Bryan S. Benn

Alveolar–pleural or broncho-pleural fistulas, leading to persistent air leaks (PALs), are associated with prolonged hospitalization and substantial morbidity. While guidelines advocate surgical repair as the primary treatment, its efficacy is limited. For patients recently subjected to thoracic surgery or those for whom surgery is contraindicated due to severe illness, viable treatment alternatives have been lacking. This article reviews the newer and less invasive treatment options for PALs. Further research is crucial, including randomized controlled trials comparing these options, and long-term monitoring of intervention outcomes is warranted.

Introduction: Lung cancer is a leading cause of cancer-related deaths globally, with approximately 1.5 million new peripheral pulmonary lesions (PPLs) detected annually in the United States. Robotic-assisted bronchoscopy (RAB) has emerged as a promising technology, with two platforms initially approved, the Monarch platform (Auris Health Inc, Redwood City, CA, USA) and the Ion Endoluminal System (Intuitive Surgical, Sunnyvale, CA, USA), offering improved stability and distal airway visualization. As RAB adoption increases, there is a critical need for comparative effectiveness data of these systems to guide clinical decision-making and institutional investments. This study aims to compare the diagnostic yield and safety profiles of the Ion and Monarch RAB platforms after introduction at a single institution. Methods: We conducted a retrospective chart review of patients undergoing RAB in the first six months following the introduction of each platform. Demographic and radiographic data were collected. Diagnostic yield was defined as obtaining a malignant or specific benign diagnosis from bronchoscopy. Results: The study included 56 Ion and 36 Monarch procedures. Diagnostic yield was similar between Ion (75%) and Monarch (72%) groups (p = 0.8), with an adjusted odds ratio 0.89 (95% CI 0.30–2.72). Complications were low, with one pneumothorax occurring in each group. Conclusions: Early adoption and use of both RAB platforms suggests comparable diagnostic yields and safety profiles in our limited sample size. Larger studies including standardized anesthesia protocol and systematic use of real-time imaging are needed for further evaluation and comparative analysis.

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Editorial | Surgery: Cardiothoracic Surgery Advances in diagnostic & therapeutic bronchoscopy Jonathan S. Kurman, Bryan S. Benn

With the increasing use of chest computed tomography (CT), more peripheral pulmonary lesions (PPLs) are being identified through lung cancer screening or incidental pathways. Once a PPL has been detected, guidelines exist to help determine the next best steps and decisions for management. While the majority of detected PPLs will be benign and require no further follow up or serial imaging, many will need a biopsy or surgical resection. Because subsolid or ground-glass lesions and PPLs located far away from the pleural surface are difficult to visualize or palpate, marking of PPLs may be employed to facilitate a surgical resection, which is an area of increasing interest with the renewed emphasis on minimally invasive, lung sparing surgeries. Numerous approaches to PPL localization exist, including utilization of metallic markers, dyes, targeted optical imaging agents, or a combination of these methods that can be deployed via percutaneous approach with CT guidance or through bronchoscopy. Each of these methods has both benefits and limitations. In this clinical practice review, we will provide a brief overview of the current landscape regarding preoperative marking of PPLs, providing a summary of localization techniques and available approaches by reviewing the current literature, and discuss some recent developments in the field that will continue to move this topic forward.

The use of transbronchial lung cryobiopsy (TBLC) in bronchoscopic procedures represents an area of considerable interest. Initially, cryobiopsy was limited to treatment of visible central airway obstructions. However, since its initial introduction for the evaluation of parenchymal abnormalities concerning for interstitial lung disease (ILD), numerous studies have shown the promise of this technique in the evaluation of ILD as well as other non-ILD lung diseases. Meta-analyses have shown that TBLC represents a reasonable alternative to surgical lung biopsy for the evaluation of ILD with a comparable diagnostic accuracy when results are presented in a multidisciplinary discussion with an improved safety profile. International society guidelines now recommend considering this approach for patients with ILD of unclear etiology, showing the value and utility of this biopsy technique. Consensus recommendations for performing TBLC with best clinical practices also exist to ensure the procedure is done safely and effectively. Evidence has also emerged for the role of TBLC in the evaluation of non-ILD parenchymal processes, including malignancy and other inflammatory or infectious processes, to both facilitate a diagnosis and establish a treatment plan. This review will highlight the available literature related to the use of TBLC for the evaluation of lung parenchymal abnormalities and discuss considerations for performing the procedure.

Purpose Determining the cause of interstitial lung disease (ILD) remains challenging. While surgical lung biopsy remains the gold standard approach, risks associated with it may be prohibitive. Transbronchial lung cryobiopsy (TBLC) is a minimally invasive alternative with an improved safety profile and acceptable diagnostic accuracy. We retrospectively assessed whether the use of Cone Beam computed tomography guidance for TBLC (TBLC-CBCT) improves safety and diagnostic yield compared to performing TBLC with fluoroscopic guidance (TBLC-F). Methods A retrospective cohort review of 120 patients presenting for evaluation of newly diagnosed ILD was performed. Demographic data, pulmonary function test values, chest imaging pattern, procedural information, and final multidisciplinary discussion (MDD) diagnosis were recorded. Results 62 patients underwent TBLC-F and 58 underwent TBLC-CBCT. Patients undergoing TBLC-CBCT were older (67.86 ± 10.97 vs 61.45 ± 12.77 years, p = 0.004) and had a higher forced vital capacity percent predicted (73.80 ± 17.32% vs 66.00 ± 17.45%, p = 0.03) compared to the TBLC-F group. The average probe-to-pleura distance was 5.1 ± 2.3 mm in the TBLC-CBCT group with 4.0 ± 0.3 CBCT spins performed. Pneumothorax occurred more often in the TBLC-F group (n = 6, 9.7%) compared to the TBLC-CBCT group (n = 1, 1.7%, p = 0.06). Grade 2 bleeding only occurred in the TBLC-F group (n = 4, 6.5%). A final MDD diagnosis was obtained in 89% (n = 57) of TBLC-F patients and 95% (n = 57) of TBLC-CBCT patients. Conclusions TBLC-CBCT appears to be safer compared to TBLC-F with both approaches facilitating an MDD diagnosis. Further studies from multiple institutions randomizing patients to each modality are needed to confirm these findings.