OBJECTIVES Energy vessel-sealing devices are being increasingly utilized to seal pulmonary artery (PA) branches during lobectomy. Heat from these devices can potentially injure surrounding tissues. We evaluated heat production from devices in a live animal model. METHODS PA branches were sealed in pigs with 4 energy vessel-sealing devices: 2 ultrasonic (US), 1 advanced bipolar or 1 mixed US and bipolar (mixed) device. Thermocouples were implanted in tissue surrounding the PA branch being sealed to measure tissue temperature. A thermal camera measured the sealing site and the temperatures of the instruments. Pathological analysis was performed on PA stumps to identify thermal damage. RESULTS A total of 37 PA branches were sealed in 4 pigs. Maximum tissue heat measured by the thermocouples for the 2 US, advanced bipolar and mixed devices was 42, 39, 42 and 46°C, respectively. The mean tissue temperatures at the site of the sealing measured with the thermal camera were 78, 75, 70 and 82°C (P = 0.834) and the mean instrument blade temperatures were 224, 195, 83 and 170°C (P = 0.000005) for the 2 US, advanced bipolar and mixed devices, respectively. The mean diameter of the region with tissue reaching 60°C or more measured with the thermal camera was between 4 and 6 mm for the 4 devices (P = 0.941). On pathological analysis, PA stumps had either thermal damage on the adventitia and external media (26/37) or transmural damage (11/37) at 1 mm from sealed site. CONCLUSIONS A 3-mm safety margin between the instrument blades and vital structures is recommended. Instrument blades can reach high temperatures that may cause tissue damage.

Background: Nonsmall cell lung cancer (NSCLC) treatment is based on an accurate staging. Mediastinal lymph nodes staging has a critical impact on treatment management. Methods: The objective was to assess the current accuracy of preoperative tools for predicting mediastinal and hilar lymph nodes staging with NSCLC. Retrospective analysis of 997 biopsy-proven NSCLC patients treated at a single academic medical center between January 2006 and April 2012. Mediastinal lymph nodes were evaluated with preoperatively with: computed tomography (CT), positron emission tomography (PET), endobronchial ultrasound-guided fine needle aspiration, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Results are compared with pathologic surgical biopsy. Results: A total of 217 cervical mediastinoscopies, 15 anterior mediastinotomies, and 952 surgical lymphadenectomies were performed. The sensitivity of CT scan for mediastinal lymph nodes detection was 18.9% and PET-CT scan was 33.8%. Specificities were 94.9% and 93.8%, respectively. For hilar lymph nodes detection, CT was less sensitive (17.0% vs. 39.7%); however, more specific (94.7% vs. 80.3%) than PET-CT. Endobronchial ultrasound-guided fine needle aspiration (72.7% sensitivity and 100% specificity) and endoscopic ultrasound-guided fine needle aspiration (51.9% sensitivity and 100% specificity) both demonstrated superior results. Conclusions: The majority of biopsy-proven mediastinal lymph nodes metastases are not associated with positive results on preoperative CT or PET. CT and PET have low positive predictive value for mediastinal lymph node. This study supports the routine utilization of invasive mediastinal lymph nodes staging in NSCLC, especially for patients with tumors of >4 cm diameter, regardless of CT or PET-CT results.

OBJECTIVE:Pulmonary artery branch sealing in video-assisted thoracoscopic surgical lobectomy is usually achieved with vascular endostaplers. Iatrogenic pulmonary artery injury may be caused by endostaplers. We evaluated the safety of pulmonary artery sealing with an ultrasonic energy vessel-sealing device in a phase I clinical trial evaluating in vivo safety of the device during open lobectomy. METHODS:Patients scheduled to undergo elective open (thoracotomy) pulmonary lobectomy were prospectively enrolled. Target sample size was 10 patients. Pulmonary artery diameter was measured intraoperatively. All branches ≤7 mm were divided with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative and postoperative bleeding were strictly recorded. RESULTS:Eighteen patients were prospectively enrolled. Eight patients were not amenable to pulmonary artery sealing with the device. In the 10 patients included in the analysis, a total of 14 pulmonary arteries were sealed with the ultrasonic device. The mean vessel diameter was 5 mm (range, 2-7 mm). One patient underwent reoperation for bronchial artery bleeding (vessel not sealed with device). There was no intra- or postoperative bleeding related to ultrasonic pulmonary artery sealing. There was no postoperative mortality. CONCLUSIONS:Pulmonary artery sealing for vessels with diameter ≤7 mm was safely achieved with an ultrasonic energy vessel-sealing device in open lobectomy. The use of ultrasonic energy vessel-sealing devices in video-assisted thoracoscopic surgical lobectomy may have the advantage of making small, short, pulmonary artery branch sealing safer than with vascular endostaplers. Further studies are necessary before widespread application in lobectomy, including video-assisted thoracoscopic surgical lobectomy.

Correct identification of mediastinal lymph node stations with endoscopic ultrasound (EUS) and endobronchial ultrasound (EBUS) requires knowledge of their ultrasonic anatomical positions and relations. The ultrasonic positions of the lymph node stations located in and around the aortopulmonary window (stations 4L, 5, and 6) can be more challenging to understand. The aim of this report is to describe the endosonographic anatomic positions of stations 4L, 5, and 6 and to demonstrate their locations using EUS and EBUS.

Background. Energy-sealing devices may be useful to divide small pulmonary arteries (PAs) during video assisted thoracoscopic surgery (VATS) lobectomy. We evaluated the safety of PA branch sealing with an ultrasonic energy vessel-sealing device during VATS lobectomy. Methods. The study consisted of a phase 1 trial. Patients planned to undergo VATS lobectomy were prospectively enrolled. Target sample size was 20 patients. Branches of 7 mm or less were sealed and cut with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative, in-hospital, and 30-day postoperative bleeding were prospectively recorded. Results. Thirty-three patients were prospectively enrolled. Thirteen patients were not amenable to PA sealing with the vessel-sealing device because all PA branch diameters exceeded 7 mm (n = 10), conversion to thoracotomy (n = 2), and lobectomy not performed (n = 1). A minimum of one PA branch was sealed with the device in 20 patients. Fifty-eight PA branches were divided in 20 patients: 31 with ultrasonic device, 24 with endostaplers, 2 with clips, and 1 with sutures. The mean vessel diameter sealed with the device was 4 mm. Two patients were converted to thoracotomy (1 with PA injury during dissection, 1 with PA tumor invasion). No intra-operative or postoperative bleeding was related to ultrasonic PA branch sealing. No postoperative deaths occurred. Conclusions. PA branch sealing for vessels 7 mm or less was safely achieved using an ultrasonic energy vessel-sealing device in VATS lobectomy. Large-scale, prospective, multi-institutional studies are necessary before widespread clinical application of energy for PA branch sealing in VATS lobectomy. (C) 2018 by The Society of Thoracic Surgeons

SESSION TITLE: Interventional Pulmonary Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: Complete endosonographic mediastinal staging modalities have become a new standard in the pre-operative staging of non-small cell lung cancer in some centers. This study was performed to understand the value of mediastinal lymph node (LN) sampling and dissection at time of pulmonary resection in the setting of a negative pre-operative staging endosonography by combined EBUS & EUS. METHODS: This study consisted of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database between January 2009 and December 2014. Two hundred and thirty-two consecutive patients with non-small cell lung cancer with negative results on lymph node staging by combined endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration (FNA) that subsequently underwent pulmonary resection or attempt at pulmonary resection were included. The endosonographic results were compared with the final pathological staging utilizing final pathology results of lymph nodes sampled during surgery. Chi-Square test was used for statistical analysis. A p-value of <0.05 was considered statistically significant. RESULTS: Twenty-five out of 232 patients with negative results on LN staging by combined EBUS / EUS - FNA had metastases in LNs sampled during pulmonary resection. 10 patients had N1 disease and 15 patients had N2 disease. The negative predictive value (NPV) of EBUS/EUS was 89.2% (p<0.01). Twenty-one out of these 25 patients who had surgical LN sampling at resection did not have the same station sampled pre-operatively by EBUS/ EUS. Therefore a direct comparison at surgical resection could not be made on these 21 patients. Eleven out of these 21 patients had Station 5 and Station 6 involvement and these stations are routinely difficult to sample using endoscopic modalities. If these 21 patients are omitted for comparison, only 4 out of 232 patients had false negative results by EBUS / EUS - FNA giving a true negative predictive value of 98.3% (p<0.01). 3 out of these 4 patients had N2 disease (Station 4L, 5 and 7) and 1 patient had N1 (Station 11R) disease detected at Pulmonary resection. CONCLUSIONS: Staging endosonography by combined EBUS & EUS in potentially resectable patients is associated with a high NPV. If pre-operative results of biopsy of a particular LN station by EBUS/EUS-FNA are negative, then sampling of the same station at surgery can potentially be omitted. LN stations not sampled by endosonography should be sampled at surgery. CLINICAL IMPLICATIONS: Can potentially change the practice and the way lymph node station sampling and dissection is done during pulmonary resection. This may reduce the operative time and avoid unnecessary dissection of the lymph nodes already biopsied at pre operative staging procedure. DISCLOSURE: The following authors have nothing to disclose: Pravachan Hegde, Vicky Thiffault, Vipul Jain, Akshatha Gowda, Pasquale Ferraro, Moishe Liberman No Product/Research Disclosure Information

BACKGROUND:Neoplastic involvement of the mediastinum can contribute to both airway and esophageal pathology. That can manifest as combined esophageal and airway stenosis, or tracheobronchoesophageal fistula. Conventional palliative treatment of these problems consists of endoluminal stent insertion. The double stenting approach consists of insertion of a tracheobronchial and an esophageal stent in parallel and allows concomitant symptomatic relief of both the airway and esophageal pathology. METHODS:The study consists of a retrospective case series of patients who underwent a double stenting procedure for concomitant airway and esophageal disease between August 2009 and September 2014. The type of airway stent chosen was determined based on the pathology and the level of the lesion (simple tubular in the mid trachea or mainstem bronchus, Y-stent for carina). RESULTS:Thirty-nine patients were treated using the double stenting approach during a combined procedure over 5 years: 15 patients with tracheobronchoesophageal fistula and 24 with stenosis. Immediate relief of symptoms, defined as resuming oral intake and breathing without an external tracheal device, was observed in 25 patients (64%). Thirty-two patients (82%) were discharged from hospital, and 7 patients died in hospital (18%). Of these 7 deaths, 6 patients died of pulmonary complications. Inhospital complications occurred in 11 patients (28%). Of the patients discharged from the hospital, 14 died during a mean follow-up period of 54 days. Mean and median survival were 49 and 24 days, respectively (range, 1 to 448), and median hospital stay was 3 days (range, 1 to 46). CONCLUSIONS:Treatment of combined airway and esophageal pathology using a double stenting approach is safe, feasible, provides reasonable immediate palliation of symptoms, and is associated with acceptable morbidity. It is a palliative procedure that allows for early hospital discharge of patients who are diagnosed with an incurable malignancy.

BACKGROUND:Pulmonary artery (PA) sealing in video-assisted thoracoscopic surgery (VATS) lobectomy is typically accomplished using vascular endostaplers. Endostaplers may be associated with iatrogenic PA branch injury, especially in short, small PA branches. We evaluated PA branch sealing with the HARMONIC ACE +7 (ACE) shears (Ethicon, Cincinnati, OH) in VATS lobectomy in a canine survival model. METHODS:Ten adult dogs underwent VATS lobectomy. Standard VATS lobectomy operative technique was used for the entire operation, except for PA branch sealing. The ACE was used for all PA branch sealing. Dogs were kept alive for 30 days. RESULTS:The 10 dogs underwent VATS right upper (n = 5) and right lower (n = 5) lobectomy. The ACE was used to seal 21 PA branches. No PA branch was divided with an endostapler. There were no intraoperative complications or conversions to thoracotomy. Mean in vivo PA diameter was 5.6 mm (range, 2 to 12 mm). One 10-mm PA branch had a partial seal failure immediately at the time of sealing. The device was reapplied on the stump, and the PA branch was successfully sealed. All dogs survived 30 days without hemothorax. Necropsy at 30 days did not reveal any signs of postoperative bleeding. Pathology of the sealed PA branches at 30 days revealed fibrosis, giant cell reaction, neovascularization, and thermal changes of the vessel wall. CONCLUSIONS:The use of the ACE for PA branch sealing in VATS lobectomy is safe and effective in an animal survival model. Human studies are needed to determine the clinical safety of ultrasonic PA branch sealing before widespread clinical use.

BACKGROUND:Endoscopic techniques, including endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS), are the initial approach for the diagnosis and staging of lung cancer and the diagnosis of mediastinal and hilar lesions. Historically, the transvascular approach has been avoided because of concerns of bleeding. Here we review our experience with EBUS and EUS transvascular biopsy of mediastinal, hilar, and lung lesions. METHODS:A prospective research database was used to retrospectively identify and review the records 33 consecutive patients who underwent EBUS and EUS transvascular biopsy in an outpatient setting over 4 years. Complications were identified as significant hematoma seen with endoscopic ultrasound, hemothorax, hemoptysis other than minor, hemodynamic instability, hospital admission, and death. RESULTS:The biopsies in 14 patients were performed through branches of the pulmonary artery, and 19 were done through the aorta. All EUS biopsies were performed with a 22-gauge needle, and all EBUS biopsies were performed with a 21-gauge needle. Malignancy was diagnosed with specimens from a transvascular biopsy in 16 patients (48.5%). Samples from 8 biopsies (24%) were described as negative for malignancy, and 9 specimens (27%) were described as insufficient. No complications were seen in the immediate postprocedural period, and all 33 patients were discharged home the same day. The median follow-up after the procedure was 12 months, with no complications described. The overall yield was 73%. CONCLUSIONS:In this series, EBUS- and EUS-guided transvascular approach for biopsy of mediastinal, hilar, and lung lesions was not associated with significant complications. However, careful selection of potential candidates and close periprocedural observation are mandatory.

BACKGROUND:The study aimed to evaluate the short- and long-term outcomes with a technique of self-expanding metallic stent insertion in palliative esophageal cancer patients. We hypothesized that a systematic attempt at exaggerated (5 cm) proximal tumor covering could prevent both stent migration and tumor overgrowth/undergrowth.METHODS:We reviewed retrospectively all patients who underwent esophageal stenting for palliation of malignant dysphagia over a 24-month period. Consecutive patients were identified from a prospective thoracic surgery interventional endoscopy database. This technique consisted of endoscopic stent insertion with the aim of landing the proximal portion of the stent 5 cm cephalad to the proximal extent of the tumor. All patients were followed at one month post-procedure and every three months thereafter, until death. Short- and long-term complications associated with the procedure and mortality were evaluated.RESULTS:Forty seven patients underwent endoscopic insertion of an esophageal stent in the context of an inoperable esophageal cancer using this technique over a 24-month period. The mean age was 70.4±9.6 years. Four (8.5%) patients underwent re-stenting due to proximal tumor overgrowth. No stent migration, perforation, tumor ingrowth or stent occlusion was reported. The mean patient survival was 146±26.5 days.CONCLUSIONS:Esophageal stent insertion under endoscopic guidance with proximal tumor covering of 5 cm is effective and safe. No cases of stent migration and a low incidence of tumor overgrowth/undergrowth were observed with this technique.

Natural orifice transluminal endoscopic surgery (NOTES) has the potential to be the final frontier in minimally invasive procedures in thoracic surgery. In order for thoracic pleural NOTES to 1 day be ready for clinical trials, each step of the procedure must be independently evaluated for both safety and efficacy. The aim of this study was to evaluate the trachea as a portal of entry for thoracic NOTES.

Central MessageWe describe a modified technique for Y-stent placement using a flexible bronchoscope for stent guidance in a Seldinger-like technique.See Editorial Commentary page 1009. We describe a modified technique for Y-stent placement using a flexible bronchoscope for stent guidance in a Seldinger-like technique. See Editorial Commentary page 1009. Airway obstruction may be caused by malignant and nonmalignant processes. The most common cause is bronchogenic carcinoma. Distal tracheal obstruction with or without involvement of the carina and the proximal main stem bronchi is an extremely challenging problem. Tracheobronchial silicone Y-stent insertion can be effective for both endoluminal obstruction and extrinsic airway compression and can achieve improvement of symptoms and quality of life. Y-stents also are effective in the treatment of tracheoesophageal fistula when it involves the distal trachea or carina. Y-stents, although effective, can be difficult to place because of loss of the airway, inability to visualize the airway during stent placement, inability to ventilate during placement, and difficulty maneuvering the stent limbs into the correct position. These difficulties led us to develop a modification of the classic technique that addresses some of the challenges during the placement. We present the modified technique for Y-stent insertion using a combination of rigid and flexible bronchoscopy and review our initial experience and results. This study consists of a retrospective cohort including 29 consecutive patients with central airway obstruction treated with Y-stent insertion using the modified technique performed at the Centre Hospitalier de L'Université de Montréal Endoscopic Tracheobronchial and Oesophageal Center between October 2009 and September 2014. The patients were identified from a prospectively accrued interventional endoscopy research database. The study was approved by the institutional review board of Centre de Recherche de L'Université de Montréal. Written informed consent was not required because of the retrospective nature of the study. The patient characteristics, diagnosis, procedure characteristics, length of hospital stay, follow-up, and complications were evaluated using hospital charts and procedural records. We describe a modified technique for insertion of tracheobronchial Y-stents with Seldinger-like guidance over a flexible bronchoscope for Y-stent insertion and review the initial experience with this technique. Insertion of Y-stents was performed using local and general anesthesia. General anesthesia was used for rigid bronchoscopy and placement of the stent through the larynx. Local anesthesia was used in selected cases in which a tracheostomy fistula was used for the insertion of the Y-stent. The first phase of the procedure started with an evaluation of the airway and followed by treatment of endoluminal disease with any of the following techniques: mechanical debulking, laser ablation, electrocoagulation, and balloon dilatation. The next step was the measurement of the diameter and length of the trachea and both main stem bronchi. The diameter of the airways can be measured using the balloon of the radial ultrasound probe, which is inflated with water until it fills the whole airway, and the diameter of the balloon is measured on the ultrasound image.1Shirakawa T. Imamura F. Hamamoto J. Shirkakusa T. A case of successful airway stent placement guided by endobronchial ultrasonography.J Bronchol. 2004; 11: 45-48Crossref Scopus (7) Google Scholar Another approach is to estimate the diameter of the airway from the diameter of the rigid and the flexible bronchoscopes after the ablative procedures are completed. The measurement allows for selection of the largest possible stent diameter to reduce the risk for stent obstruction and migration. We always measure the length of the left and right main stem bronchi and the length of the trachea involved with the disease. The length of the limbs should be long enough to cover the lesion and be as short as possible to decrease the chance for obstruction of the stent from secretions. The second phase of the procedure involves insertion of the stent into the airway, advancing the stent distally and maneuvering the stent limbs into the correct position. A Macintosh (blade sizes 3 or 4) laryngoscope is used to visualize the vocal cords and guide the advancement of the stent placed over a rigid forceps (alligator forceps or Freitag forceps) between the cords into the proximal trachea (Figure 1). Once the stent is deposited into the proximal trachea beneath the cricoid cartilage, the rigid forceps is withdrawn and a rigid tracheoscope or a rigid bronchoscope is inserted into the proximal trachea with the tip of the scope placed at the proximal end of the stent. The flexible bronchoscope is passed consecutively through the rigid tracheoscope (bronchoscope), the tracheal limb of the stent, and one of the bronchial limbs of the stent, and directed into the left or right lower lobe bronchus (Figure 2). A degree of deformation of the limbs of the stent will be seen as they are compressed together to accommodate the stent in the trachea. Difficulty passing the flexible scope through the deformed limbs of the stent may be anticipated; however, we were able to pass a 5- to 6-mm flexible bronchoscope through the bronchial limb in all our cases. The flexible bronchoscope is passed through the limb of the stent corresponding to the bronchus that is more obstructed and has a more abnormal take-off from the carina. The rigid tracheoscope (bronchoscope) is then slowly advanced pushing the Y-stent over the flexible bronchoscope using it as a guide for the stent's advancement in a bronchoscopic Seldinger technique (Figure 3, Figure 4). Intermittently, the advancement is held and the flexible bronchoscope is withdrawn proximally into the stent to check the position, help with orientation, and guide the progression of the stent limbs.Figure 3The rigid bronchoscope is advanced gently pushing the Y-stent over the flexible bronchoscope into position.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Computed tomography of the chest of a patient with a subcarinal mass and tracheomediastinal fistula. The top 2 images are before and the bottom 2 images are after the stent placement.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In patients with tracheostomy, the stent is inserted via the tracheal stoma and then the flexible bronchoscope is passed through the stent to the lower lobe bronchus. The stent is advanced distally using an approach similar to that described earlier, with the only difference being that a curved clamp is used to push the stent instead of the rigid scope. A total of 29 patients underwent 35 procedures using the Seldinger technique for Y-stent insertion between October 2009 and September 2014 (Table 1). Patients' mean age was 61 years; the youngest patient was aged 34 years, and the eldest patient was aged 86 years. There were 16 female patients and 13 male patients. The most common presenting symptoms were dyspnea and stridor; other presenting symptoms were cough, hemoptysis, and infection. Tracheoesophageal fistula was present in 4 cases.Table 1DemographicsProcedures35Patients29 Female16 (55%) Male13 (45%)Age, y (mean)61 Minimum34 Maximum86 Open table in a new tab The obstruction was caused by endoluminal lesion or by external compression. The location of the disease is presented in Table 2. Malignancy, either primary pulmonary or metastatic, was the cause of the obstruction in 23 patients (79%) (Table 3). Non–small cell lung cancer was the most common malignant diagnosis (14 patients [48%]), followed by esophageal cancer (5 patients [17%]). Tracheobronchomalacia was the most common diagnosis in the nonmalignant group; 1 patient had Y-stent placement for obstruction caused by relapsing polychondritis, and in 1 patient the Y-stent was placed for distal tracheal laceration extending to the right mainstem bronchus caused by endotracheal intubation. Thirty-four procedures were performed under general anesthesia, and 1 procedure was performed under moderate sedation with local anesthesia. The stent was placed in the trachea via the tracheal stoma in 3 patients, all of whom had severe tracheobronchomalacia.Table 2Location of lesionLocation of lesionNo. (% of patients)∗Based on information from 25 patients (4 patients without detailed location description).Trachea13 (52%)Carina6 (24%)Carina only3 (12%)Right main stem bronchus5 (20%)Left main stem bronchus6 (24%)Bilateral main stem bronchi7 (28%)∗ Based on information from 25 patients (4 patients without detailed location description). Open table in a new tab Table 3DiagnosisNo. (%)Malignant NSCLC14 (48%) Esophageal cancer5 (17%) SCLC1 (3%) Lymphoma1 (3%) Colon cancer1 (3%) Thymic cancer1 (3%)Nonmalignant Tracheobronchomalacia4 (14%) Relapsing polychondritis1 (3%) Intubation trauma1 (3%)NSCLC, Non–small cell lung cancer; SCLC, small cell lung cancer. Open table in a new tab NSCLC, Non–small cell lung cancer; SCLC, small cell lung cancer. The most commonly used stent was the Dynamic Y-Stent (Boston Scientific, Natick, Mass) with a tracheal limb width of 11 to 15 mm. In 5 patients, the Hood Y-Stent (Hood Laboratories, Pembroke, Mass) with an outer diameter of 14 mm was used (Table 4).Table 4Stent typesNo. (% of successful procedures)Dynamic Y-Stent (Boston Scientific, Natick, Mass) diameter 15 mm6 (18%) 13 mm16 (47%) 11 mm7 (21%)Hood Y-Stent (Hood Laboratories, Pembroke, Mass) diameter 14 mm5 (15%) Open table in a new tab The Seldinger technique was used without difficulty in 34 procedures (97%) with satisfactory positioning of the stent on the first attempt. The mean procedural time was 38 minutes (median time, 31 minutes). In 1 case, the endoscopist was unable to pass the flexible scope through the stent in a patient who had severe tracheobronchomalacia. The procedure was repeated at a later stage and was successful using the Seldinger technique for Y-stent placement. No complications occurred during any of the procedures. All patients remained hospitalized for at least 24 hours after the procedure (median duration of stay, 2 days; range, 1-110), and no immediate postprocedural complications were observed. The mean follow-up was 2.9 months; 2 patients were followed for 22 months. The most common late complication was obstruction of the stent from secretions, which required stent change in 4 patients. Another late complication was formation of granulation tissue at the proximal or distal ends of the stent. Seven patients died within 4 weeks of the procedure. In 5 cases, the stent was removed between 1 and 6.5 months (mean, 2.4 months) after insertion. Eight patients had concomitant WallFlex esophageal stents (Boston Scientific) inserted for concurrent esophageal obstruction (4 patients) or tracheoesophageal fistula (4 patients) during the same procedure. Therapeutic bronchoscopic interventions such as dilatation, laser photocoagulation, electrocoagulation, and mechanical debridement are used for the treatment of endoluminal bronchial obstruction.2Acuff T. Mack M. Ryan W. Simplified placement of a silicone tracheal Y stent.Ann Thorac Surg. 1994; 57: 496-497Abstract Full Text PDF PubMed Scopus (7) Google Scholar Stent placement is often needed to maintain airway patency after ablative procedures and in the treatment of airway obstruction from external compression. These techniques allow for successful withdrawal from mechanical ventilation and relief of symptoms.3Murgu S. Colt H. Silicone Y stent placement at secondary left carina for malignant central airway obstruction.J Thorac Cardiovasc Surg. 2010; 139: 494-495Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 4Dutau H. Toutblanc B. Lamb C. Seijo L. Use of the Dumon Y-stent in the management of malignant disease involving the carina.Chest. 2004; 126: 951-958Crossref PubMed Scopus (112) Google Scholar Y-stent insertion provides relief of the dyspnea and sustained improvement in quality of life for patients with central airway obstruction involving the carina, distal trachea, and proximal main stem bronchi.2Acuff T. Mack M. Ryan W. Simplified placement of a silicone tracheal Y stent.Ann Thorac Surg. 1994; 57: 496-497Abstract Full Text PDF PubMed Scopus (7) Google Scholar, 5Colt H.G. Harrell J.H. Therapeutic rigid bronchoscopy allows level of care changes in patients with acute respiratory failure from central airways obstruction.Chest. 1997; 112: 202-206Crossref PubMed Scopus (168) Google Scholar Y-stents are effective in restoring airway patency in both endoluminal obstruction and extrinsic compression of the airway. Y-stents, in combination with self-expanding esophageal stents, minimize the risk of recurrent infectious complications in patients with tracheoesophageal and bronchoesophageal fistulas.6Cavaliere S. Venuta F. Foccoli P. Toninelli C. La Face B. Endoscopic treatment of malignant airway obstructions in 2,008 patients.Chest. 1996; 110: 1536-1542Crossref PubMed Scopus (360) Google Scholar However, the insertion of a Y-stent can be technically challenging with the current techniques. Few techniques for Y-stent placement have been described. The classic method uses “push” or “pullback” techniques. The “push” technique uses alligator forceps to compress the bifurcation of the stent. The forceps and the stent are than advanced until reaching the distal trachea, just above the main carina where the forceps is slowly released, allowing the bronchial limbs to slide down in the appropriate main stem bronchi until the bifurcation of the stent reaches the carina. The forceps is then closed slightly and slowly withdrawn with care taken not to pull the stent out with the forceps.7Shiraishi T. Kawahara K. Shirakusa T. Inada K. Okabayashi K. Iwasaki A. Stenting for airway obstruction in the carinal region.Ann Thorac Surg. 1998; 66: 1925-1929Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Another way of placement of the Y-stent in the airway includes “folding” of the Y-stent in an introducer tube that is passed down the rigid bronchoscope, and then with the help of a plunger the stent is pushed out of the stent introducer tube. With the “pullback” technique, both bronchial limbs of the stent are placed in one of the main stem bronchi and the stent is pulled until the shorter limb pops into position in the contralateral bronchus.8van den Bongard H.J. Boot H. Bass P. Taal B. The role of parallel stent insertion in patients with esophagorespiratory fistulas.Gastrointest Endosc. 2002; 55: 110-115Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar The advancement of the stent can be guided fluoroscopically. The current techniques, although effective, require advancement of the Y-stent distally in the trachea and main stem bronchi without direct visualization of the airway.1Shirakawa T. Imamura F. Hamamoto J. Shirkakusa T. A case of successful airway stent placement guided by endobronchial ultrasonography.J Bronchol. 2004; 11: 45-48Crossref Scopus (7) Google Scholar Blind advancement of the stent increases the risk of injury of the tracheal or bronchial wall and perforation of the membranous part of the trachea during the stent placement. The risk of airway perforation is further increased when there is malignant involvement of the airway wall and destruction of the main carina. Furthermore, in the presence of tracheoesophageal or tracheomediastinal fistula, the blind placement of the stent may lead to inadvertent advancement through the fistula. With our modification of the classic technique, the stent is guided over the flexible scope into position. Also, the ability to withdraw the flexible bronchoscope and assess the distal end of the stent limit the blind advancement of the stent to the initial deposition in the proximal trachea. The decreased “blind time” may decrease the chance for mechanical complications. To our knowledge, no previous data on the frequency of mechanical complications during Y-stent placement exist, but in our series there were no cases of perforation, extraluminal placement, and airway wall injury other than trivial abrasion. Further, no damage to the flexible bronchoscope was seen from the advancement of the stent. The majority of patients who require Y-stent placement have poor respiratory reserve and extremely limited tolerance to hypoxia, which increases the procedure risk during the apnea time required for the Y-stent placement. Therefore, prompt placement of the stent and resumption of ventilation is of highest importance. The quick reintubation with the rigid tracheoscope (bronchoscope) after the stent deposition in the proximal trachea allows for secure airway with quick return of ventilation, and thus the apnea time is minimized compared with the classic techniques, in which the patient remains apneic until the stent is deposited in the distal trachea or proximal main stem bronchus. The mean procedural time in our series was 38 minutes, which compares well with the procedure time reported by Oki and Saka.9Oki M. Saka H. Double Y-stenting for tracheobronchial stenosis.Eur Respir J. 2012; 40: 1483-1488Crossref PubMed Scopus (17) Google Scholar In their case series, they described a mean procedure time of 55 minutes for the conventional Y-stent technique. Thus, the procedural time using the modified technique was 31% less than the their procedural time with the conventional technique. Our modification of the classic Y-stent insertion technique with Seldinger-like guidance over the flexible bronchoscope is safe, effective, expedient, and easy to master, and does not require new equipment. The advantages of this technique are visualization of the airway through most of the procedure, guided advancement of the stent, quick return of ventilation, and shorter procedural time.

Background. The objective was to evaluate whether endobronchial ultrasonography (EBUS) or endoscopic ultrasonography (EUS) staging techniques of the mediastinum for lung cancer can change the treatment plan compared with the "gold standard" of surgical staging.Methods. Patients were retrospectively identified from a prospectively collected database. Endoscopic staging was compared with the "gold standard" cervical mediastinoscopy (CM). In cases where mediastinoscopy was not performed, EBUS/EUS was compared with "ideal" CM, a virtual procedure, which was assumed to have 100% rates of sensitivity and specificity.Results. EBUS was performed in 324 patients (99%), EUS in 295 patients (90%), and CM in 101 patients (31%); 226 patients (69%) were assumed to have undergone a virtual ideal CM and a virtual surgical mediastinal staging; 108 positive biopsies (33.0%) with endosonography had sampling of targets that were out of the scope of CM. Distant metastatic disease was diagnosed by EBUS/EUS in 7 patients (2.1%); 22 patients (6.7%) had positive targets outside the reach of the CM or virtual CM. If the 14 patients who had positive stations 5, 6, 10, and 11 are excluded (accessible with anterior mediastinotomy or extended cervical mediastinoscopy), there were 6 patients (1.8%) in whom endosonography upstaged the patient over ideal surgical mediastinal staging. In 20 patients (6.1%), ultrasound-guided biopsy made the diagnoses, which changed the treatment plan over CM and ideal CM.Conclusions. Combined EBUS- and EUS-guided biopsies can access more targets, including lung and distant metastasis, and thus have the potential to upstage patients compared with mediastinoscopy and change the treatment plan. (C) 2016 by The Society of Thoracic Surgeons

From the Thoracic Surgery Department, Centre Hospitalier de L’Universit e de Montr eal, Montreal, Canada. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication March 20, 2015; revisions receivedMay 24, 2015; accepted for publication July 3, 2015; available ahead of print Aug 12, 2015. Address for reprints: Jordan Kazakov, MD, 11100 Euclid Ave, Cleveland, OH 44106 (E-mail: JordanKazakov@ gmail.com). J Thorac Cardiovasc Surg 2015;150:1005-9 0022-5223/$0.00 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.07.016

Background. The standard technique for pulmonary arterial (PA) branch sealing in video-assisted thoracoscopic surgery lobectomy consists of vascular endostaplers. We evaluated the immediate efficacy of an ultrasonic energy vessel-sealing device for sealing PA branches and compared it with the gold standard (endostapler) in an ex vivo model.Methods. This was a prospective cohort study. Immediately after anatomical lung resection, PA vessel sealing was achieved using the HARMONIC ACE+ Shears (ACE; Ethicon, Cincinnati, OH) sealing device or a vascular endostapler (VES) in a 3:1 ratio based on vessel diameter. The vessel was slowly pressurized, and the bursting pressure was recorded.Results. A total of 137 PA branches were sealed in specimens from 43 patients, of which 90 vessels were sealed with ACE and 47 were sealed with VES. The mean PA branch diameter was 6.0 mm (range, 1.7 mm to 24.0 mm; standard deviation, 3.1 mm Hg). The mean bursting pressure was 333.0 mm Hg (range, 84.0 mm Hg to 1415.1 mm Hg; standard deviation, 231.4 mm Hg) in the ACE group and 114.2 mm Hg (range, 0 mm Hg to 840.0 mm Hg; standard deviation, 124.7) in the VES group (p < 0.001). There were no complete sealing failures in the ACE group. Electron microscopy of ACE-sealed PA vessels demonstrated adventitial sealing with partial preservation of the collagen bundles and media with a sealed matrix of melted collagen.Conclusions. PA branches sealed using the HARMONIC ACE+ in a simulated ex vivo model were able to sustain high intraluminal pressures. ACE-sealed vessels burst at mean bursting pressures equal to or greater than the VES-stapled vessels. (C) 2015 by The Society of Thoracic Surgeons

Objective: Vascular endostaplers are bulky and can be dangerous when dividing small pulmonary arterial (PA) branch vessels during video-assisted thoracoscopic lobectomy. We aimed to evaluate and compare the immediate efficacy of modern energy sealing devices in an ex vivo PA sealing model.Methods: Patients undergoing anatomical lung resection or lung transplantation were recruited for a prospective cohort pilot study. Four devices were evaluated: Harmonic Ace (Ethicon, Cincinnati, Ohio), Thunderbeat (Olympus, Tokyo, Japan), LigaSure (Covidien, Boulder, Colo), and Enseal (Ethicon; Cincinnati, Ohio). After anatomical lung resection, the PA branches were dissected in vitro. Sealing was then performed with 1 of the sealing devices, the vessel was slowly pressurized, and the bursting pressure was recorded.Results: Forty-nine PA branches were sealed in 14 patients. The mean PA branch diameter was 7.4mm (1.8-14.5 mm). Ten patients had normal PA pressure and 3 had PA hypertension. The mean bursting pressure in each was as follows: Harmonic Ace group, 415.5mm Hg (137.1-1388.4mm Hg), Thunderbeat group, 875mm Hg (237.1-2871.3mm Hg); LigaSure group, 214.7 mm Hg (0-579.6 mm Hg); Enseal group, 133.7 mm Hg (0-315.38 mm Hg). There were 2 complete sealing failures: LigaSure (diameter 6.78 mm) and Enseal (diameter 8.3 mm).Conclusions: In this pilot study to examine energy sealing of PA branches in a simulated ex vivo model, vascular sealing using energy was effective and was able to sustain high intraluminal bursting pressures. Further research is needed to determine the in vivo and long-term safety of PA branch energy sealing.

BACKGROUND It is unclear whether endoscopic mediastinal lymph node (LN) staging techniques are equivalent to surgical mediastinal staging (SMS) techniques in patients with potentially operable non-small cell lung cancer (NSCLC). METHODS A total of 166 patients with confirmed or suspected NSCLC who required SMS based on current guidelines were enrolled in this prospective controlled trial comparing endosonographic mediastinal LN staging with SMS. Each patient served as his or her own control. All patients underwent endobronchial ultrasound (EBUS), endoscopic ultrasound (EUS), and SMS during a single procedure. Results of EBUS, EUS, and combined EBUS/EUS were compared with SMS (gold standard) and in patients with negative LN staging results, with LN sampling at pulmonary resection. RESULTS EBUS, EUS, combined EBUS/EUS, and SMS sampled a mean of 2.2, 1.7, 3.9, and 3.1 LN stations, respectively. The prevalence of mediastinal nodal disease (N2/N3) was 32% (53 of 166 patients). The sensitivity, negative predictive value, and diagnostic accuracy of the endoscopic staging modalities, respectively, were EBUS, 72% (95% CI, 0.58-0.83), 88% (0.81-0.93), and 91% (0.85-0.95); EUS, 62% (0.48-0.75), 85% (0.78-0.91), and 88% (0.82-0.92); and combined EBUS/EUS, 91% (0.79-0.97), 96% (0.90-0.99), and 97% (0.93-0.99). Endosonography was diagnostic for N2/N3/M1 disease in 24 patients in whom SMS findings were negative, preventing futile thoracotomy in an additional 14% of patients. CONCLUSIONS The combined EBUS/EUS procedure can replace surgical mediastinal staging in patients with potentially resectable NSCLC. Additionally, endosonography leads to improved staging compared with SMS because it allows the biopsy of LNs and metastases unattainable with SMS techniques. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01011595; URL: www.clinicaltrials.gov.

Background. Chest wall invasion in operable lung cancer upgrades the stage and can affect operative planning. Diagnosing chest wall invasion preoperatively is important in patient consent, in the choice of operative incision placement, and can be helpful in choosing an operative approach (open vs thoracoscopic). The objectives of this study were to determine the diagnostic accuracy of preoperative, surgeon-performed ultrasound (US) in assessing tumoral chest wall invasion (T3) in non-small cell lung cancer (NSCLC) patients and to compare its accuracy vs preoperative computed tomography (CT).Methods. This study was a prospective clinical trial (ClinicalTrials.gov: NCT01206894) that prospectively enrolled patients between September 2010 and January 2013. Eligible patients included those with NSCLC abutting the parietal pleura or invading the chest wall on preoperative CT scan of the chest and who were planned for surgical resection. Criteria for chest wall invasion on US included (1) disruption of the parietal pleura, (2) invasion of the ribs, or (3) impairment of pleural movement with respiration. The US chest wall examination was performed by the thoracic surgical team immediately before the surgical intervention. Sensitivity and specificity for CT scan and US in assessing chest wall invasion were calculated using definitive chest wall invasion on final pathologic analysis as the gold standard for chest wall invasion.Results. During a 28-month period, 28 patients (15 men and 13 women) patients were prospectively enrolled. Mean age was 62 +/- 11 years, and mean body mass index was 25.3 +/- 4.5 kg/m(2). The average time for surgeon-performed US assessment looking for chest wall invasion was 5.3 +/- 5 minutes. The sensitivity of US in evaluating chest wall invasion was 90.9% and the specificity was 85.7%. CT scan was associated with a sensitivity of 61.5% and a specificity of 84.6%. The positive and negative predictive values of surgeon-performed US for tumoral chest wall invasion were 83.3% and 92.3%, respectively, compared with 80% and 68.8% for CT scan.Conclusions. Surgeon-performed preoperative chest wall US can reliably diagnose tumoral chest wall invasion in patients with NSCLC. CT scan has poor sensitivity in predicting chest wall invasion preoperatively. Surgeon-performed US can be considered as a complementary adjunct to preoperative imaging in patients with pulmonary lesions abutting the chest wall to improve preoperative diagnosis, staging, and operative planning. (C) 2014 by The Society of Thoracic Surgeons

OBJECTIVESPreoperative evaluation of patients with suspected or confirmed lung cancer consists of clinical and radiological staging. Malignant pleural effusion is a poor prognosticator in non-small-cell lung cancer. Pleural ultrasound (PU) allows for the assessment of pleural effusion, providing real-time guidance for its aspiration and cytological analysis. Pleural Ultrasonography in Lung Cancer (PULC) as an adjunct to physical examination has the potential to improve preoperative staging of non-small-cell lung cancer during first surgical encounter by allowing the evaluation of previously unassessed pleural effusion.METHODSThis study consisted of a prospective trial of surgeon-performed PU in the preoperative evaluation of lung cancer patients. All patients evaluated in the thoracic surgery clinic with the new or presumed diagnosis of lung cancer were eligible. A portable ultrasound machine was used to evaluate pleural fluid in the bilateral costophrenic sulci with pleural fluid aspiration for cytological analysis.RESULTSForty-five patients were prospectively enrolled over a 3-month period. Thirteen patients had ultrasound evidence of a pleural effusion, of which 3 were significant enough for aspiration. Cytological analysis of these effusions yielded malignant cells in 1 patient. Positive PULC evaluation led to a change in clinical staging (M0 to M1a) in 10 patients and a change in pathological staging (pleural fluid cytology positive) in 1 patient. The time required for PULC examination was 15 ± 7 min. There were no complications related to the procedures.CONCLUSIONSPreoperative pleural ultrasonography is a rapid and effective way to improve precision of staging in patients with lung cancer. More precise staging may allow for more appropriate testing, patient prognostication and operative planning.

Background The gold standard for staging the local extension (T stage) and lymph node (LN) status (N stage) of esophageal cancer is endoscopic ultrasonography (EUS). When biopsy of the peritumoral LNs is performed using EUS, there is a risk of specimen contamination secondary to piercing the primary tumor; this shortcoming can be circumvented with endobronchial ultrasonography (EBUS). Moreover, EBUS allows for biopsy of LN stations not accessible with EUS. Methods The study consisted of a prospective clinical trial. Fifty-two consecutive patients with potentially resectable esophageal cancer referred for endoscopic staging were prospectively enrolled. Radial and convex EUS followed by convex EBUS were performed during a single staging procedure. The LNs not accessible by EUS were biopsied using EBUS. Results of the EBUS procedure were compared to those of EUS in terms of the addition of staging information, upstaging, and confirmation of stage. Results The combined EBUS-EUS procedure was performed in 42 patients. Ten patients were excluded. In all, 54 LNs were biopsied under EUS guidance and 48 LNs were biopsied under EBUS guidance. The EUS results were positive for metastatic esophageal cancer in 29 LNs (54%), and EBUS was positive in 10 LNs (21%). The addition of EBUS to EUS in the staging of esophageal cancer led to nodal and patient upstaging in 5 patients (12%) and confirmed the EUS stage with additional negative or positive LN sampling in 29 patients (69%). Positive EBUS that led to upstaging (5 patients) changed the treatment plan from potentially resectable to palliative. There was no morbidity related to EBUS. Conclusions A combined EBUS-EUS staging procedure improves precision in staging, leads to upstaging, and can change the treatment plan in patients with esophageal cancer.