Uncertainty analysis of chest X-ray lung height measurements and size matching for lung transplantation

Lung transplantation; Chest X-ray; PrecisionTrasplante de pulmón; Radiografía de tórax; PrecisiónTrasplantament de pulmó; Radiografia de tòrax; PrecisióBackground: Errors in measuring chest X-ray (CXR) lung heights could contribute to the occurrence of size-mismatched lung transplant procedures. Methods: We first used Bland-Altman analysis for repeated measures to evaluate contributors to measurement error of chest X-ray lung height. We then applied error propagation theory to assess the impact of measurement error on size matching for lung transplantation. Results: A total 387 chest X-rays from twenty-five donors and twenty-five recipients were measured by two raters. Individual standard deviation for lung height differences were independent of age, sex, donor vs. recipient, diagnostic group and race/ethnicity and all were pooled for analysis. Bias between raters was 0.27 cm (±0.03) and 0.22 cm (±0.06) for the right and left lung respectively. Within subject variability was the biggest contributor to error in measurement, 2.76 cm (±0.06) and 2.78 cm (±0.2) for the right and left lung height. A height difference of 4.4 cm or more (95% CI: ±4.2, ±4.6 cm) between the donor and the recipient right lung height has to be accepted to ensure matching for at least 95% of patients with the same true lung height. This difference decreases to ±1.1 cm (95% CI: ±0.9, ±1.3 cm) when the average from all available chest X-rays is used. The probability of matching a donor and a recipient decreases with increasing true lung height difference. Conclusions: Individual chest X-ray lung heights are imprecise for the purpose of size matching in lung transplantation. Averaging chest X-rays lung heights reduced uncertainty.This research was supported by the Washington University Institute of Clinical and Translational Sciences Grant UL1TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official view of the NIH

Advances in robotic lung transplantation: development and validation of a new surgical technique in animal models

Lung transplantation; Minimally invasive; Robotic surgeryTrasplantament de pulmó; Mínimament invasiu; Cirurgia robòticaTrasplante de pulmón; Mínimamente invasiva; Cirugía robóticaThe objective of this study was to describe a novel minimally invasive robotic video-assisted approach for lung transplantation, utilizing a minimally invasive technique with a subxiphoid incision, in an animal experimentation model. Two left robotic-assisted single lung transplants were performed in sheep using a robotic surgical system. A subxiphoid incision was made, and robotic ports were inserted into the thoracic cavity for dissection and anastomoses of the bronchus, artery, and pulmonary veins. The integrity of anastomoses was evaluated, and procedural details were recorded. Both animals survived the procedure, with a mean duration of 255 min and a mean console time of 201 min. Anastomoses were performed without complications, and the closed-chest approach with a subxiphoid incision proved successful in preventing gas leakage. The novel approach demonstrated improved exposure and workflow compared to existing techniques. The minimally invasive robotic video-assisted approach for lung transplantation utilizing a closed-chest technique with a subxiphoid incision appears safe and feasible in an animal experimentation model. Further studies in the clinical setting are warranted to establish its feasibility and safety in human lung transplantation. This approach has the potential to offer benefits over the traditional Clamshell incision in lung transplantation procedures

Case Report: Successful Lung Transplantation from a Donor Seropositive for Trypanosoma cruzi Infection (Chagas Disease) to a Seronegative Recipient

Lung transplantation; Seropositive donor; Trypanosoma cruziTrasplantament de pulmó; Donant seropositiu; Trypanosoma cruziTrasplante de pulmón; Donante seropositivo; Trypanosoma cruziThe increasing shortage of organs for transplantation has prompted transplant programs to investigate the use of extended criteria donors, such as those with transmissible infectious diseases. Successful cases of organ transplantation (mostly kidney and liver) from Trypanosoma cruzi seropositive donors to seronegative recipients have been reported. We present a case of lung transplantation from a donor serologically positive for Chagas disease to a seronegative recipient, and provide a review of the literature. Left single lung transplantation was performed in a 44-year-old Spanish woman presenting with interstitial lung disease in February 2016. The deceased donor was a Colombian immigrant living in Spain who was serologically positive for Chagas disease. Oral administration of 5 mg/kg/day benznidazole divided in three doses for 60 days was given for specific Chagas disease prophylaxis after transplantation. Periodic follow-up with serological reverse transcription polymerase chain reaction to detect T. cruzi DNA were performed until 6 months after the end of treatment. All results were negative, indicating that transmission of T. cruzi had not occurred. In a review of the literature, two similar cases were identified in Argentina and the United States. In both cases T. cruzi infection was detected posttransplant in the recipients, after which they were treated with benznidazole. The course of the patient described herein confirms that lungs from donors with chronic T. cruzi infection can be used successfully as allografts, and that posttransplant prophylaxis with benznidazole may reduce the probability of transmission of T. cruzi to the recipient

Riesgo quirúrgico tras resección pulmonar anatómica en cirugía torácica. Modelo predictivo a partir de una base de datos nacional multicéntrica

Introduction: the aim of this study was to develop a surgical risk prediction model in patients undergoing anatomic lung resections from the registry of the Spanish Video-Assisted Thoracic Surgery Group (GEVATS). Methods: data were collected from 3,533 patients undergoing anatomic lung resection for any diagnosis between December 20, 2016 and March 20, 2018. We defined a combined outcome variable: death or Clavien Dindo grade IV complication at 90 days after surgery. Univariate and multivariate analyses were performed by logistic regression. Internal validation of the model was performed using resampling techniques. Results: the incidence of the outcome variable was 4.29% (95% CI 3.6-4.9). The variables remaining in the final logistic model were: age, sex, previous lung cancer resection, dyspnea (mMRC), right pneumonectomy, and ppo DLCO. The performance parameters of the model adjusted by resampling were: C-statistic 0.712 (95% CI 0.648-0.750), Brier score 0.042 and bootstrap shrinkage 0.854. Conclusions: the risk prediction model obtained from the GEVATS database is a simple, valid, and reliable model that is a useful tool for establishing the risk of a patient undergoing anatomic lung resection

Grupo español de cirugía torácica asistida por videoimagen: método, auditoría y resultados iniciales de una cohorte nacional prospectiva de pacientes tratados con resecciones anatómicas del pulmón

Introduction: our study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS). Methods: we conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for '90-day mortality' and 'Grade IIIb-V complications'. Results: the series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres' median recruitment rate was 99% (25-75th:76-100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95-100% rates as reference): grade IIIb-V OR=0.61 (p=0.081), 90-day mortality OR=0.46 (p=0.051). Conclusions: more than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort

El trasplante pulmonar en la fibrosis quística y la influencia de la circulación extracorpórea

Introducción: La enfermedad pulmonar es la principal causa de mortalidad en el 80% de los pacientes con fibrosis quística (FQ). La influencia de la circulación extracorpórea no está completamente establecida. Objetivos: Evaluar la supervivencia de los pacientes con FQ sometidos a Trasplante Pulmonar (TP) en nuestro centro y las variables que pueden influir en la mortalidad. Valorar el impacto que tiene la Circulación Extracorpórea (CEC) sobre la morbimortalidad peroperatoria y los resultados a largo plazo del TP por FQ en nuestro medio. Identificar los factores que podrían influir en la utilización de la CEC en este grupo de pacientes sometidos a TP por FQ. Métodos: Estudio observacional retrospectivo de todos los pacientes afectos de FQ trasplantados en un solo centro entre 1992 y 2011. En este período se han realizado 64 trasplantes pulmonares por FQ. Resultados: La supervivencia de los pacientes trasplantados a los 5 y 10 años fue del 56,7 % y 41,3% respectivamente. El requerimiento de oxígeno suplementario previo al trasplante no parece afectar la supervivencia (p = 0,44) al igual que los pacientes que se trasplantaron con ventilación mecánica no invasiva (p = 0,63). La supervivencia a los 5 y 10 años para los pacientes que no se trasplantan con CEC es del 75,69 % y 49,06 % respectivamente, mientras que los que se trasplantan bajo CEC tienen un supervivencia a los 5 y 10 años del 34,14 % y 29,87 % respectivamente ( p = 0,001). La PaCO2 es un factor de riesgo independiente para la necesidad de CEC. Conclusiones: Los pacientes con FQ trasplantados pulmonares en nuestro centro tienen supervivencia similares a la descrita por los registros internacionales. Los pacientes trasplantados bajo CEC tienen una menor supervivencia. La PaCO2 es factor de riesgo de necesidad de CEC durante el TP.Introduction: Lung disease is the main cause of mortality in 80% of patients with cystic fibrosis (CF). The influence of extracorporeal circulation (EC) is not fully established. Objectives: To evaluate the survival of CF patients undergoing Pulmonary Transplantation (PT) in our center and the variables that may influence mortality. To assess the impact of EC on perioperative morbidity and mortality and the long-term results of PT for CF in our environment. To identify the factors that could influence the use of EC in this group of patients undergoing PT for CF. Methods: A retrospective observational study of all CF patients transplanted in a single center between 1992 and 2011. During this period, 64 lung transplants were performed for CF. Results: The survival of the transplanted patients at 5 and 10 years was 56.7% and 41.3% respectively. The requirement for supplemental oxygen prior to transplantation does not seem to affect survival (p = 0.44) nor patients who underwent transplant with non-invasive mechanical ventilation (p = 0.63). Survival at 5 and 10 years for patients not transplanted with EC is 75.69% and 49.06% respectively, while those who are transplanted under EC have a survival at 5 and 10 years of 34,14% and 29.87% respectively (p = 0.001). PaCO2 is an independent risk factor for the need of EC. Conclusions: Patients with who underwent PT for CF in our center have similar survival rates to that described by international registries. Patients transplanted under CC have a lower survival. PaCO2 is a risk factor for the need of EC during PT

El Trasplante pulmonar en la fibrosis quística y la influencia de la circulación extracorpórea /

Introducción: La enfermedad pulmonar es la principal causa de mortalidad en el 80% de los pacientes con fibrosis quística (FQ). La influencia de la circulación extracorpórea no está completamente establecida. Objetivos: Evaluar la supervivencia de los pacientes con FQ sometidos a Trasplante Pulmonar (TP) en nuestro centro y las variables que pueden influir en la mortalidad. Valorar el impacto que tiene la Circulación Extracorpórea (CEC) sobre la morbimortalidad peroperatoria y los resultados a largo plazo del TP por FQ en nuestro medio. Identificar los factores que podrían influir en la utilización de la CEC en este grupo de pacientes sometidos a TP por FQ. Métodos: Estudio observacional retrospectivo de todos los pacientes afectos de FQ trasplantados en un solo centro entre 1992 y 2011. En este período se han realizado 64 trasplantes pulmonares por FQ. Resultados: La supervivencia de los pacientes trasplantados a los 5 y 10 años fue del 56,7 % y 41,3% respectivamente. El requerimiento de oxígeno suplementario previo al trasplante no parece afectar la supervivencia (p = 0,44) al igual que los pacientes que se trasplantaron con ventilación mecánica no invasiva (p = 0,63). La supervivencia a los 5 y 10 años para los pacientes que no se trasplantan con CEC es del 75,69 % y 49,06 % respectivamente, mientras que los que se trasplantan bajo CEC tienen un supervivencia a los 5 y 10 años del 34,14 % y 29,87 % respectivamente ( p = 0,001). La PaCO2 es un factor de riesgo independiente para la necesidad de CEC. Conclusiones: Los pacientes con FQ trasplantados pulmonares en nuestro centro tienen supervivencia similares a la descrita por los registros internacionales. Los pacientes trasplantados bajo CEC tienen una menor supervivencia. La PaCO2 es factor de riesgo de necesidad de CEC durante el TP.Introduction: Lung disease is the main cause of mortality in 80% of patients with cystic fibrosis (CF). The influence of extracorporeal circulation (EC) is not fully established. Objectives: To evaluate the survival of CF patients undergoing Pulmonary Transplantation (PT) in our center and the variables that may influence mortality. To assess the impact of EC on perioperative morbidity and mortality and the long-term results of PT for CF in our environment. To identify the factors that could influence the use of EC in this group of patients undergoing PT for CF. Methods: A retrospective observational study of all CF patients transplanted in a single center between 1992 and 2011. During this period, 64 lung transplants were performed for CF. Results: The survival of the transplanted patients at 5 and 10 years was 56.7% and 41.3% respectively. The requirement for supplemental oxygen prior to transplantation does not seem to affect survival (p = 0.44) nor patients who underwent transplant with non-invasive mechanical ventilation (p = 0.63). Survival at 5 and 10 years for patients not transplanted with EC is 75.69% and 49.06% respectively, while those who are transplanted under EC have a survival at 5 and 10 years of 34,14% and 29.87% respectively (p = 0.001). PaCO2 is an independent risk factor for the need of EC. Conclusions: Patients with who underwent PT for CF in our center have similar survival rates to that described by international registries. Patients transplanted under CC have a lower survival. PaCO2 is a risk factor for the need of EC during PT

Uncertainty analysis of chest X-ray lung height measurements and size matching for lung transplantation

Background: Errors in measuring chest X-ray (CXR) lung heights could contribute to the occurrence of size-mismatched lung transplant procedures. Methods: We first used Bland-Altman analysis for repeated measures to evaluate contributors to measurement error of chest X-ray lung height. We then applied error propagation theory to assess the impact of measurement error on size matching for lung transplantation. Results: A total 387 chest X-rays from twenty-five donors and twenty-five recipients were measured by two raters. Individual standard deviation for lung height differences were independent of age, sex, donor Conclusions: Individual chest X-ray lung heights are imprecise for the purpose of size matching in lung transplantation. Averaging chest X-rays lung heights reduced uncertainty

Resultados de la estadificación clínica ganglionar mediastínica del cáncer pulmonar quirúrgico: datos de la cohorte prospectiva nacional del Grupo Español de Cirugía Torácica Videoasistida

Introducción: El objetivo del estudio es valorar el rendimiento diagnóstico de la tomografía computarizada (TC) y la tomografía por emisión de positrones (PET) en la estadificación clínica mediastínica del cáncer pulmonar quirúrgico según los datos de la cohorte prospectiva del Grupo Español de Cirugía Torácica Videoasistida (GEVATS). Métodos: Se han analizado 2.782 pacientes intervenidos por carcinoma pulmonar primario. Se ha estudiado el acierto diagnóstico en la estadificación mediastínica (cN2). Se ha realizado un análisis bivariante y multivariante de los factores que influyen en el acierto. Se ha estudiado el riesgo de pN2 inesperado en los factores con los que se recomienda una prueba invasiva de estadificación: cN1, tumor central o tamaño mayor de 3cm. Resultados: El acierto global de la TC y PET en conjunto es del 82,9% con VPP y VPN de 0,21 y 0,93. En tumores mayores de 3cm y a mayor SUVmax del mediastino, el acierto es menor, OR de 0,59 (0,44 - 0,79) y 0,71 (0,66 - 0,75), respectivamente. En el abordaje VATS el acierto es mayor, OR de 2,04 (1,52 - 2,73). El riesgo de pN2 inesperado aumenta con el número de los factores cN1, tumor central o tamaño mayor de 3cm: entre el 4,5% (0 factores) y 18,8% (3 factores), pero no hay diferencias significativas con la realización de prueba invasiva. Conclusiones: La TC y PET en conjunto tienen un elevado valor predictivo negativo. Su acierto global es menor en tumores mayores de 3cm y SUVmax del mediastino elevado, y mayor en el abordaje VATS. El riesgo de pN2 inesperado es mayor si cN1, tumor central o mayor de 3cm y no varía significativamente con prueba invasiva