Yang Bai

Background: Congenital aerodigestive fistulae (ADF) represent extremely rare developmental malformations derived from disrupted embryological separation of the primitive foregut, which can be classified by lesion location into tracheoesophageal fistulae, bronchoesophageal fistulae (BEF), and other subtypes. While typically diagnosed in neonates, isolated BEF without esophageal atresia (“H-type”) may remain undetected for decades, presenting in adulthood with chronic, stereotyped symptoms. Endoscopic interventions for congenital BEF remain poorly characterized, with limited evidence regarding patient selection and technique optimization. Case presentation: A 58-year-old man presented with a 40-year history of persistent, swallowing-induced cough, accompanied by expectoration of white mucoid sputum. Initial chest computed tomography at an outside hospital identified a left lower lobe mass suspicious of lung cancer complicated by obstructive pneumonia. Bronchoscopy confirmed an esophageal–left main bronchial fistula, and endobronchial ultrasound-guided biopsy demonstrated acute and chronic inflammation with fibrous hyperplasia. Repeat imaging at our institution demonstrated a direct, upward fistulous tract between the mid-esophagus and left main bronchus, consistent with Braimbridge and Keith Type II congenital BEF. A multidisciplinary consensus deemed surgical repair high-risk with uncertain efficacy, and the patient declined operative intervention. Combined bronchoscopy and esophagoscopy under general anesthesia confirmed a 2-mm fistula orifice 2 cm below the left main carina. The fistula was successfully closed using argon plasma coagulation-mediated de-epithelialization followed by over-the-scope clip (OTSC) deployment, with immediate resolution of swallowing-induced cough. At the 10-month follow-up, esophagography showed no contrast extravasation, computed tomography confirmed no persistent fistulous communication, and esophagoscopy demonstrated granulation tissue with white scarring and no identifiable fistula orifice. Conclusion: This case illustrates the potential for extraordinarily delayed presentation of congenital BEF in adulthood and highlights the importance of maintaining a high index of suspicion for this rare anomaly in patients with chronic, liquid-induced paroxysmal cough. Combined endoscopic de-epithelialization and OTSC closure appears to be an effective, minimally invasive alternative to surgical repair in eligible patients with congenital BEF. More clinical studies are warranted to develop consensus-based guidelines for the management of benign ADF.

Appendicolith is an independent risk factor for treatment failure with antibiotics alone in nonoperative management (NOM) of uncomplicated acute appendicitis (UAA). Endoscopic retrograde appendicitis therapy (ERAT) can relieve appendicolith-induced luminal obstruction, representing a promising NOM for this high-risk subgroup. This study evaluated the efficacy and safety of ERAT plus antibiotics in treating UAA with appendicolith. This multicenter retrospective cohort study included 11 tertiary hospitals across 4 Chinese provinces. From August 2021 to July 2023, UAA patients with imaging-confirmed appendicoliths receiving ERAT plus antibiotics or antibiotics alone as initial NOM were screened. After exclusion and propensity score matching (1:1), 139 well-balanced pairs were collected. The primary outcome was initial treatment success (successful completion of initial treatment, discharge without alternative treatment). Secondary outcomes included length of initial hospital stay, appendicitis recurrence within 1-year follow-up, recurrence time, and incidence of overall adverse events. ERAT plus antibiotics achieved a significantly higher initial treatment success rate (95.7% vs. 78.4%; P<0.001) and lower 1-year recurrence rate (14.3% vs. 43.1%; P<0.001) than antibiotics alone. The ERAT plus antibiotics group had a longer median (interquartile range) recurrence time (279 [155, 328] vs. 32 [22, 88] days; P<0.001) and shorter median initial hospital stay (3 [3, 5] vs. 4 [3, 5] days; P<0.001). Adverse event rates were low and comparable (2.2% vs. 4.3%; P = 0.50). Findings support ERAT plus antibiotics as the preferred initial NOM strategy in UAA patients with appendicoliths compared with antibiotics alone.

Background: Malignant tracheoesophageal fistula (mTEF) is a life-threatening complication of esophageal and lung cancers, often presenting significant management challenges, especially in post-radiotherapy patients with anatomical airway distortion. This case report describes a feasible modified approach for closing a cervical mTEF with anatomical airway distortion that precludes laryngeal mask airway (LMA) placement or rigid bronchoscopy. This approach utilizes thin bronchoscope-parallel, endotracheal tube (ETT)-guided stent deployment, without the need for fluoroscopy. Case presentation: A 79-year-old male with a 5-year history of stage IIIB (T3N1M0) thoracic esophageal squamous carcinoma (post-definitive chemoradiation and pembrolizumab immunotherapy with complete response) presented with 20 days of swallowing-induced immediate cough (Ono’s sign), purulent yellow sputum (30 mL/day), exertional dyspnea (New York Heart Association Class II), and subsequent fever. Diagnostic workup confirmed a cervical mTEF 5 cm below the glottis, with post-radiation airway stiffness precluding LMA placement or rigid bronchoscopy. Under general anesthesia, a 7.5-mm cuffed ETT was positioned 1 cm above the fistula under direct bronchoscopic visualization with real-time distance measurement, and a 3.8-mm thin bronchoscope was inserted in parallel to provide real-time visualization for the stent deployment. An 18-Fr delivery system with a 20 mm (diameter) × 40 mm (length) partially covered Ultraflex metallic stent was deployed via the ETT, achieving immediate and complete mTEF closure. Anesthesia was maintained with propofol-remifentanil infusion and volume-controlled ventilation (tidal volume 6 mL/kg, respiratory rate 16/min, fraction of inspired oxygen 50–60%) with continuous oxygen saturation and end-tidal carbon dioxide monitoring. The patient was extubated promptly, transitioned to oral feeding, and remained aspiration-free for 3 months with no complications. He developed recurrent coughing at 3 months post-procedure and died after declining further treatment. Conclusion: This single-stage, fluoroscopy-free ETT-parallel thin bronchoscope approach demonstrates preliminary feasibility and short-term safety for high cervical mTEF in post-radiotherapy patients with anatomical airway distortion where LMA or rigid bronchoscopy is unfeasible. Individualized airway management, precise stent selection, and multidisciplinary collaboration are critical for optimizing symptom control, and this approach might serve as a practical short-term palliative alternative in resource-limited settings. These findings are hypothesis-generating and require validation in larger studies.

Objective: Airway foreign body (AFB) in adults remains a potentially life-threatening emergency, which lacks standardized clinical pathways of management. This review aims to synthesize current evidence on the clinical recognition, imaging work-up, and bronchoscopic management of AFB in adults and to propose a practical, stepwise algorithm, enabling interventional pulmonologists to establish a systematic retrieval framework as early as possible and thereby optimize care for adult patients. Methods: A narrative review was conducted by searching PubMed for studies focusing on the bronchoscopic management of AFB in adults. The emphasis is on the tool selection, critical techniques, and procedural nuances for AFB retrieval. Personal clinical experience also informed the interpretation and contextualization. Results: Adult AFB typically presents with chronic cough, dyspnea, wheeze, or recurrent post-obstructive pneumonia. Computed tomography (CT) is the first-line imaging modality (pooled sensitivity 98.8%, specificity 96.6%), but radiolucent organic material may yield false-negative results; therefore, high clinical suspicion warrants direct bronchoscopy. The right main bronchus is the most common site because of its anatomical features. Pre-intervention planning matches AFB characteristics (site, size & shape, and substance) with patient status to decide between rigid and flexible scopes and to select retrieval accessories. Flexible bronchoscopy under general anesthesia via laryngeal mask airway achieves > 90% success in adults, which is preferred for peripheral items, whereas rigid bronchoscopy remains the gold standard for large, sharp, or proximal AFBs. Tool choice follows an object-specific strategy: forceps for metal/bone, snare for bulky, irregular items, basket for smooth, round seeds, balloon for impacted distal AFBs after dilation, and cryoprobe for semisolid, water-rich material (blood clot, mucus plug, food). Complication rates are lowest when dislodgement and extraction are performed as a single, controlled maneuver under continuous visualization; hybrid rigid–flexible approaches further improve safety. Conclusions: Consider AFB in adults with unexplained chronic respiratory symptoms. CT guides but does not replace bronchoscopy. An individualized strategy—flexible scope first (in patients with stable status), rigid scope reserved for selected complex cases—combined with object-tailored tools optimizes successful AFB retrieval while minimizing morbidity. Maintaining both rigid and flexible systems, trained multidisciplinary teams, and strict manometric monitoring are essential components of AFB retrieval.

Background: Foreign body aspiration is a recognized clinical emergency, but chili pepper fragment inhalation remains an under-recognized etiology, particularly in elderly populations. This study aims to clarify the clinical and radiological characteristics, diagnostic challenges, and bronchoscopic management of such cases. Methods: We report two cases of elderly patients with subacute respiratory symptoms initially indicative of obstructive pneumonia or neoplasia. Both underwent extensive evaluation, including serial computed tomography (CT) and bronchoscopy. Results: In both cases, high-resolution CT scans demonstrated hyperdense, V-shaped, or annular opacities within bronchial structures (best visualized with mediastinal window settings) that were suggestive of an inhaled foreign body. Prominent indirect indicators included localized bronchial wall thickening, luminal narrowing, and post-obstructive parenchymal changes. Flexible bronchoscopy identified chili pepper fragments obstructing the distal airways. Cryoextraction successfully removed specimens intact without fragmentation. Follow-up revealed residual bronchiectasis but significant symptomatic improvement. Conclusion: Chili pepper fragment inhalation may be considered in cases of unexplained pneumonia, particularly in elderly populations or those with dietary habits involving small, sharp food items. CT imaging of hyperdense, V-shaped, or annular opacities within bronchial structures might provide valuable diagnostic clues, though radiographic findings may be subtle and non-pathognomonic. Bronchoscopy remains a key diagnostic and therapeutic modality, with cryoextraction demonstrating efficacy for extraction. Increased clinical awareness and prompt intervention are essential to prevent complications.

Rationale: Complex post-tracheostomy tracheal stenosis (PTTS), characterized by cartilage destruction and tracheomalacia, is a severe, rare complication in burn patients. Concomitant severe postburn neck contractures impair airway access, rendering conventional treatments (e.g., tracheal resection and endoscopic interventions) challenging and necessitating multidisciplinary strategies. Patient concerns: A 49-year-old male with a 2-year history of banana oil-induced burns presented with exertional dyspnea (modified Medical Research Council Grade 3). He had failed prior endoscopic interventions and refused surgical tracheal resection. Severe neck contractures limited mobility and airway access. Diagnoses: Complex PTTS (Cotton-Myer Grade III, 6-mm luminal narrowing, cartilage destruction, and tracheomalacia) confirmed via computed tomography and bronchoscopy; severe postburn neck contracture (microstomia, fixed flexion deformity) on physical exam. Interventions: A two-stage multidisciplinary approach was implemented: neck contracture release with a pre-expanded 18 × 10 cm supraclavicular artery perforator flap; rigid bronchoscopy-guided placement of a 10 × 50 mm hourglass-shaped silicone stent. Outcomes: Postoperatively, the patient regained normal mastication, phonation, and respiration by the fourth week. At the 4-year follow-up, he maintained tracheal patency (modified Medical Research Council Grade 1), had restored neck function, and experienced no stent complications. He declined further surveillance. Lessons: Multidisciplinary collaboration is critical for managing complex PTTS with severe postburn neck contractures in patients unsuitable for surgery. Pre-expanded supraclavicular flaps enable safe airway interventions, while hourglass stents effectively maintain patency. Prospective studies are needed to standardize such protocols.

Background: Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma is a rare extranodal B-cell lymphoma, representing the most common primary pulmonary lymphoma (< 0.5% of all lung malignancies). Diagnosis is difficult because of its nonspecific clinical and radiological characteristics, which often resemble infections, inflammatory diseases, or other malignancies. Typical imaging findings include nodules, consolidations, or, less frequently, interstitial patterns such as ground-glass opacities. A conclusive diagnosis requires histological examination, augmented by immunohistochemistry and molecular investigations, to confirm clonality. Conventional biopsies may yield inconclusive outcomes due to small sample size and delicate cytologic atypia. Case presentation: A 36-year-old non-smoking Asian female with no history of pulmonary tuberculosis, malignancies, or autoimmune disorders was incidentally found to have patchy opacities in the left lower lobe on routine chest radiography in January 2024. She remained asymptomatic over the 18-month disease progression period, lacking respiratory or systemic symptoms, whereas follow-up imaging indicated progression to bilateral, multifocal flocculent opacities. Initial investigations, including transbronchial forceps biopsy and bronchoalveolar lavage fluid analysis through next-generation sequencing, reported only non-specific chronic inflammation and no pathogens. Empirical treatment with moxifloxacin (400 mg daily for 14 days), targeting common pathogens of community-acquired pneumonia, yielded no improvement. A definitive diagnosis was achieved by endobronchial ultrasound-guided transbronchial cryobiopsy (EBUS-TBCB), which produced larger, well-preserved tissue specimens. Histopathological and immunohistochemical examination indicated a dense, angiocentric infiltration of CD20-positive B cells, accompanied by monoclonal rearrangement of immunoglobulin genes, confirming extranodal marginal zone lymphoma of the MALT type. Staging with ⁶⁸ Ga-CXCR4 positron emission tomography (PET)/computed tomography (CT) demonstrated hypermetabolism in bilateral pulmonary opacities and multiple nodal stations, indicative of stage IV disease. Considering the asymptomatic status and excellent performance status, active surveillance was recommended in this patient. Conclusion: This case illustrates the important role of advanced biopsy techniques, such as EBUS-TBCB, in acquiring sufficient tissue for diagnosing pulmonary MALT lymphoma when conventional methods fail. It further underscores the ⁶⁸ Ga-CXCR4-targeted PET/CT for precise staging. Despite the advanced stage, the indolent nature of MALT lymphoma often allows for a plan of active surveillance in selected asymptomatic patients, emphasizing the crucial role of a multidisciplinary, risk-adapted strategy.

INTRODUCTION: Visual endoscopic retrograde appendicitis therapy (V-ERAT) involves a single-use video scope, allowing for real-time visualization of the appendiceal lumen during the procedure to treat uncomplicated acute appendicitis (AA). This study aims to compare V-ERAT to antibiotic therapy in treating uncomplicated AA. METHODS: This multicenter, retrospective cohort study was conducted at 9 hospitals in China from August 2021 to July 2023. Propensity score matching was performed to minimize selection bias. A total of 692 uncomplicated AA patients were included, with 188 undergoing V-ERAT and 504 receiving antibiotic therapy. The primary outcome was treatment success rate. The secondary outcomes included recurrent appendicitis rate, the appendectomy rate during the initial hospitalization, length of initial hospitalization, time to disease recurrence, and overall adverse events. RESULTS: The treatment success rate did not differ between the V-ERAT and antibiotic groups (93.6%; 95% confidence interval [CI] 89.1%–96.7% vs 90.5%; 95% CI, 87.6%–92.9%) ( P = 0.225). However, V-ERAT demonstrated a significantly lower risk of appendicitis recurrence compared with antibiotic therapy during the follow-up (log-rank P < 0.001), with a hazard ratio of 0.14 (95% CI, 0.07–0.29, P < 0.001). V-ERAT was associated with a lower appendectomy rate during the initial hospitalization (4.3%; 95% CI, 1.9%–8.2% vs 9.5%; 95% CI, 7.1%–12.4%) ( P = 0.027), a shorter length of initial hospitalization (3 [interquartile range (IQR), 3–4] vs 4 [IQR, 4–6] days, P < 0.001), and a longer time to recurrence (269 [IQR, 210–318] vs 70 [IQR, 21–103] days, P < 0.001). The overall adverse event rates did not differ between the 2 groups (log-rank P = 0.064). DISCUSSION: V-ERAT seems to be a safe and effective alternative to antibiotic therapy in treating uncomplicated AA, significantly reducing the risk of appendicitis recurrence.