WABIP Newsletter 2018, Issue 1

Volume 06

Issue 01

January 2018

Inside This Issue

Opinion/Editorial, 2

Technology Corner, 3,4

Tips from the Experts, 5,6,7,8,9

Humanitarian News, 10,11

Educaon and Training, 12

BOR News, 13

Research, 14

WABIP Academy Webcasts, 15

Links, 15

Upcoming Events, 16

in thoracic surgery, emergencies in inter-

venonal pulmonology). For each IP

procedure we have included: prior expe-

rience requirements, knowledge, core

basic skills, a check list for procedural

steps for praccal training, resources for

hands-on praccal training and tools for

quantave, qualitave and outcomes

assessment. The whole document is

published in full on the European Associ-

aon for Bronchology and Intervenonal

Pulmonology (EABIP) website. It should

be considered a starng point that will

evolve over me. These standards need

to be reviewed and approved by naon-

al and Internaonal Scienc Sociees

and Healthcare Instuons: the goal is

to improve, disseminate and incorporate

them in healthcare programs. In conclu-

sion, there is a great need for a road

map leading to European standardiza-

on in IP, hopefully a task group funded

by the ERS/EABIP to come up with a

soluon applicable across Europe, so as

to develop an ocial cercaon recog-

nized in the EC (and in post-Brexit UK),

as we have for Specialty Fellowships.

References

1. Lamb CR et al. Chest. 2010; 137: 195-

2. Mullon JJ et al. Chest. 2017; 151(5):

1114-21

3. Loddenkemper R et al. Breathe.

2006; 3: 59–70

4. Farr A et al. Breathe. 2016; 12(3):217-

5. Corbea L et al. Report of the Con-

sensus Conference on Training and

Competence Standards for the Inter-

venonal Pulmonology Master Program

in Italy: www.eabip.org/training

Division of Intervenonal Pulmonology,

Careggi Hospital, University of Florence,

Director of the Training Program and Master

in Intervenonal Pulmonology, Florence

Intervenonal Pulmonology (IP) is experi-

encing a rapid evoluon of new technol-

ogies. Several internaonal projects are

developing standardized training pro-

grams, capable of establishing an Ultra-

Specialty discipline (beyond pulmonary

and crical care fellowships, to be orga-

nized jointly with volume expert centres)

with validated metrics for trainee compe-

tency assessment.

A gradual progression

from theory to pracce is envisaged,

using new teaching techniques, including

live sessions, low and high delity simula-

on, non-technical skill training, ipped

classroom models and problem-based

learning (PBL) exercises – to ensure that

trainees’ skills are enhanced and updat-

ed. Europe has a long tradion in IP, with

e.g. Dumon and Cavaliere in rigid bron-

choscopy, Jacobaeus and Boun for tho-

racoscopy, Becker in EBUS: their schools

are sll the centers of excellence for

training in Europe. While the United

States has developed adequate training

standards and oers over 30 IP Fellow-

ships,

in Europe training program stand-

ardizaon is patchy. The European Res-

piratory Society (ERS) organizes since

2006 an annual board cercaon in

Pneumology, the “Hermes project”, to

standardize training within dierent dis-

ciplines of respiratory medicine, but not

yet for IP

. The ERS does however organ-

ize many advanced training courses in IP

in France, Greece, Italy, Germany and

Denmark and, since 2016, a professional

cercaon of competence in EBUS held

mostly in Heidelberg, Amsterdam and

Copenhagen.

The ERS working group on

IP plans to extend this experience to oth-

er skills and procedures, such as thoraco-

scopy and Advanced Thoracic UltraSound

(TUS). Furthermore, individual European

countries hold advanced weekly courses

or “Boot Camps on IP” and structured

Master, e.g. 1 year (500 hours) in Italy, 2

years (130 hrs) in France or in Spain. If a

trainee is interested in IP in Germany, s/

he receives IP training in the endoscopy

unit for 1 year in the best centers (e.g.

Heidelberg, Essen, Hemer or Gaung),

using a simulator for the rst few weeks

and close supervised hands-on training. In

the UK, trainees keep a logbook for 5

years, to be reviewed and signed o peri-

odically by their supervisors; in the Man-

chester region, an online based

“Pulmonary passport” has been intro-

duced, which includes all procedures

(EBUS, Thoracoscopy, etc.). But at present

we do not have a single, common curricu-

lum throughout Europe, nor is a cer-

cate of competence in IP mandatory in

Europe, while a diploma is oen required

when applying for a post. In Italy over the

years we have felt the need to standard-

ize our training program, for the 1-year

Master and also in lifelong training pro-

grams, so that trainees can gradually

achieve full competence in the majority

of IP skills. The teaching faculty on our

Masters worked on a dra standardized

training program, involving the parci-

pang centers: this can guide physicians

who want to improve their own and assist

those organizing IP training programs.

The document includes a general part on

Core Curriculum contents, innovave

training methods and technical and non-

technical simulaon, and a Syllabus de-

scribing the basic issues and skills for each

knowledge base and procedure of IP

(exible bronchoscopy and basic sampling

techniques, intervenonal endosonogra-

phy (EBUS, EUS, EUS-B), bronchoscopic

navigaon and EBUS-radial probe, trans-

bronchial cryobiopsy, transthoracic pul-

monary biopsy, rigid bronchoscopy and

related procedures, sedaon in interven-

onal pulmonology, pleural procedures,

paediatric bronchoscopy, bronchoscopy

in anaesthesiology and ICU, bronchoscopy

Guest Opinion/Editorial

WABIP Newsletter

J A N U A R Y 2 0 1 8 V O L U M E 6 , I S S U E 1

EXECUTIVE BOARD

Zsolt Papai MD

Székesfehérvár, Hun-

gary

Chair

Silvia Quadrelli MD

Buenos Aires, Argen-

Vice-chair

Hideo Saka MD

Nagoya, Japan

Secretary General

Hojoong Kim MD

Seoul, Korea

Treasurer

Eric Edell MD

Rochester MN, USA

President WCBIP 2018

Quangfa Wang MD

Beijing, China

President WCBIP 2020

Henri Colt MD

Laguna Beach, CA

Immediate Past-chair

STAFF

Michael Mendoza

General Manager

Judy McConnell

Administrator

Kazuhiro Yasufuku

Newsleer Editor-in-

chief

P A G E 2

European standardizaon prospecve for training

Lorenzo Corbea

Technology Corner

Robocs in Thoracic Surgery: Myths and Realies

Waël C. Hanna, MDCM, MBA, FRCSC,

Division of Thoracic Surgery, McMaster University,

Hamilton, ON, Canada

Introducon: Roboc Thoracic Surgery (RTS) has emerged as the most advanced plaorm for minimally invasive access to the

chest. RTS oers mulple advantages over tradional Video Assisted Thoracoscopic Surgery (VATS), including three-dimensional

visualizaon, increased degrees of freedom of moon, beer ergonomics, and enhanced precision

. Over the past decade, the pro-

poron of lung resecons that are being performed by RTS has risen steadily and now comprises close to 10% of all operaons

performed in the United States

2,3

. Although RTS is being rapidly adopted, there remains signicant equipoise about its clinical value

and associated costs. In this arcle, we address 3 myths and realies around RTS compared to VATS.

Background: The rst myth is that RTS lung resecon is associated with beer clinical outcomes when compared to VATS. The

second is that RTS Lobectomy is a beer lung cancer operaon than VATS Lobectomy because it allows for beer lymph node dis-

secon and nodal upstaging. The third is that, considering the high capital and disposable expenses for the roboc plaorm, RTS is

more expensive than VATS.

Clinical Applicaon: Mulple studies, including large database analyses and retrospecve comparave series, have failed to

show any advantages in clinical outcomes such as blood loss, length of hospital stay, or postoperave morbidity and mortality

when RTS is compared to VATS

4-7

. A recent systemac review of the literature conrmed those ndings and has demonstrated

that there are no signicant dierences in the rates of conversion to thoracotomy, prolonged air leak, blood loss, or postoperave

pain between RTS and VATS

. There is likely no dierence in short term postoperave outcomes between RTS and VATS. The ergo-

nomic advantages of the roboc plaorm have driven the noon that a beer lymph node dissecon, and subsequently improved

nodal upstaging, can be achieved with RTS lobectomy. This noon has been challenged in the general lung cancer populaon by

the ACOSOG Z0030 trial which demonstrated similar survival between lymph node dissecon and lymph node sampling at the me

of lobectomy

. Specically concerning RTS lobectomy, it was demonstrated in a recent retrospecve cohort study that the rates of

nodal upstaging are not beer than what is observed in VATS lobectomy

. Although this study was not specically powered for

survival, the results suggest that there is no signicant survival dierence between the two techniques. There is likely no dierence

in the rates of nodal upstaging between RTS and VATS. The roboc plaorm is associated with high upfront capital costs (between

$2-3 million) and ongoing maintenance costs ($150,000 to $250,000 per year). A recent matched analysis of the PREMIER database

comparing RTS to VATS lobectomy showed a higher cost to RTS operaons without any added benet in terms of short term out-

comes

. However, a repeat analysis of the same database, published recently by dierent authors, was able to measure a signi-

cant decrease in length of stay, complicaons, and conversions to thoracotomy, thereby jusfying the added cost of the roboc

plarom

(this paper was not included in the systemac review discussed above). Another study by a high volume roboc centre

has actually reported a cost advantage to using the roboc plaorm, with a measured accounng prot of $4,750 per paent

. It

is important to note that all studies which compare the cost of RTS to VATS do so in a retrospecve fashion and calculate only dol-

lar costs. This type of analysis is by denion incomplete and does not account for ulity, quality of life, and opportunity cost. To

date, there has been no cost-ulity analysis (which is the accepted gold standard in determining cost-eecveness) comparing RTS

to VATS in a prospecve fashion. A prospecve blinded randomized controlled trial comparing RTS to VATS is underway, and

scheduled to complete accrual in 2020. The primary outcome of this trial is cost-ulity, and it will provide useful informaon to

healthcare payors about the feasibility and sustainability of RTS in the long-term. It is unknown whether RTS is more expensive

than VATS, and unl prospecve cost-ulity trials are published, this will remain a point of contenon.

W A B I P N E W S L E T T E R

P A G E 3

Conclusion: Roboc Thoracic Surgery is an advanced plaorm for minimally invasive resecons that will undoubtedly usher a new era of

innovaon in thoracic surgery. Further research is required to determine its role and cost-eecveness.

References

1. Lee BE et al. J Thorac Cardiovasc Surg. 2014;147(2):724-29.

2. Rajaram R et al. Ann Thorac Surg. 2016;101(2):533-40.

3. Agzarian J et al. YSTCS. 2016;28(1):182-92.

4. Park BJ et al. J Thorac Cardiovasc Surg. 2012;143(2):383-89.

5. Swanson SJ et al. J Thorac Cardiovasc Surg. 2014;147(3):929-37.

6. Kent M et al. Ann Thorac Surg. 2014;97(1):236-42.

7. Kwon ST et al. J Thorac Cardiovasc Surg. 2017;154(2):652–59.

8. Darling GE et al. J Thorac Cardiovasc Surg. 2011;141(3):662-70.

9. Lee BE et al. Ann Thorac Surg. 2015;100(1):229-33

10. Oh DS et al. Ann Thorac Surg. 2017;104(5):1733-40.

11. Nasir BS et al. Ann Thorac Surg. 2014;98(1):203-09.

W A B I P N E W S L E T T E R P A G E 4

Tips from the Experts

P A G E 5 V O L U M E 6 , I S S U E 1

Introducon

Lung transplantaon presents a unique challenge when compared to other transplanted organs for a variety of reasons. Dual blood supply

with a lack of a vascular re-anastomosis, a contaminated site, medicaon, physical factors, as well as surgical techniques all play a role in

development of airway complicaons (AC). Airway necrosis, dehiscence, stenosis, malacia and infecons collecvely make up the spectrum

of airway complicaons and have been a signicant and persistent source of morbidity and mortality since the original lung transplant. The

reported rate of anastomoc complicaons ranges from 1.6% to 33%, although most agree with an incidence of approximately 15%-18%.

Many potenal reasons exist for this wide range; the lack of a standardized grading system may contribute signicantly. Approximately 35%

of paents with a previously treated airway complicaon will experience a second, and the chance of three or more aer the second is ap-

proximately 70%.

Frequent oce visits, the need for procedures, hospitalizaons, and addional medicaons can be a nancial and me

burden and minimize the perceived benet of transplant.

The recognion and management of airway complicaons varies based on the me from transplant, locaon of the lesion, and severity.

Instuon specic protocols also account for variance in surveillance, diagnosis, and management. Complicaons can be classied tempo-

rally (early or late), by cause (ischemia, infecon, iatrogenic, or idiopathic), anatomically (anastomoc or post-anastomoc), or descripvely

(necrosis, dehiscence, stula, infecon, stenosis, granulaon ssue or malacia). This arcle reviews a brief history of transplant airway com-

plicaons, transplant-specic anatomy and surgical technique, risk factors for AC, classicaon of AC and management strategies for the

various types of complicaons.

Risk Factors

The eology of AC is undoubtedly mul-factorial. Surgical factors and ischemia of the donor bronchus was inially felt to be primary driver,

however more complex interplay between donor and recipient characteriscs, surgical technique, post-operave recovery, infecons, and

medicaon selecon play a role.

Risk factors for the development of AC have been idened; including procurement aer extended donor mechanical venlaon (50-70

hours) as well as taller recipients.

Taller recipients are likely related to surgical technique, as the airway is telescoped with intussuscepon

leading to entrapment of organisms and an increased ischemia risk.

Indicaons and Planning:

Necrosis and Dehiscence

Post-transplant airway necrosis related to ischemic injury is common. The mucosal slough can extend from the anastomosis to lobar or seg-

mental levels (Figure 1, 2). Necrosis typically resolves by the sixth week post-transplant and dehiscence occurs when normal healing fails

(Figure 3). Necrosis and dehiscence represent a connuum from healing to catastrophic airway complicaons.

True dehiscence is uncom-

mon but rates are reported from 1- 24%, the lack of standardizaon complicates this.

Bronchial dehiscence is oen seen at surveillance bronchoscopy but must be considered with a prolonged air leak, spontaneous pneumo-

thorax, failure to wean, or sepsis. Chest radiographs are unreliable. Computed tomography may be helpful showing bronchial wall defects,

airway debris, or extra luminal air consistent with dehiscence but bronchoscopy remains the gold standard.

A full review of medicaons is too detailed for this brief piece but Sirolimus merits discussion. It is a potent immunosuppressive and anpro-

liferave with less renal impairment, appealing for lung transplantaon. Catastrophic airway complicaons occurred when used in the early

postoperave period. Two separate studies of sirolimus in de novo lung transplant paents describe severe wound-healing complicaons

Airway Complicaons Aer Lung Transplantaon

Michael Machuzak, MD

Department of Pulmonary, Allergy, and Crical Care

Respiratory Instute

Cleveland Clinic

Laura Frye, MD

Department of Pulmonary and Crical Care

Transplant Instute

University of Chicago

P A G E 6 V O L U M E 6 , I S S U E 1

with dehiscence, one resulng in a fatal event. Present recommendaons are to delay using Sirolimus unl complete bronchial wound heal-

ing, typically 90 days aer transplantaon.

5,6

Mucosal slough without necrosis of the bronchial wall may respond to a conservave approach or surveillance and as needed debulk-

ing. Oen anbioc or an-fungal regimens, including inhaled therapies, are iniated. When healing fails and dehiscence occurs, either a

surgical or bronchoscopic intervenon is required. Both have associated morbidity and mortality. Surgical opons include reanastomosis,

ap bronchoplasty, and rarely retransplantaon.

Bronchoscopic techniques include cyanoacrylate glue, growth factors, and autologous

platelet-derived growth factors; however the overall success is poor.

A novel technique of placing an uncovered self-expanding metal stent (SEMS) temporarily to facilitate healing exists. This technique ulizes

the tendency for SEMS to iniate granulaon ssue formaon. The SEMS is deployed across the dehiscence and once granulaon ssue and

epithelializaon occurs a stent exchange (if the defect is sll present) or removal (if healed) is performed, typically within a few weeks (Figure

4). Mean me to stent removal was 37.5 days.

Precise placement and removal make this method challenging with the potenal to extend

the injury. Close surveillance is recommended given the tendency for stenosis or malacia to occur at or distal to the site of prior dehiscence.

Fistula

Bronchial stulae are challenging but fortunately rare and can occur as communicaons between the airway, pleura, mediasnum, or vascu-

lature. Fistula may present as dyspnea, sepsis, pneumothorax, subcutaneous emphysema, or a persistent air leak typically in the seng of

dehiscence. Management is similar to that of anastomoc dehiscence. Success depends on the locaon and size of the defect.

Bronchovascular stulas are rare and oen fatal. Erosion from any infecon, parcularly aspergillus, is most typical.

A herald bleed must be

evaluated quickly. Case reports of surgical management with pneumonectomy (if bilateral transplantaon), bilobectomy, or stula resecon

and reconstrucon have been successful.

Anastomoc infecons

Infecous complicaons are common, parcularly in the rst 3 months, and will be seen in nearly seventy-ve percent of transplant recipi-

ents with bacterial pneumonia being most common. Immunosuppression, ischemic complicaons, impaired mucociliary clearance, impaired

lymphac drainage, poor cough reex due to denervaon, and the direct communicaon of the allogra with the environment all play a

role.

Pre-transplant colonizaon is also common.

Infecons at the anastomosis are a complicaon but more importantly are oen the precursor to issues covered later. Diagnosis usually oc-

curs at bronchoscopy. Inammaon, ulceraon, or pseudomembranes are oen seen along the airway and are treated with debridement

and anbiocs. Protocols vary by instuon and include systemic and inhaled regimens with voriconazole, itraconazole, and inhaled ampho-

tericin commonly used.

Bronchial Stenosis

Bronchial stenosis is the best described complicaon; with reported rates ranging from just over 1% to as high as one third.

They can be

anastomoc or distal. (Figure 5). Non-anastomoc stenosis can be technically challenging as they can extend into segments. The bronchus

intermedius is the most commonly involved non-anastomoc site, referred to as vanishing bronchus intermedius syndrome (VBIS).

The eology may involve infecon, inammaon, or ischemia and can result in remodeling. Paents present with dyspnea, drop in spirome-

try, cough, wheeze, or recurrent episodes of pneumonia. Chest radiography can be the rst indicator with luminal compromise or atelectasis.

CT of the chest can reveal xed bronchial narrowing. Diagnosis by exible bronchoscopy remains the gold standard.

The management of bronchial stenosis oen requires a stepwise, mulmodality approach. Successful techniques include dilaon, ablaon,

and stent placement. Dilaon can be by balloon or rigid dilaon. Dilaon by balloon is oen the rst therapeuc maneuver performed and

provides excellent results with relief of symptoms and improved spirometry. The stenosis oen recurs aer dilaon, but repeated balloon

dilaons may be the only intervenon required in 26% of cases.

While no studies have compared methods, balloon dilaon has several

advantages. It can be performed via exible bronchoscopy and under conscious sedaon. Balloons come in mulple sizes and lengths allow-

ing for specic selecon. Lastly, balloon dilaon allows for a rapid increase in the size of the balloon rather than repeated upsizing of the

rigid bronchoscope. Rigid dilaon has several advantages over balloon bronchoplasty such as expense (oset by the need for general anes-

thesia), direct visualizaon during dilaon and uninterrupted venlaon. Perhaps the largest benet of the rigid bronchoscope is the ease of

stent placement if a silicone stent is to be placed.

Tips from the Experts

P A G E 7 V O L U M E 6 , I S S U E 1

In cases where a focal web-like stricture is found, a mucosal sparing technique such as electrocautery or laser should be employed followed

by dilaon. Techniques reported include those previously reported including: cryotherapy, electrocautery, argon plasma coagulaon, laser,

brachytherapy, or photodynamic therapy.

Topical applicaons of mitomycin-c or submucosal applicaons of steroids have also been used. There are no controlled trials of these inter-

venons, however literature supports that the use of these therapies may potenally delay the me to re-stenosis.

If the stenosis is recurrent, stenng may be required. This is a dicult decision as stent complicaons can be signicant. The technical aspects

of a complicated anastomosis has led some to favor placement of self-expanding metal stents (SEMS) However, while SEMS provide immedi-

ate relief as well as some protracted success they are fraught with long-term complicaons and must be carefully considered.

7,8

The issues with SEMS make silicone stents generally favored for the management of benign stenosis as they have advantages of the ease of

reposioning, removal and reduced granulaon ssue formaon (Figure 6). They are more prone to migraon and require rigid bronchosco-

py for placement and removal but can be customized to length, diameter or “notched” on site (Figure 7). Data suggests no increase in com-

plicaons of customized stents for complex airway diseases.

Issues with stent placement and complicaons have led to the development of new technologies, including 3-D printed or biodegradable

stents (BDS). Biodegradable stents are well tolerated and completely dissolve aer months. In one prospecve study of BDS, eleven stents

were placed in ten paents. All had improved spirometry and airway patency was achieved in 9/11 at 1-year follow-up with complete degra-

daon aer 141 days.

3-D reconstructed stents may play a role in transplant airway complicaons as they allow for a personalized t.

In paents with recalcitrant stenosis alteraon of immunosuppression with the addion of sirolimus can be considered (once airway healing

has occurred). A retrospecve review of 10 paents with recurrent stenosis reported 8 of 10 paents achieved airway patency within 3

months and 7 of 10 had a signicant response within the rst month of starng rapamycin.

7,8

A muldisciplinary approach is ideal and if endoscopic therapy fails, a surgical approach should be considered. An invasive approach is risky

but somemes required, with bronchial anastomosis reconstrucon, bronchoplasty, sleeve resecon, lobectomy, pneumonectomy, and re-

transplantaon all described.

Excessive Granulaon Tissue

Occluding endoluminal granulaon ssue occurs in up to a quarter of lung transplant recipients, most commonly at the anastomosis. Airway

infecon, parcularly with aspergillus, can exaggerate this.

Progressive dyspnea, cough, diculty clearing secreons, post-obstrucve pneu-

monia, or hemoptysis may be the presenng symptoms. Reduced spirometry or a chest CT showing obstrucve granulaon ssue may be

seen but bronchoscopy remains the gold standard.

Forceps can remove granulaon ssue easily, but in some cases the beveled edge of the rigid bronchoscope is required to quickly restore

patency. Heat or cold modalies as well as the micro-debrider can be used to restore patency. A superior safety prole, the cryosensivity

of granulaon ssue, excellent hemostasis and the ability to use around stents without the risk of ignion even in high concentraons of oxy-

gen make cryotherapy an appealing opon. APC, electrocautery, and laser ablaon have a long history of successful management. High

dose rate (HDR) endobronchial brachytherapy, or photodynamic therapy have also been reported but should be used with extreme cauon

as serious complicaons including fatal hemoptysis, have been described.

Endobronchial applicaon of anbrocs (Mitomycin) or injecon of an-inammatory agents has been described in the management of

granulaon ssue with limited success. Although randomized trials are lacking, anecdotal success and excellent safety prole encourage con-

nued usage. Bronchial stents have been reported to improve patency in refractory cases but can promote granulaon ssue.

Stent place-

ment is complicated by granulaon in 12 to 36% of paents.

Tracheobronchomalacia

Malacia of the airway presents in a myriad of ways. A “barking” cough, diculty clearing secreons, or a drop in spirometry more marked

during expiraon are typical. Signicant malacia is dened as luminal narrowing of 50% or more on expiraon (Figure 8).

The management is extrapolated from the non-transplant populaon. Aggressive pulmonary hygiene, mucolycs, and non-invasive posive

pressure venlaon are tried rst. Stenng may improve spirometry if medical management fails. Stenng should be carefully considered.

If pursued, silicone stenng is typically preferred by experts with close surveillance and oen a stent-free trial aer 6-12 months.

P A G E 8 V O L U M E 6 , I S S U E 1

Quality Control: Classicaon of Airway Complicaons

A potenal reason for the wide range of reported AC may be the lack of a standardized, well-accepted grading system. Early grading systems

relied on bronchoscopic inspecon with some excellent ndings including predicon of subsequent anastomoc complicaons; however they

were subjecve and captured only early complicaons. This shortcoming was later addressed. Subsequent addions included bronchial stric-

tures, suture status, and presence of granulaon ssue, dehiscence or malacia. The most recently proposed system, by Dutau and colleagues

known as the MDS grading, approaches AC in a slightly dierent manner. Unique to this approach is the ability to include the extent of the

abnormalies, from the suture line to more distal lobar and segmental levels.

The M designaon describes the macroscopic appearance ran-

ging from normal healing to include carlaginous protrusion, granulaon or necrosis. The D classicaon describes airway diameter and the S

designaon assesses the suture line for dehiscence and ranges from the absence to a full dehiscence.

A universally accepted classicaon system is the rst step allowing for scienc study and consistent reporng to truly dene the incidence,

prevalence, morbidity and mortality. A taskforce of the Internaonal Society of Heart and Lung Transplant has recently completed such a

classicaon system with results soon to be published.

Bronchial Artery Revascularizaon

Roune lung transplantaon does not reestablish bronchial artery circulaon leaving the anastomoc site dependent on retrograde ow.

Anastomosis of bronchial arteries has been successful with promising short and long term results.

A pilot study at the Cleveland Clinic looked

at a series of 131 lung transplant paents who underwent BAR with an overall success rate of 90% including a 95% success in bilateral trans-

plants. Bronchial artery patency was associated with uniformly normal airway healing. The 5 and 10-year survival for bilateral lung transplant

was superior for BAR paents. A higher risk of bleeding was seen, not aecng safety.

While encouraging, mul-center studies are needed

to establish these benets.

Summary

In paents with advanced pulmonary disease, lung transplantaon can improve survival and quality of life. However, airway complicaons

remain a major obstacle with associated morbidity and mortality. Paents with AC need addional visits, procedures and adjustments of

medicaons. The increased need for care in an already complicated regimen can lead to a lower perceived improvement in quality of life.

This can be discouraging, costly, and me-consuming. Recent improvements in donor and recipient selecon, surgical technique, periopera-

ve management, and immunosuppression have decreased the incidence of AC.

The management of lung transplant associated airway complicaons is complex. Many therapeuc opons exist and there is no strong data

to suggest one is superior. Management is best delivered in a muldisciplinary approach performed by individuals experienced in the above

techniques with an understanding of the intricacies of the post-transplant paent.

References

1. Machuzak M et al. Curr Opin Organ Transplant 2010; 15: 582-7

2. Murthy S et al. Ann Thorac Surg 2007;84: 401-9

3.Van De Wauwer C et al. Eur J Cardiothorac Surg 2007; 31: 703-10

4. Garfein ES et al. J Thorac Cardiovasc Surg 2001; 121(1): 149-54

5.Groetzner J et al. J Heart Lung Transplant 2004; 23(5): 632-8

6.King-Biggs MB et al. Transplantaon 2003; 75(9): 1437-43

7. Maloney JD et al. Ann Thorac Surg 2001; 82(6): 2109-11

8.Mughal M et al. Am J Respir Crit Care Med 2005; 172: 768-71

9.Knight J et al. J Heart Lung Transplant 2008; 27: 1179-85

10. Ahuja J et al. Radiol Clin North Am 2014; 52(1): 121-36

11. Santacruz JF et al. Proc Thorac Soc 2009; 6(1): 79-93

12. Chhajed PN et al. Chest 2001; 120(6): 1894-9

13. Machuzak M. In: Principles and pracce of intervenonal pulmonology. New York: Springer Science + Business Media; 2013. p463

14. Cosano-Povedano J et al. J Bronchology Interv Pulmonol 2008; 15(4) 281-3.

15. Breen DP et al. Respiraon 2009; 77(4): 447-53

16. Fuehner T et al. Transplant Internaonal 2013; e58-60

17. Mulligan MS. Chest Surg Clin N Am 2001; 11(4): 907-15

18. Tendulkar RD et al. Int J Radiat Oncol Biol Phys 2008; 70(3): 701-6

19. Saad CP et al. Transplantaon 2003; 75(9): 1532-8

20. Simo M et al. Thoracic endoscopy. Advances in intervenonal pulmonology. Malden (MA): Blackwell Publishing; 2006

21. Dutau H et al. Eur J Cardiothorac Surg 2014; 45: 33-38

22. Peerson, GB et al. Curr Opin Organ Transplant 2010; 15: 572-7

Tips from the Experts

P A G E 9 V O L U M E 6 , I S S U E 1

Figure 1: Necrosis and stenosis of the distal RBI and RML

Figure 2 : Mild necrosis of the right mainstem anastomosis

Figure 3 : Dehiscence of the right anastomosis, note the loose su-

tures and separaon of the donor bronchus

Figure 4 : SEMS placed to iniate granulaon ssue for a dehiscence

Figure 5 : Right Bronchus Intermedius stenosis Figure 6 : Right mainstem stenosis aer dilaon and stent place-

ment

Figure 7: Customized stent placement ; note the

notch for the RUL stent

Figure 8 : Malacia of le mainstem

Humanitarian News

W A B I P N E W S L E T T E R P A G E 10

The “Proyecto Horizonte” is an iniave between the World Bronchology Foundaon and SEPAR Solidaria, born in 2015.

Between the 12th and 26th of November, the “Proyecto Horizonte Honduras 2017” resumed its acvity. Dr. Manuel Núñez,

Dr. Enrique Cases, and nurse Merce Cuña, travelled to Tegucigalpa (Honduras) to accomplish 5 objecves, which were 1) to

support the apprenceship of future pulmonologists in Honduras, 2) to make a Second Theorecal and Praccal Cen-

troamerican Course with the engagement of pulmonologist from countries near Honduras, with the aim of updang the

pleural and bronchonscopic techniques, 3) to aend to paents, 4) to donate an an ultrasound machine to the “Instuto

Nacional CardioPulmonar”, and 5) to control the donated material in Nicaragua one year ago.

Specialists from Honduras, Guatemala, San Salvador and Panamá took part in the Second Theorecal and Praccal Course of

Intervenonist Pulmonology. The experience was rewarding and the level of the course, with the involvement of specialist

from Honduras, was very high. The praccal part helped for the apprenceship of the assistants and was highly valued. It is

important to highlight the high level of parcipaon in the nursing sessions -a constant in this Centroamerican Course-,

which shows that nursing raises concerns and arms the necessity of training and smulang it. The work and eorts of

Merce Cuña during the course and in the Instuto asistencial was very outstanding and appreciated.

Humanitarian News

W A B I P N E W S L E T T E R P A G E 11

During our stay in the Instuto, we acvely parcipate in the dierent assistance acvies, complex procedures and forma-

ves and clinic sessions that were organized. The contribuons made were highly valuated. We have to highlight again the

acvity developed by Merce Cuña, above all in encouraging the nursery, and the work of Manuel Cuña in forming future pul-

monologist in Honduras, as well. At the same me, it is important to appreciate the facilies that Dra Suyapa Sosa gave to

us, not only by leng us develop our acvity, but also by bringing us the opportunity of constantly being with pulmonology’s

residents.

In the rst visit to Honduras, because of the high quanty and complexity of pleural pathology in the medical centre, it was

consider that there was a priority need of an ultrasound machine for studying the pleural pathology. Because of this, SIM-

MEDICA donated an echograph with a high-resoluon linear and mini-convex transductcers. We would like to thank the

complete willingness of SIMMEDICA to donate material for the Proyectos Horizonte, it has become a key contributor in these

projects.

Controlling the donated material its fundamental, not only to know that it remains in good condions and that is being cor-

rectly used, but also to let the responsible people of these material feel that World Bronchology Foundaos and Separ Soli-

daria the connues supporng them. Because of that, a visit to Chinandega (Nicaragua) was made, and it was checked that

the donated bronchoscope in September 2016 was being used correctly and that remained in good condions. It is im-

portant that the interns of SEPAR Solidaria in Nicaragua resort to this hospital, where Dr. Amaya, who is the head of the pul-

monology department in the hospital, will receive them cordially.

The use of the allowed material in the Hospital Militar de Managua it is being very useful for the paents. The rst results of

the transbronchial lung cryobiopsies and central airway obstrucon recanalizaon, have been submied. Moreover, the pul-

monologist in charge of the department, Dr. Chrisan Sánchez, stayed for three weeks in Spain –Fundación Jimenez Díaz and

Hospital Universitario y Politécnico La Fe- with a grant from the WBF and Asociación Española de Endoscopia Respiratoria

(AEER), in order to improve its knowledge in intervenonist pulmonology procedures. Dr. Chrisan feels highly inspired, and

is conscious that the development of the intervenonist pulmonology depends to a large extent on him.

This Proyecto Horizonte its possible thanks to many people. Between them, can be named, Dr. Julio Ancochea, who is sensi-

ve and commied with this project, which began in 2015. Thanks to him, SEPAR Solidaria has facilitated the necessary

framework to make the Proyecto Horizonte known in all Centre America. Javier, Luisa, Harold and Gerardo, who are the fu-

ture pulmonology residents in the Instuto Nacional CardioPulmonar, who are enthusiasc for learning, and who are always

sensive and warm with us. Dra. Suyapa Sosa, who is the core of this group. Without her, the Project would have been im-

possible and pointless. Drs. Judy Enamorado, Carlos Alvarado, José Castro, Leslie Padilla, Elías and the nurse Walleska and

other persons who have help and encourage us. To all of them, thank you very much, we always bring back home more

things than what we leave there. Finally, recognizing the generosity, kindness and willingness of SIMMEDICA, without them

it would be really dicult to donate material of good quality, with such an ecient cost.

*The views expressed in this arcle are those of the author and do not necessarily reect the ocial posions of the Execuve

Board or Internaonal Board of Regents of the WABIP. Dr. Enrique Cases is the chair of the World Bronchology Foundaon.

In September 2017, Dr. Henri Colt, with Doctors Maria Simon (Romania) and Mihai Olteanu (Romania), conducted a Train-the-Trainer program

with its aached Introducon to Flexible Bronchoscopy Courses for physicians in the Balkans. Organized and hosted by Dr. Spasoje Popevic

(Belgrade, Serbia) and the University Hospital of Pulmonology, Clinical Center of Serbia in Belgrade, the program included invited leaders from

Serbia, Moldavia, Bulgaria, Macedonia, and Bosnia. These experienced bronchoscopy teachers came together to discuss competency-oriented

pracces, and to enhance their teaching skill using checklists, assessment tools, and case-based 4 box approach exercises in a muldimensional

instruconal program. Role-playing exercises were used to pracce individualized, learner-centric teaching techniques, and several technical

skill staons comprised of airway models were helpful for learning to teach inspecon bronchoscopy using our me-tested step-by-step tech-

niques.

During the Introducon to Flexible Bronchoscopy course (IFB), trainers were able to apply their newfound skills and increased understanding of

the Bronchoscopy Internaonal/WABIP philosophy. They then shared cognive, technical, experienal, and aecve knowledge with more

than 20 IFB course parcipants. Parcipants in the IFB program were, for the most part, junior specialists from local and regional medical cen-

ters, although several surgeons from Serbia were also present, providing helpful insights and clinical experience.

Dr. Spasoje Popevic, now a BI Cered Instructor, provided key leadership during the enre program. In addion to enhancing teaching skills,

trainers discussed educaonal philosophies, and ways to overcome exisng obstacles to implemenng the widespread use of assessment tools

and checklists in the Balkans. An excing “spirit of collaboraon” immediately ensued during the program, and enthusiasc Serbian leaders are

already well into the process of translang The Flexible Essenal Bronchoscopist and several checklists and assessment tools. The Informed

Consent summary page (downloadable from www.bronchoscopy.org) is already translated and being distributed with great success. Mean-

while, leaders from Macedonia, Serbia, Romania, Bulgaria, Moldavia, and Bosnia are moving forward with establishing competency-oriented

training guidelines to complement the apprenceship models currently in place in their respecve pulmonary sociees.

Once more, a direct result of this training program was increased collaboraon and true friendship among colleagues who share a common

interest, colleagues who are able to discard personal egos in order to work together for a greater good, and ulmately, greater benet to their

paents who will may no longer suer from the consequences of procedure-related training. The Bronchoscopy Internaonal team and WABIP

wish to congratulate al these leaders, who, as proacve agents of change, are consolidang the educaonal paradigm shi from a tradional

apprenceship model to a competencyoriented model using assessment tools, checklists, simulaon, and a muldimensional, learner-centric

approach to skill development.

Education and Training

P A G E 12

Figure 1: Leaders from Serbia,

Bosnia, Moldavia, Bulgaria, and

Macedonia discussing denions

of paent suering and roles for

cometency-oriented training at

the Belgrade Train-the-Trainer

seminar

Figure 2: Doctor Marija Zdra-

veska from Macedonia using a

(instructor) hands-o student

(hands-on) approach to teaching

bronchoscopy step-by-step while

working with parcipants in the

Belgrade Introducon to Flexible

Bronchoscopy

Figure 3: Drs. Maria Simon

(Romania), Henri Colt (USA), Spaso-

je Popevic (Serbia), and Mihai Ol-

teanu (Romania) were faculty at

the Trainthe-Trainer program held

in Belgrade, Serbia in September,

2017.

Figure 4: Train-the-Trainer and

Introducon to Flexible Bron-

choscopy Course parcipants

in Belgrade

Bronchoscopy Educaon Project Acvity in Belgrade, Serbia

WABIP NEWS

P A G E 13

2024 WCBIP Host Applications – This is a reminder that applications for hosting the 2024 WCBIP

congress are now open. This is an excellent opportunity for you and your colleagues to host and

organize WABIP's biennial scientific event in your city. Visit the link to read more about the

application process https://www.wabip.com/news/324-call-for-2024-wcbip

Left: Dr. George Eapen (AABIP); Right: Dr. Luis Gonzalo Ugarte Fornell (Ecuador IP Society)

Member Society Spotlight - Since its founding in 1992, the American

Association for Bronchology and Interventional Pulmonology (AABIP) has

been a unifying source for information regarding the fields of Bronchology

and Interventional Pulmonology. Over the last few years, the AABIP has

achieved significant milestones, including having the Journal of Bronchology

and Interventional Pulmonology become indexed on Index Medicus, having

IP Fellowship programs become part of the National Residency Match

Program, running twice-yearly scientific symposium and developing and

implementing the first Board Certification Exam in Interventional Pulmonology. For more information

about this association, please visit: https://aabronchology.org

Reduced registration fees for the 2018 WCBIP/WCBE are still available. Register Today!

https://www.wcbipwcbe.com/general#fees

Call for Nominations for Next WABIP Vice-Chair

–

Nominations for the next WABIP Vice-chair are still

open. The Vice-chair is a voting member of our Executive Board and is entitled to all rights and

privileges therein. This member shall carry out leadership responsibilities and tasks in accordance

with the principles and objectives of the WABIP to assure the continued growth of our organization.

The current Vice-chair will assume the position of Chair immediately after the current Chair's tenure.

Send us your nominations at https://www.wabip.com/news/323-wabip-vice-chair-2018

New Board of Regents Members

–

We are pleased to welcome Dr. George Eapen (AABIP) and Dr. Luis

Gonzalo Ugarte Fornell (Ecuador IP Society) on the WABIP Board of Regents (“BOR”). With now 57

members, the BOR will meet in Rochester this June to take part in and vote on the next WABIP Vice-

chair, the 2024 WCBIP host site and other important WABIP business.

Biodegradable and Drug Elung Airway Stents

It's like a tailored suit, just for you

Ideal airway stents have been a topic of every major Intervenonal Pulmonology discussion, conference, and a book for over a decade. The de-

nion of an ideal airway stents broadly encompasses, easy to deploy, easy to remove, minimal to non-granulaon forming, and aordable. Bio-

degradable material of stent was included in the wish list as the me went on.

In the last few years, the technology has made possible just about all the above-menoned qualies and much more in the airway stents. Now,

we can order a stent designed according to the measurements, contours, and bifurcaons of a specic airway of a parcular paent. A 3D print-

er can create such a stent in a short period. We can also choose one of many biodegradable materials for the specic longevity of the stent aer

which the stent dissolves and disappears. The pre-specied life of the stent precludes unnecessarily prolonged irritaon of the airway epitheli-

um which leads to brosis and formaon of strictures of the airways. Furthermore, the material used to construct the stent can be impregnated

with chemotherapeuc or an-broc agents which are slowly released locally giving a very high concentraon of the drug locally and drama-

cally low levels systemically thus minimizing systemic toxicity and side eects.

In a European pilot study (1) of biodegradable stents manufactured with bio-absorbable Polydioxanone (PDS), the stents were placed in post-

lung transplant paents with airway strictures. These stents were found to be easy to deploy and due to their biodegradable material, did not

require removal. They served their purpose for a predetermined period with good radial force and tensile strength maintaining patency in the

majority of the airways without any short or long-term complicaons.

In an animal study (2), biodegradable and drug elung stents were implanted in the trachea to study various properes of the stent. The stents

were made of Polycaprolactone and impregnated with Cisplan as the chemotherapeuc agent. The local concentraon of Cisplan was very

high while the systemic levels of the drugs were minimal. The drug slowly released over approximately four weeks and stent disintegrated over

me without any airway strictures.

These customized and individualized stents carry a broad potenal of maintaining patency of the benign and malignant airways while awaing

denive treatments and also providing localized therapy for malignant endobronchial or peribronchial diseases with minimal systemic eects.

It seems like we are very close to having an "ideal stent" if we are not there already.

References

1. Lischke et al. Eur J Cardiothorac Surg. 2011; 40(3):619-24

2. Chao et al. Chest 2013; 144(1):193-9

Editorial Staff

Associate editor: Dr. Ali Musani

Associate editor: Dr. Sepmiu Murgu

Editor-in-Chief: Dr. Kazuhiro Yasufuku

Research

Primary Business Address:

Kazuhiro Yasufuku, Editor-in-Chief

WABIP Newsleer

c/o Judy McConnell

101 College St., TMDT 2-405

Toronto, Ontario M5G 1L7

Phone: 416-581-7486

E-mail: newsleer@wabip.com

P A G E 14

P A G E

WABIP ACADEMY- WEBCASTS

The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-

vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.

Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC

You can reach these webcasts by using this link: hp://www.wabipacademy.com/webcast/

www.bronchology.com Home of the Journal of Bronchology

www.bronchoscopy.org Internaonal educaonal website for

bronchoscopy training with u-tube and

facebook interfaces, numerous teachiing

videos, and step by step tesng and assess

ment tools

www.aabronchology.org American Associaon for Bronchology and I

ntervenonal Pulmonology (AABIP)

www.eabip.org European Associaon for Bronchology and

Intervenonal Pulmonology

W A B I P N E W S L E T T E R

Links

www.chestnet.org Intervenonal Chest/Diagnosc Procedures (IC/DP)

NetWork

www.thoracic.org American Thoracic Society

www.ctsnet.org The leading online resource of educaonal and

scienc research informaon for cardiothoracic

surgeons.

www.jrs.or.jp The Japanese Respirology Society

sites.google.com/site/asendoscopiarespiratoria/

Asociación Sudamericana de Endoscopía Respiratoria

P A G E 15

P A G E

W A B I P N E W S L E T T E R

P A G E 16

Upcoming Events

IP National Update 2018

 When: February 24-25, 2018

 Where: Hotel Radisson Blu, Nagpur, India

 Program Director: Dr. Sameer Arbat, MD

 Program Type: Educational seminar (postgraduate may include physicians in practice and trainees),

Hands-on workshop, Conference (didactic lectures)

 Website: http://www.ipnationalupdate2018.com

Faculty Development Program & Introduction to Flexible Bronchoscopy

 When: March 1-3, 2018

 Where: Auckland, New Zealand

 Program Director: Henri Colt, MD

 Program Type: Educational seminar (postgraduate may include physicians in practice and trainees),

Hands-on workshop

 Website: https://www.wabip.com/events/328-trainthetrainers-nz2

Advanced Diagnostic Bronchoscopy Workshop

 When: March 23-24, 2018

 Where: Fort Lauderdale, FL

 Program Director: Atul C. Mehta, MD, FACP, FCCP, MD

 Program Type: Educational seminar (postgraduate may include physicians in practice and trainees),

Hands-on workshop

 Website: http://ccfcme.org/gobronch

3rd Annual Lung Cancer Update: Advances in Screening, Diagnostics and Therapeutics

 When: April 13, 2018

 Where: William and Ida Friday Center, UNC Chapel Hill, Chapel Hill, NC

 Program Director: Lonny Yarmus, DO, FCCP and Jason Akulian, MD, MD

 Program Type: Educational seminar (postgraduate may include physicians in practice and trainees),

Hands-on workshop, Conference (didactic lectures)

 Website: https://hopkinscme.cloud-cme.com/aph.aspx?P=5&EID=7187

Ibero-American Symposium on Basic and Advanced Bronchoscopy (SIBBA 2018)

 When: April 13-14, 2018

 Where: Centro de Convenciones Torre AR, Bogota, Colombia

 Program Director: Adnan Majid, MD

 Program Type: Educational seminar, Hands-on workshop, Conference (didactic lectures)

 Website: http://www.sibbaneumo.com