pT1N0 and R0 resection status. There were no perioperative complications. All patients underwent bronchoscopy prior to discharge and serial bronchoscopies were carried out 6 weeks, 3 months and at >1 year. All patients had complete integration of the scaffold by epithelialisation and the patch was not evident at 3 months. All segmental bronchi were widely patent. At 18 months there was no tumour recurrence. The use of decellularised porcine intestinal submucosa extracellular matrix (CorMatrix®) as a bio-scaffold is safe and shows remarkable epithelialisation and integrity. It is an option for airway reconstruction to facilitate lung-sparing surgery without compromising oncologic margins.

Thoracoscopic lobectomy for the treatment of tracheal bronchus. A paediatric case report

Abstract Background Tracheal bronchus is considered a rare, congenital anomaly, which implies the abnormal origin of a bronchus. When related to repetitive infections the bronchus must be resected, usually via an open procedure. Objective The aim of this paper is to present the case of a patient with tracheal bronchus of the upper right lobe who presented with repetitive pneumonias. Additionally, this text intends to expose the methodology for its diagnosis and surgical resolution through a thoracoscopic lobectomy. Clinical case One year old female patient who presented with the disorder at two months of age. The patient presented with constant coughing and persistent fever alongside repetitive pneumonias in the upper right lobe. In order to discard the possibility of gastroesophageal reflux, a bronchoscopy and a panendoscopy of the digestive tube were conducted. The aforesaid procedure demonstrated the existence of a tracheal bronchus located in the right lobe, with functional bronchial segmentation. With these findings and due to the presence of repetitive infections, an apical right lobectomy was performed through a thoracoscopy, with favourable results. Conclusions Tracheal bronchus is a rare anomaly that on many occasions is asymptomatic; nonetheless, when related to repetitive infections, a lobectomy must be carried out to avoid further pulmonary damage. This can be done through a thoracoscopy, as was the case with our patient. When treating these patients, it is worth considering they tend to have a different anatomy and to consider the ease at which they can sustain severe inflammation due to repetitive infections.