 when there is a Malaysia or any other problem. So, this APC being applied for base of the Chuma 2, base of Chuma 2 just to cotrize that. So, this deep raider offers advantage of effective and rapid de-bulking high-risk population as well as broad-based infusely spread tumors. It also coupled with suction. It is also coupled with suction allows continuous vision, potentially shortens the duration of the procedure, cost is comparable to other identities. So, this is the paper published in BABIA. So, there are 6 patients with endobronchial lesions, mainly in the bronchial, one in the trachea. So, all these patients were taken up by microdebrator. So, all these patients were done under GA, jet ventilation order, with use in 12-minum rigid bronchoscope and 14-minum tracheoscope. Perhaps this was taken prior to the procedure. Procedure time varied from 5 to 15 minutes. Our post-procedure all had patented with less than 10 percent residual tumor, 3 required stenting for malaysia or extensive compression, none had any adverse events. We had them monitored for any significant bleed, pneumomedia stenum, rapid therapeutic bronchoscopy. So, limitations can only reach the trachea main bronchee and bronchocentrum medias need to be cautious about airway valve damage. So, take home points, copulation is an alternative to low-temperature radar frequency operation, which can be used in self-life obstruction with modified vans. So, the debreder offers an advantage of effective and rapid debulking and you can share the system with your ENT colleagues with modified vans and modified blades. Thank you. Thank you, Dr. Lokesh. So, any question and answers in the first session, we will begin. Thank you, Dr. Arvind, for sharing your time with me here. If time is money, today you have spent a few years. Thank you very much. Any other questions in the way of being to answer your questions? Thank you, Dr. Arvind, for sharing your time with me. Thank you very much. Yes. The first case was C.A. thyroid, but actually, the thyroid tumors usually be the peak present in upper trachea, sublodic region. That was the case when C.A. was tried. Then, C.A. was offered surgery, but tracheostomy followed by pteridectomy, pteridectomy, pteridectomy, pteridectomy. But that was the reason after tracheostomy we evoked with the copulation van. So, it didn't take much time, probably 15 minutes after debulking and we followed up after 45 days. You can see that there was no recurrence. It was invasive. It was invasive. It was invasive into the trachea. Only 10% of the women is free. 90% is uprooted. Your wall was abated. No questions, sir. We will proceed. No questions, sir. Now I request the honourable chairperson to present momentous to the speakers. I kindly admit Dr. Rakesh sir, Dr. Lokesh sir, Dr. Sudhakar sir, director of Manipal Hospital's Vijay Vada to present momentous to the chairpersons. I request the dignitaries on the stage to stay back for the inaugural ceremony and I request the following people to join the inaugural ceremony. Dr. Krishnareghi sir, medical oncologist at Manipal Hospital's Vijay Vada. Dr. Chandrasekhar sir, observer APMC. Dr. M. A. Rahman sir, IMA president. Dr. Uday sir and Dr. Lokesh sir, please join for the light-lamping ceremony. And I request Baburao sir to join for the light-lamping ceremony. I kindly invite Dr. Sudhakar sir, director of Manipal Hospital's Vijay Vada to address all the delegates. Good morning everybody. Welcome to the interventional pulmonary meet with Dr. Rakesh. I take this privilege to welcome all the doins of the pulmonary medicine and other related specialties today. My hearty welcome to Dr. Baburao garu, senior pulmonologist, Dr. M. A. Rahman garu, IMA president, Dr. Chandrasekhar garu, APMC. I extend my warm welcome to all the international speakers, all the renowned faculty and students from various institutions. At this juncture, I would like to take this privilege to present my hospital in a very, very brief note. Manipal Hospital today is the 250-bed quaternary care center with all the facilities under one roof. We are currently running a very successful liver transplant, renal transplant, and also in oncology, I think we are the first international state in the divided underprivileged to do the first allogenic bone marrow transplant and several otologous transplants in a very successful manner. We have, for a period of time, we have developed several centers of excellence in cardiac sciences, neurosciences, pulmonary medicine, orthopedics and joint replacements, surgical gastro-critical care as well. We are currently running D&B programs in Anastasia and Medical Opology and two students have also joined the programs. So that's a very brief note on my hospital. And I congratulate my dynamic duo of the location and Dr. Uday for conceptualizing this wonderful event and hoping that today's academy session will be very fruitful. Welcome once again. Thank you. Now moving to the next session, I request Dr. Raghu Sir, Professor and Head of Department of Pulmonology, Guntur Government Hospital and Dr. Ramakrishna Sir, HOD of NRI hospitals to be as the chairpersons of this session. I request Dr. Loge Sir to welcome them. Thank you. Thank you. Thank you so much sir. It's a pleasure to be in Vijay Vada. I would like to thank my friend Lokesh for having me here and talking on bronchoscopic management of the 9 tracheal stenosis. So the next 20 minutes, what I would like to do is a huge topic but I would like to thank Dr. Guntur for having me here and talking on bronchoscopic management of the 9 tracheal stenosis. So the next 20 minutes what I would like to do is a huge topic but I would like to give the basics and approach when we decide to do a bronchoscopic management for the 9 tracheal stenosis. So we just read through the spectrum of diseases which cause the 9 tracheal stenosis in India. How do we describe or define, classify these stenosis and finally the management strategy which is important. Before I start I would like to say that the so-called N9 is actually an insurmountable because it is not N9, it is because of the significant morbidity and mortality. So any one of us who manages the space will know that it is more malignant than the so-called malignant diseases. So if you look at the causes, the list of causes, there are a lot of these ideas which can cause tracheal stenosis. I will not read all these things but then in India what are the common causes? This is a couple of months back we analyzed our own data of 70 cases of stenosis. 51 were in the trachea, 24 in the bronchill and 5 were involved in the trachea and bronchi. Look at the causes of tracheal stenosis. Two most common causes are post intubation and post tracheostomy. So which means to say that most of our tracheal stenosis are actually preventable. Following, this comes to good places. Again TB is a common cause of both isolated tracheal, isolated bronchill and tracheal bronchill stenosis. In many other single digits, so you do come across patients of idiopathic stenosis, you come across GPA, you come across relapsing coliconitis, so on and so forth. But the most common cause of tracheal stenosis is actually preventable cause of tracheal stenosis. Again we look at the bronchill stenosis, TB leaves the list followed by transplants. Now this is the spectrum of diseases which we see in our country. Now when we have a person with benign tracheal stenosis, the first thing which we have to do is to classify or describe the stenosis. I think this is most important for us to define the treatment plan, to describe the treatment plan. So how do we classify them? There are several classification systems. This is one of the classification system. Basically you have to look at the type of stenosis, the degree of narrowing and the site of stenosis. The three things which are very important are these three. So by type you mean it can either be a fixed stenosis, that is a structural cause or it can be a dynamic. So dynamic stenosis means either you have a Malaysia or an Iraq. Structural is a fixed stenosis. Again fixed stenosis can be a structure that is a common cause again. It can just be a significantly distorted trachea because of the fibrosis of the lab or it can be an extra-luminal obstruction. So these are the various types of stenosis. Again some of the images, these are tumors, they are not actually stenosis. But the second thing is when you look at the morphology of stenosis it is important to differentiate these two types, the so-called simple tracheal stenosis or the complex stenosis. So when we call stenosis a simple tracheal stenosis means it should be a short segment, that is ideally less than 1 centimeter and it should not have cartilage injury. So there is no cartilage injury, no Malaysia and it's a short segment. If all the criteria satisfy the quality of impulse stenosis. Why is it important? I'll come to it when we talk about the management strategy. Whichever is not simple is actually complex. So complex is basically erase stenosis which is long in length or which involves the cartilage. So there is associated cartilage destruction, associated Malaysia so you call it a complex tracheal stenosis. So complex is some photos of complex stenosis where you can see there is long segment, extensive involvement of cartilage, eccentricity, pseudo-protic stenosis and so on and so forth. In fact most of the cases which we see are actually complex. We come across very few simple stenosis, most of them are complex stenosis. Once we describe the pattern of stenosis, next is the degree of stenosis. Again this is very important to decide whether to intervene or not to intervene and when to intervene, how fast to intervene. So several classification systems have several cut-offs. The most commonly cut-off is this Mayor Cotton thing. So basically any stenosis which is less than 50% occlusion of trachea is called great one and most of these do not require intervention, the person is asymptomatic. So anything more than 50% the person is usually symptomatic and it would require intervention. And grade 3 is 71% to 99% grade 4 is complete. Unfortunately in our setup, most people come in either grade 3 or grade 4. They do not come in grade 1 or grade 2 stenosis. That is the common late clinical presentation is what I would say. Then this is some again some of these photos of complete tracheal stenosis. Most of these patients were serving on tracheostomy. Again complete bronchi stenosis because of some other causes. So this is complete cut-offs and these are near complete. So that is grade 3 where you only have a few millimetre lumen and most people come with fever's writer in this situation. So wherein you have to do something to make them better immediately. The third point which we have to understand is to look at the location and extent. So you have described the type of stenosis, structural, functional, what type. It is simple complex. Then you look at the degree of stenosis. The third thing you have to look at is the location. So where exactly is it? Upper tracheal, middle tracheal, lower tracheal. Where exactly it is? What is the distance from the vocal cord, distance from the carina? What is the length of stenosis? Because all of these have therapeutic implications. So if you look at our experience also of the tracheal stenosis, the most common location is the upper tracheal stenosis. In fact that is the case everywhere you are not wrong that upper tracheal stenosis is the common side of tracheal stenosis in our country. Why is it important? Because if you have stenosis in the upper tracheal, if surgical applications are there, if you have to present a stent, also there is a higher chance of migration and granulation and so on. So to just summarize, whenever we have a case of a benign tracheal stenosis, you have to first look at the cause. You have to look at the type of stenosis, the location, length, degree, mechanism, morphology and most important is the patient factors also. What are the symptoms and what is the promo-operatives and what in India also the financial status of the patient. So once you look at all these things, then you come up with a different plan. Now, so how do we manage these cases of benign tracheal stenosis? Again, we have three options. One is don't do anything, just wake and watch. Second is surgical dissection, which Dr Mohan, my friend, will be talking. And third is the bronchoscopic management. So when to do what is what I will be talking about. So first is no intervention. Again, this is something which you have to understand that we are not aiming at an anatomically normal airway. We are aiming at a functionally normal airway. So if the person is asymptomatic and the woman is more than 50% retain. So this is the most important thing. I will just be showing one video of a case where there is actually a follow-up of one of our patients. If you can see in the interactive, there is some mild intervention. More than 14%. So these three sort of mild, pretentious nurses, just one person, you don't have to intervene. You can just leave them, you can close with all of them and most of them do very well actually. Then if you have a symptomatic, take the bronchoscopic nurses. Now the person where he comes, you have to intervene. Now here is the important thing and you have to define them into either simple or complex. So why, for a simple, pretentious nurses, the long-term outcomes are good for both bronchoscopic techniques as well as the surgical techniques. For more centers, if you have a simple, short-signal stenosis, would recommend bronchoscopic therapy as the initial option over surgery because it is less invasive. Whereas for a complex, pretentious stenosis, the long-term outcomes of bronchoscopic interventions are not very rewarding. We will talk about it. So whenever possible, in complex nurses, we would recommend surgery as the first-line therapeutic choice. So simple techniques, you know, so how can we manage bronchoscopic therapy? Call it mechanical dilation. So again, how do we dilate your two options here with any other use, CRI balloons? So whoever is doing procedures, you know that you have CRI balloons. So the second thing is to try to prevent pretence. Again, these are some of the things people have tried, CRI balloons, something called CRI balloons, bronchoscopic procedures, but some say they are very expensive. The most popular is 0.4 milligram per hand. The contact position thing, this is my favorite from India. CRI balloons will prevent recurrence. This is something in a small case. Of course, this is one of the algorithms that you can go for a dilation plus technique. So here, if you have some surgeries, you want it to be better. This is another surgical procedure for whatever it is, or if the stenosis recurrence, it is always by using rigid bronchoscopic therapy. So this is the same step. So this is the same step you have. So when we do not have auto-accessions, cases with data which has been published. So long-term efficacy and signature you are going to want stenosis. If you see the long term, there is only 40 percent. So this is the reason why we again say that if surgery is possible, go for surgery in complex surgical synopsis. In this here, you can see this is beyond the synopsis. So stenosis is migrated. So stenosis is migration. You have to choose the current size of stenosis, or placent instinct sometimes is required to prevent stenosis. We have also had patients who have called those stenosis also. So if you see the stenosis, there is a lot of infection. Again, if you can see there is a lot of mutating, this is also the same formula. So most often we use innate nucleotic agents and oscillatory peptidizer. Then stenosis. You can see here stenosis of the trachea, but there is actually not more stenosis. The stenosis is below and there is stenosis above the stenosis. So this is called stenosis graduation. And if there is where the stenosis is there, there is a lot of problems. So stenogenization again, there are reasons for oscillating, how to prevent ideally optimal size, optimal position, avoid infection and so on and so forth. So you have to be very careful to prevent all these complications. Then the quality of life, I think Dr. Pavan also will be talking about this as well as the malignant perspective, but this is a good factor on quality of life for patients with benign stenosis. Again, they have shown that the longer the person is living with a sten, the poorer the quality of life of the person is. So I am also, there is stenosis. You place a sten, the person is happy, you leave it for one year, two years and then remove the sten. It is said that up to 20 to 25 percent of them in this stenosis have been side of original stenosis. So standing for, the first thing is that you have to be very careful to prevent all these complications as much as possible. Thank you very much, Dr. Nagarjuna. Thank you so much. Now, Mohan Mitesh, I am very happy to invite him, he is my student and he is doing excellent work in Delhi. He is a consultant, thoracic and lung transplant surgeon Institute of Chestnut and lung transplantation and Medanta, the Medici P. Gurugram, one of the best hospitals in Delhi and I congratulate him for having done a double lung transplantation so at Delhi recently, but I participate in your own man. So I think we are very happy to have you such a day. Thank you sir, thank you so much. Very good morning, the respected chairpersons, the ladies and gentlemen it is a pleasure duty to thank the dynamic duo of Manipa's interventional pulmonology team Dr. Lokesh, Dr. Uthai for inviting me to this prestigious conference. It is very difficult to speak after when Dr. Nagarjuna speaks and he has really highlighted the importance of interventional pulmonology, the role of strengths, when to vote, when not to vote in clinical stenosis. So the topic that has been alluded to me is a surgical approach to the benign clinical stenosis getting from this beautiful institute Medanta the Medici P. from Gurugram and this is the team I work with, the center person is Prof. Arvind Kumar, who is the director of Jurassic surgery and I have the privilege to get trained under him and present them working with him in Medanta the Medici P. So till now you have seen the one side of the picture so it is always said that the truth has two sides so this person here one person is saying six, the other person is saying nine so it is very important to look the both aspects of the truth before coming to ourselves to the agent. So let's see the other aspect of the benign clinical stenosis it has been highlighted well before but I will more reinforce it with more data. So the objectives of this presentation so my job is to tell when the surgery is indicated when not to do the surgery and how it is done and a special mention about the language tracheal stenosis and the outcomes of the tracheal surgery in India scenario. The ideology I will skip it it can be post intubation, post tracheostomy, tubular, adiopathy and so on and so forth and then the treatment strategies are either bronchoscopic or surgical including the sectional stenosis so bronchoscopic mainly for the diagnosis and the procedure management but if the surgery can be done so it is the best opportunity for the definitive management of benign tracheostinosis. So let's see the post intubation or post tracheostomy tracheostinosis so it can be a mucosal disease like in a simple stenosis or it can be intramural disease where the underlying cartilage has got destroyed where it is called as the congex stenosis I have no doubts in saying that the bronchoscopic methods treatment modality for the simple tracheostinosis and also I don't have any doubts in saying that surgery is the best modality of treatment in complex tracheostinosis so the therapeutic bronchoscopic of course it is in simple stenosis and in inoperable cases it can be done but in complex tracheostinosis the surgery is the gold standard so because why you say gold standard because if it can be done properly with the proper technique it has the success rate of more than 90% it is not our data it is the whole literature that shows that it's more than 90% success rate provided we have some the conditions that patients the situation is that the length of the stenosis should be less than 50% of the total tracheal length so once we take the patient we see a patient of tracheostinosis we actually see what is the total length of the trachea what is the total length of the stenosis if the length of the stenosis is more than 50% of the proper tracheal length so out of the 10 cm the stenosis is more than 5 cm then in such cases with all the minuers or least minuers we cannot approximate the end to end approximate and do end to end stenosis in such situations surgery cannot be done and the patient should be of course fit for the surgery there are some contraindications as I said sometimes 50% of the tracheal length if this stenosis then and many sequence stenosis and the severe commodities associated pathology so of course surgery is not indicated so this is the information why don't we take a patient for the surgery so in the CT scan we do this kind of measurements so the things what we see in this are what is the total tracheal length here from here to here from the vocal cords to the carina what is the total tracheal length of the stenosis what is the proxial distance from the vocal cords to the upper border of the stenosis what is the distance from the carina to the distal border of the stenosis because why it is important because the the importance of the 50% comes here and the level of stenosis is also very very important as it is cervical or mid month or lower month because the approach to the surgery varies according to the location of the stenosis if the stenosis is located in the cervical region we do the transverse cervical and then surgery if it is mid and lower so you can approach it by the stenotomy or by the horoscopic approach and the another important thing that we see in the CT scan is the precoil involved or not so the involvement of precoil how to what is the surgical approaches for this complex condition I will come when I discuss about the larynal precoil stenosis so of course in all cases we do the diagnostic bronchoscopy the location, the shape, the length the severe area of obstruction the type of suture, the components associated unknown quantities of the discolour base so lot of information can be gathered by the diagnostic bronchoscopy so this is how the precoil section is done so after exposure exposure of the precoil here so this is the upper end of the precoil this is the head end of the patient this is the foot end so this is the normal precoil this is the precoil here after the first and second precoil it is normal, you have the hourglass precoil here completely stenose, scar trace and then you have the normal 4th or 5th rinse downstairs so this is a complex diagnosis because the underlying cartridge has been destroyed malnutrition completely collides there is no point of delay dilatation in such cases so the side perverse surgery was done we looped the precoil we cut the discol and the proximal ends and we did the end to end anesthmosis here yes, we cut and joined but there are a lot of mobilization maneuvers that we do so one thing is the digital mobilization we actually mobilized the whole precoil by putting a finger between the precoil supply cartridge and the precoil and the precoil plane we mobilized the endometrial surface of the precoil like this so this is after exposure of the precoil and the cervical plane this is the head end and the foot end now we are going with the digital mobilization we are actually mobilizing the retrosional of the criteria and then we do some release maneuvers it's called supra-hyoid release maneuver once we expose the criteria completely we actually divide the muscles that are supra-hyoid so that you have a drop-off approximately 2 to 3 centimeters so you actually mobilize all the muscles you have the laryngeal mucosa here so without injuring the underlying laryngeal mucosa you mobilize this is the hyoid bone the greater Hanover you can see here the right end mobilization and the left end mobilized first and this is the right side mobilization you can see here there is the hyoid previously was here and after a drop-off supra-hyoid drop you got an approximately 2 centimeters length so when you reset 2 centimeters straight here and you pull both the ends and the endostomals to achieve action-free endostomosis this kind of release maneuvers are very very important so after that at the end of the surgery we do it's called a guardian stitch and the sternum switch into neck stitches we keep it for approximately 5 days after the surgery so that the patient can keep his slightly flexed and he don't extend the neck during his hospital stay and I want to there are so many misconceptions about the surgery so one thing is the non-surgical methods are as effective as surgery and second thing is the high cost of the procedure and potential harm of the surgery is inconstant so I want to break all these myths with the data so this is the meta-analysis that Dr. Nagarjuna has shown so is that the stability rate so this is the a tumor stem for the benign reticulostinosis approximately 300 plus patients data that showed that the stability rate of 41% the curative rate of only 40% and re-stimulation rate of 31% stem migration rate of 25% the granulation of 50% and mucous retinus not 28% so at this present the science the advancement of science how can you accept a 60% failure rate in complex reticulostinosis with the method which is having 90% success rate how can you agree a 40% success rate technique and I have no doubt in comparing our surgery here with all the the monoscopic techniques especially in complex reticulostinosis especially if you can do surgery in the complex reticulostinosis that gives the best chance of cure for the patient and the second thing is the high cost of the procedure is it real so the surgery is a one time scenario you get rid of the patient, you do the surgery and within 7 to 8 days the patient gets discharged whereas the bronoscopy as we said you do the you do the bronoscopy first bronoscopy you do a delay second time you put the strength and the patient has to undergo strength surveillance every 2 months every 3 months he has to come to the routine bronoscopy and the strength will be there within the next 1 to 2 years and you remove the strength after 6 months there is a possibility that the stenosis can recur so you can compare so we have to see if the cost is really high so you know the answer now there is a paradigm shift in the outcomes that we measure so we are all considerate about the physician reported outcomes so what is the symptom relief what is the duration of the strength still no we have seen this but now the important thing is the patient reported outcomes you have to answer these things to the patient is it a permanent cure how many times I have to visit the hospital how many loss of working days I have can I do my normal activity in my life and will I have complications with this procedure so we have to answer all of these questions when we are talking to the patient so the world equation was quality and safety so the patient used to ask Dr. Meera patient Diego does the patient live and with the problem gets fixed now the answers we have to answer apart from these we have to say how frequently I should visit the hospital and what is my quality of the hypothesis to answer these questions we have to know what are the benefits of the risk of each and every procedure so with this I will come to, I will stop the tracheal stenosis and another important thing is the laryngeal tracheal stenosis which is a different entity apart from the tracheal stenosis where the subcutaneous region actually gets involved you can classify the laryngeal tracheal stenosis it can be the anterior stenosis where only the anterior half of the laryngeal tracheal part is involved it can be a subcutaneous region where anterior as well as posterior parts involved and it can be a side to side stenosis so we have surgical solutions for each of these problems so in anterior stenosis you actually there is a build-up technique where you reset the anterior part of the tracheal and your anastomals trachea to the thyroid it's called cricot tracheal resections so in addition to that if you do some extra maneuvers so it's called cricot tracheal resections where you reset the anterior part of the tracheal and in addition to that you do either dorsal mucosectomy or anterior laryngeal split lateral cricoplasty depending on where the thickening was actually present and you can tailor according to the type of stenosis the patient is having and the another most difficult situation to deal is the single-stage, the side to side stenosis where the side to side damage of the laryngeal inlet is got decreased and in that case you can do single-stage cricot tracheal resection where you cut the posterior plate of the cricoid you interpose a rib graft in between and you can achieve the side to side damage so these are the various resections this is the grillo technique I was describing and this is the you can see the pictorial representation here so this is the cricoid bone where the anterior part is thickened so they have resected the anterior half of the cricoid cartilage because you cannot resect the posterior cartilage of the cricoid because the recurrent laryngeal goes by the side of it if you resect the posterior part both the laryngeal nerves will get injured so the only resectable structure in cricoid is the anterior half so you resect it and do the anastomosis of the cricoid with the parietal and in addition if the posterior wall also get thickened you do the sub-nuclear section of the posterior part and do the appropriate anastomosis if the lateral parts of the cricoid is mistaken you resect the sub-nuclear and sub-nuclear part of the lateral part of the cricoid and do the anastomosis and this is the single-stage laryngeal reconstruction for side-to-side anastomosis where you actually interpose a rib cartilage in between after dividing the posterior part plate and do the anastomosis and we have these are the techniques that have been described in the literature and we have our own institute of Cesare Medanta technique where we actually don't resect the cricoid either it is anterior or lateral or posterior involvement what we the technique what we use is cricoid augmentation in this cricoid augmentation this is the case where we take a rib graft we do either anterior split or anterior and posterior split so that the side-to-side diameter will increase we take a rib graft we shape it in the form of a small square as I shown before and we interpose in the anterior half or the interpose between the cartilage so which will increase the diameter side-wise or anterior post-to-bis so this is how we do this is a regular section with recorded involvement you can see here the anterior cartilage split is being given and after that we take the second posterior rib cartilage from the second anterior post-to-space and we harness it and we place it in between so that the transverse as well as anterior post-to-diameter subrata stenosis can be increased so we used these post-to-cartilage in long-segment stenosis also this is one case where a 9 centimeter total fracture with 5.5 centimeter triglycinosis what we did so we took a post-to-cartilage and we actually cut the longitudinal tracheotomy and we interpose the cartilage between the defect here so you can see this is about 5.5 centimeter total stenosis and we put the post-to-cartilage here so sometimes you may not because this is a tracheostomy the actual stenosis was sublottic here but the tracheostomy was 10 centimeters below the stenosis so once you go inside you have to reset the tracheostomy part also along with the stenosis so in such cases what we can do is you can do 270 degrees stenosis leave the anterior part leaving it and you put a tracheostomy there and after one week also you can remove the tracheostomy and this is the 10 days of the surgery so we published our data so this is our first experience in 2014 of 18 cases and then we analyzed our data and predicted the enosomal the factors affecting the complications and we got to know that the length of the restriction presence of diabetes and the prolonged use of corticosteroids before the procedure increased our complication rate and we have a lot of experience managing the tubercular tracheal and bronchial the bronchial stenosis for the time sake I am not discussing here so this is our experience in the sexual management of tubercular tracheal bronchial stenosis so the key points are the preoperative and postoperative adequate evaluation and optimization and then adequate mobilization within the trachea as is shown the adequate mobilization techniques so that we can achieve a tension free enosomal with the maintenance of blood supply at the both tracheal ends and keep your neck flexed in the postoperative period so that the patient will have the best outcomes so our approach to the surgical strategy if it is a pure tracheal condition you can achieve complex stenosis tracheal dissection and exo-enosomal if it is anterior laryngo tracheal stenosis you can do picot tracheal dissection anterior plus posterior x-ray dissection and sinus anosomal you can do single stage laryngo tracheal dissection or our technique of augmentation that can be used so I want to account note by saying in carefully selected cases the complex stenosis surgery offers the single and the best chance of cure so it is always perceived as surgery versus the bronchoscopic methods and I have I strongly believe that surgery and bronchoscopic methods are always complementary to each other because when the surgery phase the bronchoscopic when the bronchoscopic phase the surgery will be enough so while doing the surgery sticking to the surgical principles will give the best outcomes and the team approach the surgical, the thoracic surgeon, the pulmonologist and the ENT surgeon in case of laryngo tracheal stenosis will give the best outcomes thank you so much for thank you very much Dr. Mavanu for your presentation of surgical treatment and stenosis now the talk is open for discussion in a few of you have produced yeah Mavanu it's a nice so we have 140 cases, experience of tracheal, keratinum, tracheo- bronchial stenosis in none of the in fact the world data says that the use of ECMO in tracheal sections is very very minimal, maybe 1% also, maybe in future we may use depending on the clinical scenario but till now we haven't used ECMO in our cases so in tracheal sections the technique what we use is called cross-stream ventilation so the technique is called cross-stream ventilation, once we cut the trachea so we have the proximal and distal end differently so we put a inner tracheal tube to the distal end from the surgical field and we continue to ventilate the bumps during the surgery so we continue to ventilate for 3 to 4 minutes before the saturation drops so during that process 3 to 4 minutes we start suturing the trachea to trachea and keratinum stenosis so once the anesthetics start no saturation is going below 90 okay give me the endotracheal tube and continue the ventilation for next 5 minutes so it's a continuous process that we do it's called cross-stream ventilation and the modified technique what we do what we did in the recent 50-60 cases is that so from above down from the larynx we put an aerobic exchange candidate so and we continuously instill the continuous hydro oxygen to the distal end so we don't ventilate the pressure to the we just only give the oxygen so with this we have got about 20 to 25 minutes of precious time where you need not to intervene in your surgical technique so at the end of 25 minutes if you see the CO2 it becomes 70 or 80 and you can do the hyperventilation and CO2 becomes normal so we have modified this kind of technique so this is how we do it in case of caranal surgery the problem comes in caranal surgery in caranal surgery once you are going to suppose to the right the left main broncus can be integrated with the aerobic exchange and you can ventilate the left and you can get the saturation but the use of echo is very very very attractive and people are doing the conscious techniques we have a lot of techniques what are the real world challenges we get this kind of patients even though when we know that the surgical is very different in management blood vessels can be used so we can all discuss so many questions what is surgical management how we get all these kind of cases we can do the management session thank you thank you so much thank you now we have a next speaker Dr. Avan Vidarish he is assistant producer faculty he is an employee Dr. Avan Vidarish so, Navi Mumbai and he is talking about therapeutic proposcopy in management central area of section in technical section always man thank you thank you sir for that kind introduction can we see the screen please thanks Dr. Lokesh and Manipal came for inviting me here I will be talking on therapeutic proposcopy first two talks were so excellent and Dr. Avan Vidarish has spoken about most of the heart and cold therapy my job is actually to summarize all this put it all together in multiple management of palanquin syndrome obstruction second part of my talk I will try to answer this is technical success always clinically relevant the question itself carries a lot of wisdom malignance after obstruction please, the tumor which is obstructing trachea right-wing bronchus, left-wing bronchus bronchus is intermediate is essential or proximal there most of times tumors the secretion edema and bleeding are responsible for critical air canal we all know the air balloon diameter traditionally it is thought that 5 millimetre will lead to symptoms on exertion while less than 5 millimetre because symptoms are pressed however practical purpose any obstruction more than 50% will lead to symptoms and we need to do something about it whether it is surgical, whether it is from hospital and also remember all these patients will have co-existence pulmonary comorbid C-O-P-D-I-L-D, pulmonary embolism or effusions so one has to be very sure that your patient's symptoms are related to central area rather than any other comorbid so that the success of the procedure depends on for symptomatic patient and in further talk we will keep on listening what symptoms are symptomatic because that is the key when you want to intermittent if this disease is untreated it will lead to comorbidity a lot of morbidity including the respiratory failure or semenopthesis the survival just 4 to 6 is not treated among the ekilavachi it is most common it is air cut tumors, central air tumors surrounding structures like lung cancer miso-virus thyroid medestinal tumors, lymphoma of that matter we have already taken this but in endoluminal disease in endoluminal disease in endoluminal disease you have external compression by a tumor which when you have both endoluminal as well as app or luminal or external luminal component the common signification of chest x-ray and PFT they are of least use during management of mining and sensory obstruction chest x-ray may show you collapse consolidation or medestinal division that point towards the possible airway tumor the first investigation of this patients available against contrast it will tell you about location, height, extent of the disease and it will give you idea about historical area especially the reconstruction imaging with virtual microscope we will tell you more about the area architecture present where it is better it is functional below the tumor obstruction contrast is especially used when you need to know vascular environment your medestinal and vaginal vascular structures because you would not like to intervene it is a bad prognostic marker when you try to intervene in suspicions and it will help you to rule out alternative diagnosis like eye, knee or muscle embolism bronchoscopy is the next investigation of choice in addition to the CT fine advantage it will tell you about the tissue diagnosis ultimately your treatment depends on what is the viscopathology suppose you are living with a lymphoma or small cell lung cancer the treatment they get from the surgery or intubation process to chemotherapy therapy you want to be very cautious during the bronchoscopy and you should have region bronchoscopy stand by because you may have bleeding or edema that is compromising the environment and it will convert your relatively stable patients to unstable patients for the management of vaginal central obstruction you look at certain factors how emergency is your that obstruction is causing the respiratory failure how symptomatic is your patient if the woman is more than 50% obstructed and it is a high risk high risk region is likely to progress if not treated early if these factors are absent we look at whether there is surgical colleagues and we have extended surgical department and data whether there is curative surgery is possible it is not most of the patients not but a primary error tumor yes the benefit can be given looks for whether evo radiation but you see this all will lead to a delayed resolution rather than an immediate effect so for immediate effect what we look at is the therapeutic bronchoscopy and in case of emergency therapeutic bronchoscopy will lead to improvement in around 85 to 90% patients though the effect lasts only for 3 to 4 months the tumor will regrow and patient will start having symptoms if not treated with any other further therapy it will prevent and impending respiratory failure and this is the data from aqua registry where the complication rate was around 3 to 9% with rigid bronchoscopy the mortality was around 0.5% of all the patients around who are performing this in the history 30 days mortality was 14% and it was mostly related to the disease progression rather than the center among the investing indications of therapeutic bronchoscopy palliation is the most common palliate for the symptoms palliate for the improvement quality of life second indication is the bridge has a definitive therapy you buy time for your chemotherapy radiation therapy or targeted therapy in our days or if the other patient is surgical candidate if the patient is in emergency carcinoma if you ever develop tumors whether you have benefit of surgery before chemotherapy in presence of infection post respiratory pneumonia you will not be able to do chemotherapy in that situation definitely you would like to review that obstruction first and go ahead with chemo and rarely it is cumulative your surgery success of a procedure depends on certain factors and they are very well described in literature how acute is the presentation if there is patient presence with breathlessness for a period of 2 to 3 months the likely obstruction is disturbed so the chances of success are more in the proximal obstruction than in the distal area imaging wise if you have functional vascular supply or if you have a recent collapse if you have a previous imaging for comparison you are excited that did not had a collapse earlier and now efficient electrolysis have collapsed within the 4 to 6 weeks the chances of opening that airway is definitely beneficial regarding the tumor characteristics if you have a proximal tumor if you have pediatrics where you can grasp the best of a tumor and restrict it in total where the disease when it is purely intrinsic or purely exclusive the chances of success are more and evaluation for the distal area or parenchyma in concurrence with the CT scan you will do a bronchoscopy with a thin bronchoscope enterothin bronchoscope see your distal airway and you can do a simple suction catheter test put the suction catheter around the ball of the tumor in the first term in a recent collapse the chances of improvement are more the poor prognosis factors are patients poor performance care the patient is not even able to walk he has brain metastasis or he has extensive lung disease there is no point in opening that airway because patient is not able to enjoy that benefit chronic respiratory diseases active smokers those who have systemic diseases like diabetes, respiratory failure who has anesthesia higher prognostic ear follow anesthesia related complications and if you have fistula improvement with your intervention process are less more distal airway and no functional parenchyma is better in your contraindication in management all depends on what type you have if it is extra luminal you do balloon dilatation and stenting in end luminal disease you go for immediate effect like mechanical cori, microdebrator and Dr. Lokesh has seen two nice cases about it you can use a hot therapy like ABC laser quadtree Dr. Arvindalaga has already spoken about it and cryotherapy as a cryo-lubal key in addition to mechanical cori you can use therapies with delayed effect state cryo therapy which is not available here brachica therapy which is a radiation therapy and a photodiagnetic therapy which depends on time injection photofilm time injection followed by light therapy of a laser frequency around 630 nanometers first they give the dye photofilm followed by potato as down the line they give light therapy inside to debug the tumor this will all have delayed effect in India we don't have photodynamic therapy and one of the conditions is the photosensitivity where even in western countries where there is no sun for most of the year still the chances of having photosensitivity is around 60% in India sun exposure around the year definitely this therapy is not practical at present and experimental intranational therapies and micro wave therapy are still experimental even Kivo and immunotherapy have been tried inside relations with promising results but we need more prospective trials in interest of time I will just go through a practicality which is still practice at Kata and we have few patients who have been treated with this these are for patients who have localized disease who have symptomatic and you see again symptomatic who have unfit for surgery or those who are external due radiation patients are not fit you are irradiating the medicine of practically so if the medicinal life structure are getting irradiated or more than 50% of lung paragraph is already getting irradiated we don't opt for radiation therapy and those who have significant life expectancy of the malignancy more than 3 months I still call it significant because there are 3 months are really suitable for patient those patients are candidate for brachytherapy contraindications if you have ulceration if you have fistula if you have major recesses around which are going the chances of hemoptasis are more because anyways you are going to cause necrosis and the area may open up that time tumor is complete obstruction if you are not able to put a catheter at this clinic you are not going to take inspection for radiation the doses are decided by radiation oncologist mostly Iridium is used you can have low dose or high dose therapy what is our job comes is putting a catheter and it can be done as a conscious sedation or under general anesthesia we use nasal most of the interventions are performed through oral but for this we use the nasal drug we use the polyurethane catheter guide wire flutoscopy you put the catheter on 2 centimeter distance to the lesion mark it at your nostril and fix it arrange the catheter in sub segment so that it is difficult to then it does not get discharged when you are actually moving patient from your bronchoscopy unit to a radiation unit do not force the catheter if there is resistance use a fluoroscopy to identify your markers where you are going to have a radiation implanted gently remove the scope and keep the catheter in secret and you can see pre and post significant improvement but it takes 12 days for effect to start and patients have given radiation for for few minutes there are weekly therapies you may need a chitronchoscopy and lung toileting for this patients coming to ARS 10 it is set in the topic for this patient in Nalimansi the indication is mostly valuable because we do not have any other definitive therapy the patient needs immediate release you do work for a validation purpose only for spending there are silicon, metal spin the promise indication is expending this for expending this is we do not have any other option you just have to give the patency on the airway so that patient can be extubated from ventilator or patient can enjoy life at home in this tumor or mixed effect where you are not able to completely debunk the tumor you are not able to achieve 50% which is cut up in set for most of the studies that you are not able to achieve 50% improvement whether it is active bleeding and you want to have a camponad effect if you are in Visrila, Kepronco, Malaysia or post-radation stitches the strength may come in as a local region which are restricted to the prakya or main promise we use a state strain where the paradise is involved by states coming to church the two states as I said self expending metal states mostly hybrid states are used they are preferred for patients who are short of survival they are easy to insert you can do with flexible bronchoscopy or anti-radial and the radiologic items however after 3 months it will be difficult to remove that strain and you will start experiencing more and more strain related complications than the tumor complications the advantage of metal states is that it can adapt the nature of the airway so the medicine anatom is distorted in malignancy the states still hold better it has good internal to external diatomation means you have a better lumen with the strains but the complications like fracture, infection, burglaration after 3 months definitely and the radiation issues are expected silicon strains are they require rigid bronchoscopy, they require special skills to put in they require a deployer but those patients who have longer survival those who have some other therapy options like surgery or radiation we prefer these strains the combination is definitely migration is expected, radiation issue and because of that we keep on giving them cellar and proliferation so bronchoscopy to summarize the bronchoscopy management we have for intrinsic disease you carefully plan your ablation with hot and cold therapy you respect the tumor the US says whether you need to do it further and you really need to be wise and experienced enough to where we need to stop during the bronchoscopic debugging, for extrinsic you use state 2 or states and for misdefect you use both both the techniques respect for extreme mechanical engineering, coming to second part of my talk is technical success is really clinically very much, what is technical success achieving more than 50% achievement in the symptom but does it really translate into clinical practice like relief of patient's symptoms improvement in quality of life rescue from life-threatening conditions like hemoptysis and respiratory failure bridge for further therapy means the patient is candidate for further therapy like immunotherapy chemotherapy and you need to buy time so the vitro bronchoscopy many has put and finally whether it needs to overall product survival we are going to discuss this thing in few cases, the first case of 40 to 30 men presented in 10 days of miscarriage of the CP shows there is a tumor in the mid and lower criteria, it is standard respect for failure of patient gets intubated, transferred to our institute we went into the rigid bronchoscopy for this patient with all the concepts and all the complications explained you see the right hand left hand bronchoscopy current is free, you locate the tumor it is located in the mid to lower cancer of criteria, it had a good electroparty snares, you use the multimodality treatment, you like it the best, you characterize, achieve hemoscasies, you need to use additional therapies like apc to achieve hemoscasies, you get a balloon to get a good tumor and you can see that tumor was debilitated with most of part, the diagnosis of adenocystic carcinoma, the advantage here was that we relieved the symptoms we extubated the patient, this is a short segment diagnosis so we referred to Dr. Rohan, Dr. Mohan for further management and surgical colleagues whether they can receive it and with all the mobilization techniques, definitely this patient can have a good chance of cell life so the data also backs this thing, most of the studies are documented there is significant PFT improvement in dyspnea and quality of life improvement after the therapeutic bronchoscopy so it should be given a chance irrespective of what ideology it is when I'm not married then and the site of intervention, it is independent and understand the symptoms are in it the survival is most better with malignant sector obstruction who had successive procedures compared to those who did not succeed with this therapeutic bronchoscopy the second case is the case of lung cancer with brain metastasis who has progression on osmopedic therapy on third month of osmopedic dyspnea and having a collapse on the lung right side with active breathlessness you see a CT there is significant tumor on the right side, we went in with a CT with flexible and all the other arsenals available with snareing, we have laser and snare available at other places we debulk this tumor you try to achieve a good improvement and as you can see post debulking there was a tumor already in the right we debulked the proximal part this patient had symptomative we gave additional as this patient was already progressing on osmopedic therapy and additional time he can buy for next these are few cases where the lung cancer and central area debulking was discussed, those patients who did not had central area disease and those who had central area disease managed with rigid bronchoscopy and had no defences in survival therefore even for lung cancer the rigid bronchoscopy and debulking stands a good role few other studies mentioning the same factors, same findings this was the third case which was called calcium of lung was presented in multiple episodes of haemoptysis, you can see a subcaral mass compressing the left main bronchoscopy we went ahead and rigid bronchoscopy for this patient, as there was active haemoptysis this patient was positive, the survival expected was almost to 18 months so you see a tumor on the left side it is a mixed effect, external compression as well as the hallucination you can see in the wall for achieving a lumen we used the balloon we opened up that airway the lung collapses again, the airway collapses will have post-operative pneumonia and the active haemoptysis you go ahead with the stent which will have tamponide effect as well as it will open up your airway as well to prevent and eat for post-operative pneumonia with Alk, this patient is still making good, it was done 3 months prior so stents in malignancy though we know that the stent infactuation should be avoided, more and more stents you do you start differing from that procedure this was studied last year where they compared stenting in most of the central airway tumors and you see isophageal cancer and the worst survival coming to the lung cancer if you see patients who were stented and this use further therapy like haemorrhagation therapy also should be survived better than those who did not have stent or those who were only stented and have visual radiation therapy so the survival is definitely better you can buy time for the for the further therapy the discussion cannot end without the stenting in malignancy is the case of chlamydia carcinoma of trachea recurrent disease given chemo, given radiation but low relapse, there is another recurrence we have entered with rigid bronchoscopy we try to develop how we do it this is not the best way to do it we need to achieve a good hemostasis for this patient don't use your microdevelopers and all those directly on such kind of patients, you will have more and more bleeding so we achieve a lumen for the tamponade achieve a hemostasis followed by coring, though it is a rare manoeuvre but coring helps especially you have a broadest tumor rather than pedunculated we put a silicone stent the stent was fitting in place in the well we achieved lumen for the 50% this patient was extubated and went home because there was no other follow-up therapy available this patient was tired around 3 months down the line but why silicone stents in malignancy and this was the discussion cannot end without the SPOC trial the SPOC trial compared to the rigid bronchoscopy debulking in patients who were symptomatic who had endolomial disease irrespective of whether they had external component or not the SPOC results were that there was significant improvement after silicone stenting and the effect lasted longer the STIA improvement lasted longer than the patients who did not had a stent stent also acted as a barrier effect as you can see in this example the stent acted as a barrier that prevented regrowth the benefit lasts only for 4 months after that you will have a tumor growth below or above and you may need to do another procedure if your patient survives stents are beneficial for patients treated with chemotherapy as you have seen in our patients the oral survival is not affected so whatever you do the malignancy is going to take a toll and the survival is not affected by majority of interventions so silicone stenting was very good without any negative effect on quality of life so we talked about quality of life we did everything, we opened the airway success we celebrated that day we achieved a lot, patient went home but practically it does not translate this is data from Acquire agency largest institute from US the clinical symptom improvement was only 48% the quality of life is only 42% so why this happens apart from respiratory center because there are other factors which affect patient's quality of life the mobility in psychological space financial space the pain, the loss of appetite all those things will contribute to patient's deterioration subsequent to the intervention but the findings were little surprising the greater the disney, the greater the improvement and patients who are sickest those who have high risk for complication those we try to if you know we do not want to do any intervention this had the best greatest potential from benefit from central airway another study mentioning the same factor small numbers but both the documented that non-descriptive factors pain, loss of appetite are responsible for poor quality of life it's not a disney, the disney improvement was almost in 80% of patients so you need to take in account a total counseling of the family, counseling of patients look at the finances, look at what support patient has at home, where he stays whether the stagnated complications if the services should be accessible to the patient or not any therapeutic intervention another question which is commonly asked when should I intervene, what is an ideal time for bronchoscopy in 9-2 if we do activity we do with thoracic surgery, intervention, neurologist our radiation oncologist, medical oncologist all we sit together in a high risk joint concentration weekly and we decide whether this patient should be taken for bronchoscopic or surgical procedure for emergency, yes definitely to go for therapeutic obstruction the early obstruction patients who are treatment in 9-2 we have not explored any chemotherapy options and if they are chemotherapy response like small cell cancer or lymphoma you go for the chemotherapy radiation therapy and weekly or monthly follow these patients closely, if they land into symptoms you offer them therapeutic bronchoscopy those who are post treatment who have already failed on first line therapy we suggest early therapeutic bronchoscopy because you don't wait for emergency to happen and you do debugging for the patient prophylactically reduce the risk of disease progression and it maintains the quality of life but this is not proven, we need to have a prospective data on this, this is the institutional protocol and policies what we call so mostly if the procedures are reserved for symptomatic patients for patients who have high risk of progression bleeding or hemorrhagic resistance you need to consider in an entity whether this patient should be given a therapeutic bronchoscopy as an option look for whether it's a proximal obstruction if you have functional area, panicama if none of them are present, don't do an intervention if they are present, look for whether it is extrinsic, you offer them the strength if it is intrinsic or endoluminal component you do oblation followed by stenting, if the loom is less than 50% if the loom is more than 50% you can observe them, you can offer them other therapy and those who have failed on first line therapy as shown in the spotlight you can consider strength including a cynical strength so to conclude, the main indication is the symptomatic patients those who are not very much symptomatic in terms of therapeutic progress I think MLEP is the option Institutional Protocol should be followed and the sectors with high work burden should come with some perspective trial, medical center trial for this lung cancer becomes a crony this is now because of the Ayurvedic even immunotherapy the patients are survived in 2 years, 3 years so maybe in therapeutic bronchoscopy we have a shift from palliation to bridge dosage you respect your learning curve in early phases you would I think you might say I want to avoid the stenting because definitely you are going to have more complications as the months go or the patient are survived then technically feasible successful procedure may not be clinically relevant address all the factors affecting patient's quality of life including the therapeutic bronchoscopy but do not refuse it, in fact individualization center strategy should be planned in most of the institutions thank you thank you very much there are some very good amount of information there are any questions for the so I like the idea this central area of friction may not always the removal central area of friction may not always translate into improvement of patient that's the information from you that's the information from you so we go to the next topic next topic is the next topic is from Dr. Ravidra Mehta senior consultant intervention pulmonologist at Polo hospitals Bangalore on the complications of visit bronchoscopy and product shooting how to perform safe visit bronchoscopy and range wave forwarder so Dr. Ravidra Mehta chief consultant pulmonologist at Polo hospitals Bangalore is American Gold Supplement pulmonary and refugiate physician so finally in the field of information pulmonology more than 100 papers in literature innovative techniques like stitch customized spigots and modified machines thank you Mr. Sir for having you let us hand out the mic I am going to do the next Dr. Ravidra Mehta we have a few questions so we have any quality questions Hi everybody my name is Dr. Ravidra Mehta and my topic is pulmonoscopy complications staining and more first of all thanks to Dr. Lokesh who has organized this lovely meeting and called us also to deliver a talk clearly he is proceeding the leaps and bounds in this interesting upcoming field and I see a great interview of talks which have set the stage for this particular discussion so in the time given to us we will talk of these issues let us be very clear that we will talk only of complications of rigid bronchoscopy per se we will talk of rigid bronchoscopy as the actual insertion procedure and not about what happens after you have heard a whole bunch of talks on heart therapy which can have its own complications when the rigid concrete is used but we will not address those because those having had a discussion are part of a different overall understanding we will touch on training and I will give you experiential tips and tricks and as part of an interesting wine lab so the complications of rigid bronchoscopy very important we are putting it into a patient who has a borderline respiratory status or a imperative issue to resolve and you will have to deal with issues related to either the insertion process or a sequel of dealing with the conduit which is for in a patient who has issues so local complications that you can imagine if you take such a big metal bar and put it down somebody's throat then you have to be very sure that it is a giant lovely soft fishing component you will be very cautious and careful so engineering is the major issue globally and systemic is like as I said the systemic the add-on component of kind of respiratory issues which can happen in a borderline patient the medications used to present this procedure and of course analyze medical and cooperative issues which the patient already carries so how we do the procedure what is the substrate we have what exactly do we like to do about this issue and what is the strategy used to present it all can have their own complications paradigm complications as we said probably it is related to the local anatomy injury to the local structure this can be quite bad if it happens you have to be very careful and this is unlikely uncommon but not impossible depending on certain issues such as skills, experience and the learning curve so where as we said and the way around this is very clear just like if I am taking a talk and I don't know how to speak English I don't know my content and I don't know what exactly am I supposed to deliver then I would obviously take a bio talk so if you don't train in the procedure in the right way under supervision and know more about the science and the technology with the skills then this is going to be a problem so once you know that these things are by and large not common at all and you can elevate both your standards of care and training as you try to proceed with the science pictures of local complications unfortunate but there in literature vocal cord injury keep in mind very fragile structures narrow structures, crowded anatomy soft tissue and borderline patient all of these are issues less common than actually talked about an unfortunate laceration with the pussy revolve and of course the whole stack which led to a complication preventing complications as you already talked about it it's exactly the ABCD of how we plan to do these procedures the do's and don'ts will be do your homework make sure your technique is good make sure you protect the structures such as feet canal know your scope and this has been covered by Dr. Gulada earlier always visual and don't go to the line for ever if you lose vision always make sure you get vision there's no point using Indian mythology as a brush like approach over there make sure that your pathway is correct over there and by and large put everything into place related to patient assessment procedure plan technique couple shooting and the collective responsibility of these things to do a successful procedure a few tips for this would be that first of all is the earlier learning what some people like to do is called laryngoscopic intubation but over time the direct one where you go step by step which is being talked about and shown is probably the right way to go the last technique good at it is don't apply and you force this pouring and dilapation seems very short but it is to be done with the right understanding for example pouring never to be done before de-vascularization dilapation to be done with both immediate and long term sequence so many of these things have to fall into place addressed in the prior talks quite likely but have to be deliberately looked at to avoid complications so these are the mantras which are followed to make sure that you do a safe procedure whenever we talk about fairway there is pneumothorax and pneumomedia sternum again not common as a direct complication of laryngoscopic but more related to the procedures out there only has to perforate the procedure or some horrible thing you are not going to get these things on it is an anesthesia strategy patient substrate, he has a bullae or she has a bullae and so on so a lot of it is related to interdisciplinary multifactorial cause rather than the procedure first what about how to manage a flimentary and very susceptible and submit, you talked about that it will be set in the talk pouring you said don't do anything blindly or without having an action plan in mind if something happens something is out of the way sudden de-saturation which is not expected no clear cause and out of the ordinary event keep your eyes clear and make sure that your blood is high lower the excess suspicion quickly add a zoophthoroscopy ultrasound or something to catch these entities and make sure you have a chest tube in the process to be squeezed with modern intervention skills it is quite possible that we will be able to just stock everything and have the skills to manage all these things in a proactive way okay hypoxia and hypercarbia which is the next part of it the cardiovascular part of it the reasons are related to the fundamentals and this is talked of again and again when we talked of bridgedon of horoscopy in general a common pathway shared by the facilitator and the operator so that is very fundamental to our science and of course it is now complicated by a tough airway using thermal applied modalities which you have to drop the FIO through with which the hypoxia has a lower pressure to happen some people like to have apnoic spills when they do their work and so on so that can be a problem if you don't have a good ventilation seal there is a problem with the learning curve and God help you go into bleeding in a borderline situation where hypoxia can be precipitous rapid and protection is better and just be connected fast because the patient substrate the reason we are doing this and so on so a combination of the fundamental aspect the anatomy you take up the tools we use the strategies you use the ability to maintain the homestresses of the patient and these complications are all associated with hypoxia and hypoxia and believe me guys there is hardly any procedure to get into advanced procedures so be ready for it and the only thing is extend reversibility, determine to the patient and your ability to catch them well in advance and correct them so end of the procedure you are coming out with our sequence prevention is related to the discussion on what and how final it is related to teamwork optimization we can use antibiotics and steroids depending on the case ventilated procedure antisemitic carbon dioxide viruses or hypoxemia monitoring that inside a carbon dioxide or transcutaneous is talked about airway securing and there is a bit of doubt nobody can help you if you cannot secure an airway in crisis anesthetists can't do that there are random stories of anesthetists telling people to pull out the religious scope and intubate may be done in crisis by and large a skill should be able to fix his airway with all that dissipation and planning which we mentioned repeatedly having said that you have to make sure this is going to happen sometime or the other so preparation and knowing what to do in a very planned fashion teamwork and work for a blink reflex sequence development is very important take your time we talked about not easy to do and then some nuances of ventilation strategy the check is very useful because it really allows oxygen ventilation to go on machine we usually have simple hand check which we use with oxygen and room air on the other side the other thing which I touched on is planned quick in and out fast appropriate and the things we use are better than any of good you have a good outcome, get up you don't have to give the best outcome all the time if it has a chance of leading to complications and especially when you talk of rigid non-costury so this is the mantra of how we kind of approach this particular science with respect to both the events and complications current complications again this is relative to the hand-latch procedures in the substrate unusual thing so fortunately ECG monitoring is a standard form of blood pressure this is included for you this is something you have to really look at carefully before you do stuff and of course once you have an anesthetist then it's a no-brainer to have the life saving but something which can really be the real thing and even positive policies we talked about there is no specific provision from the hospital it can be part of any procedure specific to scope insertion and some sort of procedures can be manicured and this is either because of a vagal stimulation some kind of stretching areas like your carina or balloon or it is not rigid per se directly medications and especially portfolio fentanyl and manipulation so these two medications and manipulation are the two major things over here and usually you can watch it because this is very fast I think anytime you have to give medications persistent cardiac area there is a couple of major things and one of them is hyper-captain inadvertent, unmonitored progressive, high-talented it can lead to problems literature we have already shown in the Chattas stuff over there now here is one more in respirology a good number of patients where they had 6.7% non lethal complications there was a 1% very procedural mortality and a larger 30 day mortality but by and large this was related to the procedures in a stick court and so insertion of the conduit which I am trying to focus on and trying to delineate A from B should not have such a high complication rate it is more the stuff we discussed in the prior sites and then something which is very painful to us so when you fast children this is not relevant to me I am good in what I do rigid bronchoscopy is not a problem it comes down to maintaining your equipment so damage to bronchoscopic equipment and just think a large metal conduit relatively if not sharp relatively sharp edges over there going in and out of there is an ankle issue then you can get into trouble understand that though rigid bronchoscopy is talked about most of us put the flexible scope for distilled access and for procedure so the flexible scope going to a conduit can rub on the sides it can be lack of leading to damage and so on so equipment damage is an issue for the person if you are not cautious and the telescope goes ahead of the bevel then you will not see properly you can get telescope damage also also excessive bending people who try all sorts of maneuvers and they they should think as they are not able to get through you see them bending doing all those things stay calm, watch your equipment straight stuff to stay straight flexible stuff to stay flexible few mantras are there and you can prolong the life of your equipment it is a big problem and it can be an unfortunate show big environmental progress in brown college what about Indian data and complications there was some current in games and has not from HGPGI where they said that they had you know in their first series had some complications which included minor bleeding, upper lip injury the same lot but not a lot keep in mind both are teaching centers so the teaching centers probably in the course of training will go through some more stuff similarly Dr. Ashwin's series also in 121 patients bleeding and all was there but not related to vision per se the very few complications related to local complications related to the insertion procedure but keep in mind it is there for example in this paper you have 10 patients who got all this sort of complication and vocal cost which includes that it is 11 you just see the series over there well so in case you are not careful this will be a major problem and that is an issue because you start with one issue and on the other hand the patient gets unfortunately literally stuck with a second problem so something to keep in mind now a case to show you how these things can be looked at is the real world situation try and decide how to handle this and it cannot be totally only related to vision per se insertion but illustrates an approach a 60 year old male with C.F.H.A. technical upper airway central air obstruction you can see a large mass out here it makes you wonder if I put a vision, can't you what's going to happen? it has to be fast, it may it has to stop before the tumor and eat some hot cold therapy do I have to go so right from with procedure local complications hypoxemia hypercardia, bleeding sequelae, all of those are possible in the first two minutes of putting the scope so then what do we do we plan further so we see that this is a complex issue we then do a sort of a hybrid procedure in this case we passed a tiny tube a macro lens sort of tube distilled to the tumor to try and secure the airway so that we are not going to deal with that you put a vision from the top you can see the MLS within within the vision and then we position the vision at the vocal thoughts and use the very effective fuller lasers to try and re-fascularize and then we go through the whole thing so the more atroast and skillful of us would say I don't need all that I can just use the snare and do it but the more experienced that will also say but do we have everything in mind when it comes to safety so here illustrating those principles of local issues hypoxemia, hypercardia and problems we have used a multi-modality approach so this is what is mentioned over here where we use this sort of out of the box strategy to make it safer now the last viewers are training in digital microscopy now guys got up and said you know what let's fix procedures so this is debated all over the place in chess they said you need 20 to buy a large learn and maintain per year so that is the whole thing so different guidelines over there 20 to 15 they said use the simulator you know on a damaged people's anatomy in your learning process and can be life threatening and then comes this particular BTS guideline and says that you know what some guys are brilliant and some guys are slow can be nearly put a cookie cutter model or should we actually look at an individual as customized learning nobody knows the answer but in my opinion most people will require that 25 to 15 to get their hands on a good confident all situation into which it's not that you can't do it but somebody has a short neck somebody that is sticking to the vocal or somebody has a difficulty in jaw opening all these are patients so you need a certain learning before the anti coordination is able to go through it outliers will always be defined the rule but that doesn't define the rule. I'll try to end with some facts and after results and tips and tricks so I'll leave you with this which is potentially dangerous instrument so away from the typo this is picked up from Henry Ford statement articles. Technique is gradually perfected over time most complications are related to poor insertion technique we've talked about it and the major avoidable complications are everywhere perforation this is to be mentioned hopefully never to be seen don't try to intimate there before there a speaker sufficiently and is surprised and that's why your messages matter a lot and you have to be also on board with this particular understanding after you get this open then the game is what you have picked up as a patient what is the procedure what are your skills and what is gas exchange and arena and so it's a different discussion but it's part of a comprehensive procedure understanding understand that whether it's insertion or later oxygenation and ventilation always take priority or worry manipulation so one I always say that interventionist is basically multitasking to the head so anybody who told you that you don't have to multitask probably will not be able to get into this suite because though you have your anesthetics and practitioners you are the ringmaster over there and you have to call the shop and everything which is happening so keep in mind you have to be very sensitive, high alert and always do it on a fresh mind body complex so that you have to minimize all these complications with a clear level of understanding tips and tricks do this carefully, worth the investment and know yourself, if you are a slow person take your time, if you need time for hand dry coordination it's okay no competition, no race do it carefully, do it safely and don't forget intubation is just the beginning of the whole thing, then you are going to see the start so don't have a mishap or a goof up in the beginning in the learning curve you get probably an initial learning of the topic and often anesthetics will do it but it's nice to know direct or later because it represents a skill set and understanding which is also important this cannot be undermined or understated under vision, you lose vision in the beginning at the beginning later get vision back leave the scope, do whatever strategy keep in mind no other scope switch has been covered by in the beginning of this most of a lot of this has been partly covered or mentioned in the top statement, know your scopes, know your anesthesia, your techniques what don't therapy and so on take time to establish adequate ventilation, that there is growing things are coming out, then only can you start working, don't start in a rush, pause and pontificate to allow gas exchange if the patient is okay you will get tired, if you deal with a borderline situation you will require higher skills, don't do that, keep your skill level moderate, the requirement of skill level moderate, that better planning and a few precautions including time management use instruments judiciously you keep on suctioning all over the place and so on, you wouldn't cause hypoxia and hypercardia, be careful it's very nice to see some jelly instruments and some high technology it doesn't matter to the patient fellow walks out stable, you do a successful procedure, you give him a good outcome, his work, everything and no technology really will be important to the patient unless you ensure the basics I'll go with caution no need to caution, this a mature tendency to say I want to go has to be tempered with the understanding of going so it's not necessary to go in and go everything upfront, unless you have thought out the ABC of the whole thing this word has been talked about everywhere and I keep putting it here work as a team and the acronym is expanded to together everybody achieves more which is a nice thing to say understand that the digital grandmaster becomes to survive, you move up you'll be dealing with too many issues and we none of us want to go on that pathway more nuances, complications in my opinion are seen and there's multiple scope changes happening in a rapid procedure crash information, which also can be a problem, inability to position well, with no spinal cord issues or something you haven't planned it well and operator aspects, you know and experience with freeze and panic and you move here and there so established setups will not go through this but they will have to suffer in training and teaching as was shown in the AMS and HGPGA papers so somewhere or the other we need to be very cautious so to summarize the whole complications, inevitability restitution, the statement is there for all of us, if you do the numbers you will see complications more in the learning program and in the circumstances, inevitable but detrimental, so you got to do everything for prevention basics, planning assistance, procedure aspects, what are we doing and understand that on a reality note that happens if we don't put all the precautions into place it is exciting to do this in a very proactive way but it is also discerning and discomfortful if you have any major issues keep the values uproar so as to be a good professionalist. I end on this funny note that the practice of intervention can put you in a tight spot manual metro, we are the representative of all these things and it's important to be aware of input system into place, technology but you need both experience and application. Thank you for the close attention and have a lovely meeting with me. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. in Act 2 and we are doing this procedure because the safety of the patient and first procedure life of the patient is most important. Thank you one and all. I take the privilege to thank the chairpersons for chairing the session and I welcome Dr. Ramu sir and Ramakrishna sir to present momentous to the speakers. I invite Dr. Nagarjuna sir, Mohan Menkates sir, Dr. Paran sir. Sir, Satchegra Singh sir, head of E&D department from AIMS to present momentous to the chairpersons of the session. Now moving to the third session, I welcome the chairpersons, Dr. Banu Rekha man, head of Palmanji department from Dr. Peasants and RF. Dr. Yugandhar sir, professor of Ashram Medical College AIMS. Yes, Mohan, 30 publications in various industries and it is also one of the first to perform OCD medical arts is done by absolutely. So with this, I welcome Dr. Visweshwari, continue the talk. Good afternoon chairpersons, seniors and friends. So today I will be taking you to the very interesting topic which is the tale of two fistulas and how are we going to manage it by the anthroposcopic route. The first and the foremost thing which we will be dealing about is the tracheoesophageal fistula. So tracheoesophageal fistula is nothing but a pathological connection between the trachea and the esophagus which leads to the spillover of your oral as well as the gastric secretions into the respiratory tract. So it can be either a congenital disorder or it can be an acquired and when it is an acquired it can be because of a benign etiology or a malignant etiology. The common cause of an acquired tracheoesophageal fistula is generally esophageal cancer which happens in more than 10% of such patients. And moving on to the etiology and risk factors of the benign tracheoesophageal fistula, this can be seen whenever there is a history of any prolonged mechanical ventilation by means of an endocrine tube or a tracheostomy or whenever there is an excessive pressure of the eti tube or the tracheostomy or there is a trauma to the chest of the neck or a traumatic area of intubation or because of granulomatous gastrointestinal infections especially in a country like India where there is a high incidence of tuberculosis, stent-related injuries as well as an ingestion of foreign bodies or a corrosive body. And with respect to the malignant tracheoesophageal fistula, any cancers that arises from the esophagus, the trachea, the lungs, the larynx and thyroid has a propensity to cause the tracheoesophageal fistula. And the most common site generally where the fistula occurs is in the upper and the middle of the esophagus that there is a connection between them and the posterior wall of the trachea as well as in the left main stem bronzes. In addition to the cancer whenever you treat a patient with cancer, response to treatment can also result in a tracheoesophageal fistula because what happens is when a treatment is given, the malignant cells disorder and during the process of healing tracheoesophageal fistula can occur and generally when we take biopsies from such tracheoesophageal fistulas it may come malignancy negative as well. And with respect to the clinical manifestation, most of your patients who come to you generally presents with a history of cuff, they can also present you with aspiration, features such as the aspiration pneumonia like fever, they can have dysphagia, pneumonia, haemopsis and chest pain and there is a peculiar sign which is related to the tracheoesophageal fistula which is referred to as the onosync where there is a worsening of cough with solid or liquid foods which has an underlying aspiration due to the test. And whenever you have a mechanically ventilated patient, if you feel that there is a continuous air leak in the ventilated circuit despite a well inflated cuff or there is an abdominal bloating with ongoing ventilation or there is a loss of a tidal volume or a worsening of oxygenation or there is recurrent pulmonary infections in an intubated patient or if you are not able to leak then always suspect that there could be an element of a tracheoesophageal fistula. And with respect to the radiology, most of what you see in the lungs are the aspiration related changes and you can also find out what could be the possible etiology of the tracheosophageal fistula like you can find out whether there is a lung cancer or there is an over-inflated cuff or there is a widening mediasystem from the granulometous disease or there is a pre-existing esophageal stem. And the most important thing that will help us in definitively saying that there is a tracheosophageal fistula is the barium swallow and it detects the P.E.F. in 70% of the cases but however it cannot be done on a patient who is already on a ventilator. So in such patients one thing that can give you a clear-cut idea whether you are dealing with the test is the CT scan of the chest which can help us to understand whether there is a P.E.F. or not and it will also provide information what is the anatomy at which it is occurring as well as the pathology that is causing this tracheoesophageal fistula. And this is how you see when you do a barium swallow for a patient with a tracheoesophageal fistula as you get a case of lung cancer you can see a clearly demarcated tracheoesophageal fistula. In addition to this you can see secretions coming from the esophages into the ovaries. You can see fungating growths which mimics the tracheosophageal fistula or very rarely what you can see is like a tumor like thing. But when you suck out the secretions from that you can clearly make out a presence of adhesions in the posterior wall which is nothing but a tracheoesophageal fistula. So before we move on to the management of the tracheoesophageal fistula there are few things which you have to do on a conservative basis before you take up these patients for a therapeutic aspect. The first thing is an acid suppressive therapy with either a H2 antagonistic or a proton pump inhibitors. Make sure that your patient is propped up with at least bed eluated to more than 45 degrees and strict limitation of an oral intake and a frequent oral sectioning and in case if the patient is mechanically manipulated put the endotracheal tube distally so that the cuff is below the level of the tracheoesophageal fistula and try to avoid nasal gastric tube and oral gastric tube because that is going to increase the tracheosans and can worsen your tracheoesophageal fistula and in case if you are planning to feed a patient for whom the tracheoesophageal fistula is that mean for a quite long period of time, make sure you place a gastrochomy tube or a judging of the tube for an endone feeding so that you remain the risk of asphyxiation. And now comes the role of the bronchoscopy in the management of the tracheoesophageal fistula and one of the most important things that is always tried when we see a patient of tracheoesophageal fistula is the stenting. This stenting can act like a bridge for a benign tracheoesophageal fistula before you take these patients for a complete surgical therapy or it can also help in palliating the symptoms when you are dealing with a case of a malignant tracheoesophageal fistula especially when the patient complains symptoms of aspirations, dysphagia or worsening respiratory status for a poor nutritional status. And esophageal and or arrhase stenting can seal the fistula and can prevent the spillow of these contents into that arrhage and thereby can prevent the pneumonia. But however one thing of caution is that when you use an oversized stent you may even end up increasing the dedicence and that it may even worsen your tracheoesophageal fistula. And with respect to the tracheoesophageal fistula most of the cases unfortunately lands up with our gastro colleagues and so what happens is the first thing which they will do is an esophageal stenting. Whenever you have got a middle and distance sections of the esophageal then probably only your esophageal stenting may be sufficient enough to prevent the risk of aspiration. And generally the covered stents can provide much better protection than your uncovered stents. But the problem with the covered stent is there is going to be a higher risk of migration. And for a patient with benign esophageal disease self-expanding plastic stents can also be considered before they are taken up for a permanent surgery where there is a complete closure of the esophageal fistula. But here comes our rule as a pulmonologist when are we really going to consider the airway stenting for a tracheoesophageal fistula generally the self-expanding metallic stents are preferred over the silicone because if you have got an ease of deployment you don't require a rigid conduit you are able to achieve a better opposition of the airway mucosa it can be placed with just a flexible bronchoscope using a guide wire or a direct fluoroscopic guidance and can be deployed and revised in technically difficult locations compared to the silicone stents. And therefore since it has got a better approximation it also results in a lesser incidence of your migration. And the indications of airway stenting whenever there is a pre-existing airway stenosis along with the tracheoesophageal fistula the airways are to be stented first. Again if you are going to have a tracheoesophageal fistula in the proximal airway then the airways are to be stented first before the esophageal stentate and whenever you stent such fistulas make sure that you give a safety zone of at least 2 centimeters at the either ends of the stent. And in few cases silicone can be preferred over the metallic especially when you are dealing with a case of a benign tracheoesophageal fistula like in a case of a tubercular bone causing a fistula's communication between the trachea and esophagus that probably putting a metallic stent might be risky because that has its own set of stent-related complications And this is just a video for all the post-graduates here and this is how the metallic stenting is done So first the guideway is passed and you measure the proximal and the distal end and you place the markers now you can see that you are placing these markers over the radiopic markers as in the form of a pin you place it over the chest wall so that you know where your proximal and distal end of the stent should be Then once it is done you introduce the deployant this is how a stent deployant looks like and when you pull out the cap you see that the stent is getting deployed from the distal end into the proximal end and you should make sure that the proximal end and the distal end of the stents are covering the entire part of the dedicence as well as providing 2 cm margin on either side of the tracheoesophageal fistula and this is how your, when you place the stent this is how your bronchus really looks like that there is a complete closure of the anatomical dedicence and in addition to this in case let's say that you are going to have deal with the case of a benign tracheoesophageal fistula or if the tracheoesophageal fistula is at the lower end of the trachea which is very close to the carina then there is also a role of the silicone stents and in this case what is being shown is a silicone wise stent which is getting deployed for a case of a tracheoesophageal fistula which is involving the lower end of the trachea again some of the things which are tried is dual stentings that is we are going to put a stent boat into the air base as well as into the esophageal we are going to do the dual stentings so dual stentings can be considered as a first line intervention in the management of the tracheoesophageal fistula especially when it is involving the middle to the crystal trachea the idea behind putting a dual stent is you want to close the opening from both the ends so that you are going to have a 100% surety that the contents are not going to spill into your air base but the problem is whenever you put that your upper margin of the esophageal stent should be higher than that of the air base stent but if you are going to put too many over sized stents then you can also result in the worsening of the decisance as I said before and it may even land up in complications so generally these stents are put when you feel that you are not having an adequate approximation or you are having an associated airway abnormality or an airway stenosis and now once you have stented these patients with the self expanding metallic stents how you are going to know that your procedure is successful you put an esochastric tube or a orogastric tube and inject the methylene blue and then pass your bronchostopia to see if this methylene blue is entering into your airway or not if it is not entering into your airway then probably you have attained the goal with which you started the procedure and using a barium swallow can also be helpful if you are not able to do the methylene blue installation to check for the closure of the recto esophageal system in addition to the self expanding metallic stents and the silicon stents there are few other things which are tried one such modality is the fibrin blue so what they do is these are generally used for small fistula such small fistula can occur when you are taking a biopsy of a tumor of the airway or it can occur because of some node erosion into the airway so whenever you feel that the diameter is less than 5 mm then probably you can use a fibrin blue which causes the opening to get closed and it also forms a scaffolding for the re-epithelization to have in addition to this there are other materials like ace and matrix which is a desiliterized coarsen urinary bladder matrix these all can help in granulation and that way closure of your recto esophageal system one another device that has been tried in the closure of the recto esophageal system is the amplacid device this is nothing but a device that is used for the closure of the ASD as you can see from here it has got two baskets one which covers the opening at the end of the esophage and one which covers the opening at the tracheal level but the problem with this is since there is a protuberance of the material into the airway it can cause airway abstraction from mucostasis it can cause excessive granulation formation and it may even result in a new tracheal esophageal system and generally these are not indicated for routine cases of tracheal esophageal system and can be tried in some exceptional cases when you feel that the defect is too large or you are not able to properly extend this patient for a tracheal esophageal system in addition to this from the esophagus side our gastro colleagues do something which is referred to as the over-the-scope clip if the dedicence is too large where they feel that the stand putting a stand can result in further worsening of the dedicence they put a clip so that the two ends of the dedicence are held in place and the esophageal fistula is closed in addition to this something has been newly come up which is called as an endoluminal vacuum assisted closure which means they pass a dedicated mesogastric tube which has got a foam at its tip and this foam enters into the point of dedicence and causes granulation and a vacuum is supplied so that all the secretions are taken out that like preventing the risk of immediate aspiration as well as helping in the closure of your esophageal site of the fistula so to put everything into a nutshell if you first of all you decide whether your tracheal esophageal fistula is a 100 litre or an aquaid if it is an aquaid make sure that you are dealing with a benign meteorology or a malignant meteorology if you are dealing with a benign meteorology see if your patient is if this is onto your left hand side see if your patient is hemodynamically stable or not if the patient is not hemodynamically stable you first if it occurs it's been 30 days of operation and we call it as late BTF if it occurs more than 30 days of operation and what we as phenomenologists especially in a TB endemic country see is generally a very foreign BTF here there is a communication between the pleura and the avid of the lung panicama and very rarely until and unless you are dealing with a transplant unit or to see a lot of RPA or a corkotomy cases being done we generally don't see this central BTF and this is how you see a CT scan whenever you get a BTF there is always going to be an evidence of a hybrid pneumocorex and this clearly indicates that there is a fistula communication between your bronchus as well as the pleural cavity so several factors has to be taken into consideration if you deal with such a case of bronchopulmonary fistula see the medical condition of the patient if the patient is going to be extremely sick then these are the patients who may not be amenable for surgical correction and in such cases your bronchoscopic can act as a bridge to the surgery mean when you make sure that the patient condition improves time of the onset of the fistula as I said to you before when it occurs within the 30 days then probably there is a surgical complication and that has to be addressed it also depends upon the size and the location of the fistula as well as the state of the pleural cavity and most of these patients with the BTF generally are sick looking, emaciated they have got a lot of pus in the pleura so then put your ICD, drain the pus fluid and then take up these patients for intervention and with respect to the bronchoscopic approaches in the management of the BTF you have got a lot of things in your armatorium you can use a sealant as we saw in the hybrid pneum you can use a silver nitrate coterie you can use coils, you can use endocromical stems as well as you can use spigots so in most of the western countries where there is an access to the endocromical valve people use these endocromical valves what you see on your left hand side to close the particular segmental bronchoscopic from which the leak is occurring similarly what people have tried is they try to bypass, let's say that the leak is arising from the right upper-load bronchoscopic so they put a stem so that the covered portion of the metallic stem covers the right upper-load bronchoscopic and therefore the BTF closes in addition to this people have tried using a customized silicone stem where they take a portion of the silicone stem make sure that the distal end of the silicone stem is sutured so that now it becomes a blind end and that is then inserted beyond the stem so that BTF closes in addition to this it is our own way of doing we did it in one or two cases where at that time we didn't have the spigot there was a shortage of spigots so what we did was instead of taking the stem we used a silicone urinary catheter we took a portion of it we made our own silicone stem and then we inserted and we worked in on one cases but in another case it didn't work so here I end my presentation with last two cases so this guy is a 60-year-old male he has got a bilateral extensive emphysema with old pulmonary tuberculosis with a left lower-loaded bulla with left side of pneumothorax with ICD with non-resolving ablique for one month so when the patient came to us this is how the CT was looking like the end pair lung was bulla and when you see the lower-load of the left side the end pair lung was filled with the bulla and there were complications where surgically neither you can do a lower-cumming or a pneumonecumming because this patient is not going to come out of that medallion so in such cases the only thing which we had was a bronchoscopic lotion so what we are doing is we are doing the sequential balloon dilation so we go into each of the sub-segment and inflate the balloon and that means we know that this is the particular sub-segment from which the leak is occurring so once we know from which sub-segment the leak is occurring then we are going to occlude that particular segment now what we are saying is a proprietary balloon which is being passed into the balloon and sequentially each bronchi is occluded to see from which part it is leaking and once we know now what we are doing is we are taking a silicone spigot these are called as the water knobby spigots we are holding it with the help of a grasping force going down under a general anesthesia and once we have identified we are putting these spigots in that particular portion from where the leak is occurring and we are leaving this spigot there and once it is done this is how the patient on the day one had reduction in the BPF but it was not a complete closure but by day two the lung has completely expanded and almost by day three or four we were able to take this patient out of ICU these are such cases that could not be done that is why we ended up doing a bronchoscopic closure of a BPF this is yet another case where there was a 75-year-old male, he had a CA pyriform sinus the patient had a sudden worsening of breathlessness this is the case of an ILD with a CPF with a secondary spontaneous pneumothorax black patched stride, not resolving there is a persistent BPF with a self-folio classification of grade 4C and multidisciplinary discussion was taken and in view of high risk of surgical correction and comorbidities and high oxygen requirement the patient was then subjected to what we referred to as the bronchoscopic closure of BPF so this is how we are going to do so this was the BPF that was there according to the procedure as you can see that there is a continuous bubbling from the ICD column which suggests that there is a self-folio grade 4C BPF once we know that the BPF is there now what we are doing again is again we are doing the sequential balloon occlusion to identify from which sub-segment the BPF is coming so once we have identified the sub-segment this is the customized silicone spigot which we used in this case because we didn't have enough what an obvious spigot we identified a particular loop from which it is occurring and we left the spigot in place in addition to this since the leak was occurring from multiple sites we had to use multiple spigots so we took almost 2 or 3 spigots we left the spigots in place but one problem with these spigots is sometimes these spigots may get dislodged when a patient coughs or when the patient comes out of general anesthesia so what we are doing now is we are bronchoscopically instilling the blue which is the cyanocrylate blue so that this balloon sticks in place and once the cyanocrylate blue is passed and this spigot is placed in position you can see that the BPF is decreasing so this is how it was there it was not a complete closure but there was a partial closure but after 3 days there was a closure of the BPF and the patient was doing good so I would like to end my presentation here and if there are any questions we can take Thank you Dr. Suresh for your lucid presentation on the various cases where there are things to add also the bronchocrylate blue so we have the questions now I have a comment yes I wanted to I wanted to tell the institution about that we follow at our H.U. we have the trachea or bronchiocytitis experience of more than 14 or 15 cases in the last 4 or 5 years and about 10 less trachea than the last B9 so straight forward the benign cases goes for intervention, non-surgical aspects so the benign cases we prefer not to put any kind of spines in the A-way because the peri bronchial and peritracheal adhesions if we want to go for the deferential surgery they can cause difficulty during the surgery that's why when it is possible so we prefer the strands within the A-way and then we directly go for the surgery if it is in the thoracic cavity like few days back we did a 90-year-old female from Pune with carion isopetal fistula sometimes we have 3 or 4 cases with left-made bronchus isopetal fistula, mostly close to the blood in all these cases what we can do we can go by max and we can loop the isopretas and divide this fistula with the staples and we can interpose a vascularized tissue between these two structures so that we can have the hermitage patients if the surgery can be done as you said so it is the best way of therapy and it's not of course the strategy of the best way in vinaigretiasis even we generally try to avoid as much as possible and most of the cases for what we have done was also we had a limited experience of dealing with a classical central BPL so we don't have much of experience because we don't deal with so much of central BPL we deal with most of these peripheral BPL like as I showed to you as you rightly said any case of a vinaigretia generally the stent is not to be put and in case if it is any so we do a central as window procedure we have to completely drain the plural carassials and then we do the definitive surgery after that post tuberculosis patients most of your posts they do the PC window and the even the post marital disease for a new moment I am very happy to introduce and welcome Dr. Bahraraj to talk about the second intervention pathologist just hearing Karthi Deshmukhi and he will be talking about age of foreign bodies and he doesn't need much introduction he is welcome for age of foreign bodies all of you are well known so I welcome you sir thanks for the kind introduction I would like to thank Dr. Lokesh Dr. Uday in the team and brother for giving me an opportunity to talk here so good afternoon everybody can I have my presentation so first of all greetings from I come from this coastal city so today we want to talk about the problem in its time is to see what are the different types of instruments available to remove every foreign body whether it can be rich or flexible because some different types of presentation, different techniques so each has its own how to take out the air for a particular to come to the instrumentation so in the flexible what we need to understand especially in pediatric age group we need to know the exact type of the dimensions of the bronchoscope because as the age decreases the size of the trachea changes so that's the what kind of bronchoscope are we are dealing with and what are the instruments which can go into that bronchoscope otherwise we are not going to have a good case so these are the four categories what we have in flexible instruments the most commonly used one is the basket so it depends upon the age so if you have an adult you can use a larger basket and if you have an infant or a pediatric case you can have a small 1mm nightmare basket this is a 0 tip 1mm nightmare basket it is very very good if you are doing infant and small child next is the forceps ideally you should require something called a sharp tooth forceps to have the maximum grip to hold the foreign body or you can use any kind of biopsy forceps what you have it all depends upon how you hold the foreign body so that you have the maximum grip next is the balloon so the balloon used to basically dislodge the foreign body so that once it comes proximally you can use any other instrument to extract it so balloon primary for extraction is difficult to have much control over the foreign body so it literally slips at the area of the large so that's the reason balloon is most used for dislodging and impact at foreign body next is the triumph no need any introduction dislodge and extract the foreign body so people should be very careful when you use trigo in pediatric age group in adults it should be fine as long as the airway caliber is good so these are the different different techniques how we use so sort of basket you just have to pass it distally open the basket try to grasp the foreign body inside and when you hold with the forceps always remember you should hold at the hinge joint so that you have the maximum grip and always remember you hold the leading edge rather than any two surfaces and as I told you balloon is mainly used to dislodge the impacted foreign body so you pass it distally inflate it and pull it proximally once it's dislodged you can use any other instrument to extract it so the trigo you know basically any authentic foreign body which has a water content in it the trigo can freeze the foreign body and it has a very good grip so it can be used for disimpaction and also extraction of the foreign body at the same time so as I told you this is the gastro forceps this is a large I mean this is a gastro biopsy basket so this can go into a two point day time working channel microscope this is ideally good if you have a larger foreign body so coming to the rigid instrument so this is the pediatric ventilating rigid microscope as you know it all depends upon the size the size changes the first size is the yellow much more 3.5 size cube and it all depends upon the size of the outer diameter of the microscope so what we require is the rigid microscope itself and few adapters this is called the bridge so the bridge is helpful to connect the telescope and the rigid microscope into one piece and this is the jet ventilation adapter this is the full adapter which is usually used for the closed circuit ventilation if you use a bang circuit and this is called as proximal illumination prism deflector light prism deflector and this is how you can connect all the various axis to the rigid microscope so this is the prism and this is the bang circuit and this is the jet ventilation and this is the rubber tip to pass safely secure it so that you can pass in forceps into it and the most important part of the rigid instrument is this optical forceps so this is very very useful and in one instrument you have the forceps and the vision so that with one instrument you can perform extraction easily so this has the maximum grip in rigid microscope so that you can extract which are tightly impacted foreign bodies once you have a good grip problem so there are different types of forceps available one is soft foreign bodies another is hard foreign bodies that's called a beam and this is called an archery forceps this is how it's going to look once you pass this inside the broncosis so coming to the rigid optical forceps so that's the hard optical forceps or the serrated ones which is basically used to extract hard objects like seeds plastic tubes and metallic objects so the idea is to have a good grip any one of the leading edge is sufficient the care should be taken not to damage any other structure once when you are extracting so this is another optical forceps called a beam forceps this is basically used for softer foreign bodies mainly used for beam so there is no hard and fast tool that you have to use a pinet optical forceps for a pinet so as long as you have a good grip with any of the foreign bodies it's more than sufficient to extract so I'm not going to discuss in detail about the different types these are rigid broncoscope instruments we have different companies available but so what we need to do is to know what are the sizes of the rigid broncoscope and in its accessories again we have a dedicated optical forceps for adult rigid broncoscope so as I've told you the advantage is in one instrument you have the forceps and the vision so you don't have to hold optical telescope in one hand and forceps in the other hand with one instrument you can able to extract the foreign body so how do you approve this foreign body cases as I've told you the presentation is in an emergent situation or with minimal symptoms the most important are this because you don't have much of time to investigate and to do necessary investigations and most of the foreign bodies especially the bi-life foreign bodies laryngeal foreign bodies upper tracheal foreign bodies present in this emergent situation history and age are important and if you look at other important presentation whether the baby is conscious echemic or oxygen status and most important is the regional variation of aeration that is the most important point in identifying a foreign body so most of the time this is what is missed and if any patient, any baby child comes with a sudden onset of lower respiratory tract symptoms with the possible regional variation of aeration that is a very very good foreign body CTA and chest x-ray are helpful but at the end of the day you need to go back and ostentate the chest again once you have some kind of x-ray or the CT finding so that you can able to demonstrate the regional variation of aeration CTA is definitely better over the chest x-ray especially in organic foreign bodies chest x-ray is not going to be of much help except there are radiological signs so when metallic foreign bodies chest x-ray so what are the different sites for foreign body impacts the majority of aspirate foreign body are in the bronchate so laryngeal and trachea bodies are less common and if you look at the sites the maximum is at the right one because it is in line with the trachea the least as the larynx and in the trachea and perinus and these are the most dangerous because they obstruct the airway and the presentation is phara so coming to the first presentation which is most common is what you see is an abstract to hyperinflation as you can see very subtle change of hyperinflation on the right side if it is very very evident in like this case it is not easy to miss but these cases are easy to be missed so the idea is to once you see some kind of an x-ray change especially abstract to hyperinflation if you see a collapse there is no wisdom that definitely you can pick it up but once you see an abstract to hyperinflation any subtle you go back and oscillate the chest again so if you feel that there is regional variation of variation that is a very good indication that there can be an informed body impact so in this case there was very subtle abstract to hyperinflation there is a peanut which has been extracted so in this cases you don't require a CT scan to identify whether there is something there and 61 year old hypertensile history of choking up an ingestion of a gelnut presenting with the left lung collapses doesn't require anything so in the so what you can see in a large foreign body which is deeply impacted in the left proximal main bronchus so we tried the flexible forceps balloon and everything everything fair because there is no margin around the foreign body to pass the balloon out of the basket distally so I had to use an optical forceps and extracted piecemeal post elderly lady presented with left lung collapse after addition of the calcium tablets these calcium tablets causes very good granulation reaction whether not easily can be removed unlike the seeds so this calcium tablet causes very good granulation tissue reaction because most of the times you can't extract this tablet in one piece so it has to be extracted piecemeal it's going to take some time so coming to the foreign bodies which are radio orbit and which have a central pole like this is a pearl bead so the easiest technique is to pass a balloon at the central pole inflate it distally and pull out proximally so idea is the main principle in extracting foreign bodies in this case is you should have an instrument in such a way that when you are extracting the foreign body it should not dislodge while extracting in the airway especially at the subglottis so that's the narrowest place in the airway that's the only way most of the times you are able to drop the foreign bodies if you have a correct instrument you can easily extract it so coming to the acute presentation this is the case of a bilateral airway foreign body as you can see there is an acute presentation it was intubated in the ear it is an endotracheal tube which is in the trachea and it is slightly in the right main so as you can see in the right main there is a foreign body there and also in the left distal main bronchus so this is the case of an obstructive airway where you are arrested in the ear so what you can see is one foreign body in the right intimate bronchus and another in the left main bronchus it is an emergency bronchoscopy but the problem was it was very difficult to ventilate so what we have done was once we see the two foreign bodies in the airway what we have done is slightly pushed the right one inside so that we are able to achieve the ventilation remove the foreign body and for the left main bronchus it went inside the lower room we had to use a balloon and dislodge it approximately then only we are able to extract so this is the case where you can see not one instrument has done the job so you need to have either of the instruments or both instruments so that you can able to extract the foreign body in this case the rigid bronchoscopy has failed in the left main distal bronchus so the flexible bronchoscopy was a bigger failure so coming to the tracheal foreign body another acute presentation 12 months old child's unconscious of breathlessness, baby was unconscious gasp in saturation 70 abs and blood sounds both sides so in the rigid bronchoscopy what you can see so just below the just at the subplotus there is a large foreign body that is slightly impacted the subplotus so here there is no amount of ventilation is going to happen in this case so ideally what has to be done is before extraction because there is a big movement down there the moment you try to catch this foreign body immediately dislodged so the best way is to push the foreign body inside in the largest possible diameter that is the carina so you push the foreign body, maintain the ventilation then you can extract with any of the instruments so the idea is first priority when there is complete obstruction first priority is ventilation then extraction because you know that because there is a distilled trachea which is open the moment you try to catch it will fall deep so you are going to waste some precious time so another tracheal foreign body which is mobile so this was not uploaded this was a pen cap what you can see it was moving with respiration so even when this foreign body is moving with respiration it is not so easy to hold it the idea is again just slightly put it in one place let it be there and use another instrument to extract it so what I am trying to tell you in this tracheal and bilaterary foreign body the main issue in this case is before extraction is management of ventilation so ventilation there is no point in extracting the foreign body the patient is dead so it is not going to do any purpose ideally in these cases especially in obstructive cases idea is to maintain the ventilation first then extraction another case presentation of mid-estinal emphysema subcutaneous emphysema with you can see a collapse so what you can see there is a mid-estinal emphysema so that is the lower end of the trachea as you can see the right main bronchus is there is a foreign body the left main is pated and the right intermediate is open so that means there is foreign body there and that is the reason there is some ball ball mechanism hyperinflation probably rupture that is caused mid-estinal emphysema so when you have mid-estinal emphysema you don't have to put a chest strain we had two cases one with mid-estinal emphysema and other with mid-estinal and the left pneumothorax so we placed the chest strain in mid-estinal emphysema care should be taken ventilation again takes place you have to be very very careful when you are ventilating because baby can go into hypoxia because if the mid-estinal emphysema increases so this was a concy which is impacted so we didn't do anything there was no chest tube and all once we extracted the foreign body everything returned back the emphysema subsided by itself so what if you have a sharp foreign body in the area so idea of sharp foreign bodies once you have a sharp foreign body the idea is to secure the sharp tip inside the airway so the best way to secure the sharp tip inside the airway is to pull the foreign body inside the endotrache tube or a rigid romper stroke so safely secure it and you pull the whole thing in one go so that's the easiest way so that the airway new color is not damaged so this is the principle to be careful when you have a sharp foreign body so what if your rigid romper stroke is failed as I've told you I've shown you one case it's almost the same as that older case this was 6 kg 18 month child left main romper's foreign body my pediatric optical forces was not opening inside basket, initially tried with the basket but failed it was dislodging at the level of subplotis we had to use an optical forces to safely secure the edge of the band up and extract it because the grip and power you attain with an optical forces is nowhere compared to the basket, balloon or a cryo so this is an interesting case the young child with a foreign body impacted that's a visible which is impacted in the subplotis there it was better when I saw her around 1 a.m. in the area but suddenly it deteriorated so that's the XA which was showing the visible in the subplotis so initially we tried to push the visor down, maintain the ventilation try to extract it after many attempts what has happened was the one part of the jaw of the optical forces has broken now there is an extra foreign body inside with an visor so luckily in that case I had an extra optical forces the same optical forces were able to retrieve the hydrogenic foreign body first but the problem is the visor was not coming out the reason because at the level of the subplotis because probably of the edema or the impact of the visor the subplotis was very narrow so what are the other options you have balloon, basket definitely it's going to fail when the optical forces fails balloon and basket definitely will fail at the level of the subplotis the reason is subplotis edema that is probably because of prolonged impact in the subplotis after multiple attempts with the rigid bronchoscope so what next we did a serial dilatation with the rigid bronchoscope and extracted the visor in one go so in another case another case a tamarind seed is impacted in the right main bronchoscope these tamarind seeds are very very notorious whenever you get a call of a tamarind seed the foreign body be very very cautious because they can cause immense amount of granulation and this granulation bleed like hell and this was the case where we tried just dislodging the right main bronchoscope of a tamarind seed as you can see there is so much of bleed it's basically oozing at the level of right main bronchoscope imagine the whole tamarind seed was occupying the trachea and we had a very difficult time to extract it because it is so large we cannot be able to remove from the subplotis what we did so we did a tracheosomy the EMT colleagues did a tracheosomy so I was holding the optical forceps the foreign body at the level of tracheosomy and we were able to retrieve it through the tracheosomy side so another distally impacted foreign body basically thought this is some kind of malignancy but it turned out to be a foreign body it was attempted removal elsewhere but what has happened was it has distally impacted more so once it gets distally impacted all your balloons the baskets will fail because they don't have any place to open up and extract it so the best tool if it is an organic and distally impacted foreign body if you can safely finish the surface with a cryoprobe so it can be easily extracted so this was the as you can see so that's the initial place where it got impacted so because it was distally launched it was somewhere in the right level of segment 10 so what you can see once it goes inside that's the segment 10 segment sub sub segment the foreign body was impacted that's the segment 9 so in the sub sub segment that's the foreign body which is deeply impacted so in that whatever the instrument balloon basket there is no way I mean distally open up and extract it so we have to use a cryo and extract it I'm just going to speak up another challenging case an open safety pin at the level of subglottis and upper trachea so what we did in this case was we did a tracheostomy and we went retrograde all the hinge joint and extracted it so we were discussing how to extract this safely but we felt that this is the easiest way in one shot we can extract it so we did a retrograde bronchoscopy, hold the hinge joint and extract it it must not much of any issues so another case I'll just skip this case it's a multi-modality approach what was where was initially what we thought there is some kind of consultation in the right level what we went inside there was a polyp which is sitting there in the right intimate bronchus polypid is a granulation tissue so we did a snare retrocortory, removed the granulation so once we removed the granulation we saw there was an impacted foreign body there so we used a basket to open up and extract it so another interesting cases these foreign bodies can be very very tricky and this was an isophageal foreign body at Panicab so initially they did an isophagoscopy they could not see anything because the color of the foreign body is the same as the mucosa but in that case we did a bronchoscope inside the isophagus we could see a plastic of it, we removed it with a faucet another case non-resolving obstructive pneumonia in an elderly lady so we were seeing some kind of floppy material inside the airway so we were just thinking what was it so it finally turned out to be red chili so you can also have an isophageal foreign bodies mostly this is very very common these are the coins inside the isophagus so with the same instrument your rigid bronchoscope and optical forces you can safely extract it but case should be taken to maintain the ventilation so once you maintain the ventilation this foreign body does not have much time so this is my last step this is an impacted chicken bone in the left main bronchos you can see this just past the bronchos mucosa then there was no significant subcutaneous embossing or anything so you could safely extract this foreign body rigid optical forces to summarize we have seen multiple types of foreign body presentations each case of foreign body is a challenge we need to choose the right instrument and the right technique for the safe procedure so foreign body aspiration should be provided to children when they have sudden onset of lower respiratory symptoms history of choking is highly suggestive but actions of choking does not rule out a foreign body aspiration the presence of asphyxia indicates need for immediate resuscitation and examination of the airway normal chest radiograph do not exclude the presence of an aspirated foreign body and the radiology may alien diagnosis the bronchoscopy should be performed if you suspect a foreign body even if the radiology studies are normal for short foreign bodies secure the foreign body inside the airway for safe retrieval there is no single best instrument for all foreign bodies rigid or flexible, either one can fail no one is superior to others so this is another case of obstructive hyperinflation subcutaneous embossing initially we thought it was a foreign body and once we went inside there was a large tumor sitting in the right main bronchos in the carina and the left main bronchos please be cautious you should have the right to expect this was the BNED tumor we safely debugged thanks a lot for your patience listening nice illustrations thank you very much sir for your presentation any questions any questions any questions questions, comments how you want to comment thank you Thanks to God Hi Dr. Sulakar he is not only a man behind this program but also my inspiration, because I was supposed to join this hospital sometime back at start intervention program here and then we had bought up these questions and I am very happy to see locations establishing state of darts also doing very critical vices and this is the beginning of the in this area and we expect more and more in forward for future collaboration. So I was asked to talk on and also I would like to thank the chairperson's boundary commitment and all the seniors, my teachers are also sitting around Krishna sir. So I was asked to talk on future of area strengthening. So I will be a little practical. So we will not deal with a lot of theories, papers and all because since this is a very serious session of digital oncoscopy, it is very good to listen these things like an ideal strength doesn't exist or strength is never placed. Patients get married to the doctor when he puts an annual strength and surgery remains the mainstay of treatment for women and industry. So let's look at very practically. If this is the real world scenario, why all of you are sitting here listening to talks on annual strengths. So practically, there is a need for annual strength in many of our patients and this needs a lot of education and also practice. Coming to surgical aspects in the area stenosis, how many of our surgeons really like we don't have good experience in doing any of the stenosis management especially in these areas. And we don't have surgeons like Mohan sitting in Vijayawada or Hyderabad. So there is a role where you move stenting in these patients, bridge these patients and then send to the surgeon. So in my opinion, area stenting remains a very important aspect when it comes to interventional oncology and digital oncosis. So why? I will substantiate my statement with this case also. Now in the middle of the night you are called when you are sleeping and then the resident calls you saying the patient had undergone an OGD scoping and then the ADG shows like pH of 7.6 PCO of 100. The patient was sent to the emergency room after the procedure. In the middle of the night they will call you and say that the anesthetist was not able to intubate the patient. And then when we were called for an emergency bronchoscopy, the attitude is there and then when you pass beyond, this resident of the year was bagging these patients for almost 2 hours by the time you reached it. So you come across these scenarios. Hardly I was able to push my bronchoscope through the ET tube what they have put in the trachea and then you can see almost there is a complete closure of the trachea there. If you cannot go and place a stent in the middle of the night where the availability of stenting is not very easy in our hospitals and these are the kind of scenarios we come across. So this case also shows you the importance of airways stenting in these patients because there is no other treatment available for such patients unless you put a stent and release obstruction. So we have to take this patient on an ECMO support and then do an airways stenting and then discharge the patient. So if you ask me really, I am not very happy to do such a case in the middle of the night counter with all these bleeding and then try to save this patient. So these are flight stenting procedures where airways stents become a very important aspect. So why they make these statements is choosing the right stent like just because you finish an intervention pulmonary fellowship or something because why we place stents there are lot of reasons. So the spectrum of airways stenting is like if you are an intervention pulmonologist like the IT fellowship doesn't come complete like once you finish you want to put a stent and then you get the feel of this is practically true. And these aspects every one of us have gone through that phase and then we develop some wisdom over period of years like if you ask me personally in my first three years of practice I placed around three to four wide metal stents but if you see the last four years none of the patient we placed a wide stent. That's because we have seen the complications that happens once we place these stents. So wisdom develops after some time and then you try to choose the best stent that is available and place these stents. So why those statements were made is because not to create these kind of problems where you put metal stents and the surgeons need a lot of time to remove these stents because of the complications. So instead of a silicone you place a metal stent and then that complicates and then creates a scenario like this. So this is why we and also when it comes to lung transplantation very important area where you definitely have to make a decision that you have a transplanted patient here and then there is a stenosis. So you initially deal with dilution and all these things but again and again there will be a recurrence. So this is one area you put a stent and release the obstruction. So in my opinion definitely there is a role of area stenting in some cases. So let's talk on the future of area stenting. So the future is very brief because there is not much going on when it comes to area stenting not much research is going on and whatever is happening in area stenting developments is happening in the best not in an Indian scenario. So these are the currently available stents you see white silicone stents, you have metal stents fully covered, uncovered metal stents and all these things. But are we all happy with these stents? Look at the computation. They have granulation mainly as a computation and then if you place some uncovered stents again there will be tumor involved into the stents and mucus which is the main problem after placing stents. And if paper was published from Kether and the Russian they looked at different practices of putting stents. Again area stenting doesn't have a universal approach like some are trained in rigid bronchoscopy or flexible bronchoscopy approaches. So it again depends like what is the operator experience in placing a silicone stent. So you tend to do something to relieve the obstruction. Nobody wants to put a stent just to place a stent. They want to help the patient but based on their experience sometimes they have to make decisions to relieve that obstruction temporarily. So if you look at the survey they did there is lot of variations in area stenting practices of growth not only in India even in the US if you see some use rigid bronchoscopy some use flexible bronchoscopy and some use both the techniques to put stents. So then Eric Faulk has mentioned in his paper what is an ideal stent. So in theory first we should understand that this is all in theory not in real life practice. So ideal stent should be stable strong enough to withhold an extensive compressive force and it should be biocompatible available in all necessary sizes resistant to migration and easily deployed and removed and can act as a barrier to in growth of the tumor. So if you practically think of all these characters you will not find or will not will never be able to make an ideal stent. That doesn't mean that you don't place a stent for a needy patient. And currently the available stent materials include silicone, methanol, stainless steel and hybrid stents. And recent advances Locust told like Dr. Harre was speaking on so I am not going through this. And what we should ideally be doing is like we should sit as a group and then discuss on how to develop stents that will help our patients so that we are not doing and we are trying to use stents that are made in the western countries and not because if you look at the development of products like mostly before it was China and now it's all Indian. So there are good companies coming up in the Indian market as well where they are customizing stents within 2-3 days. So we need to make a form and then tell them these are the things we need and these are the things we should keep in the market because I think most of the faculty who are doing every stent they know the difficulties of procuring a stent. So if you need it if you have a patient in the year and you ask for a stent it can come up to 3 days. What was the patient base for many times the patient's base during these procedures. So these things we should address. So if you look at instead of talking on not putting a stent let's talk on how we can develop good stents. What are the problems with the currently available stents? So the currently available stents usually if you see the structure it has got an outer sheath and then the stent is either folded inside a small cotton wire over the stent which once you remove the cotton wire and then the stent gets deployed. So the usual problems what happens is why it is difficult to place the stents or why these are not ideal is because some have like if you look at the Boston stent, the discolour of the stent has got a very long end. So sometimes if you are trying to go into the left wing bombast and replace the stent if it doesn't go into the upper row or the lower row you will not be able to place the stent properly. And look at the y-stent design here. So if you look at the y-stent design, the outer diameter of the y-stent is so big sometimes the stenosis is small and you will not be able to place the sheath to expand the stent. So these are the common problems that is where people are looking at developing newer stents. So if you talk on every stent that are being studied widely and one of them also got an FDA approval mostly in the U.S. not in India that is a customized silicon stent and second one is biodegradable stent. So if you ask me in the coming 3-5 years if once the approval comes for biodegradable stents, India will be one of the primary managing patients, biodegradable stents what we have to tuberculosis. So in tuberculosis biodegradable stents are played a very important role. Just because we don't have the availability we are not studying them properly and then there is a concept of observable stents that are coming coming up in coronary diseases that also will translate into pulmonary medicine. So these are customized ARB stents again if you ask me position statement or if you ask me the clinical guidance usually these are not included in the there is no point talking when we don't have a normal silicon stent talking on a given customer stent is of no use in our country and then this is one thing we are actually looking at like how this will shape up so this is how the biodegradable stent will act. You place the stent you don't have to remove it or anything so once removed you see the last picture the material gets absorbed into the mucosa and that is a biodegradable material so that doesn't harm the patient. And what are the recent advancements that are coming in practically possible advancements that are coming up is one is called a bonus stent so these are called through the scope stents so these stents you will be able to place them through the flexible bronchoscopy. So the only problem is the deployment will be from proximal distance so you should not place the stent beyond the stenosis and then deploy you have to see that the stent is above the stenosis and you push the stent otherwise it will go fall in the sub segments and you will not be able to deploy. So this is one good advancement that is coming so this will be very useful for those patients who want to go lung transplantation and all. What happens in lung transplantation once the LMS denotes it happens ideally you have to place a silicone stent there but sometimes the rigid bronchoscopy barrel will not pass through the LMS denotes because the lumen is very small so that is one application where you can put these bonus stents temporarily removed in 3-4 weeks and then place one more stent until you get a lumen. So this is one advancement that is practically possible and also if you look at the way they make this stent so usually the wrapper is inside the stent not outside the stent so that adherence of the stent also will be very good when the sticker is inside not outside the covering is inside that is one thing and through the scope stents and one more company is coming closely is these mini stents you see the size of the capitals that we deployed are becoming less and less so to make them more easy to deploy so now we have mini stents for the bronchus as well so if you have a bronchus problem you can just put these stents through the flexible bronchoscopy so these are new things that are coming up which we can use in our clinical practices so every stenting once these kind of stents come it becomes easy for everyone to manage a problem when they have a simple flexible bronchus scope and they don't have expertise in rigid bronchoscopy but that doesn't mean that again complications of stent should also be understood when you are trying to place a stent so the numbers will increase and at the same time the complication also will increase if you don't handle them properly and literature on these bone stents there is one paper that looked at the utility I'm not saying this is the ideal stent but they also had some problems like fracture is little more common with bone stents because of the diameter it is a very thin diameter stent more in the bronchus than in the trachea and then when it comes to silicone stents this is one area where there is no development that has happened and this is the first time developed for trachea bronchial tree and then there are new silicone stents that are called genus stents where the stents can be like usually that woman stent has studied in this fixed way so these new genus stents will have either forward or backward stents to prevent migrations so this is one advancement that is happening in silicone stents and coming to white stents there is one Indian group that is evaluating this white stent so what happens is white stent the main problem is the outer sheet many a times you will not be able to push the outer sheet so this company called Medora which is an Indian India concept so they have designed a very good stent which has got an ODI of 6mm so 6mm ODI will be very very useful to deploy a white stent this is how so we clinically evaluated the first stent and then you can see how small the white stent they have already improved so it is very easy to place the white stent also now with a thin bronchoscopy so you have two links here so the decoing mechanism remains the same but you can use a flexible bronchoscopy and then deploy the stent and then once deploy decision so this is one development that is happening so my take home message is every stenting will remain to be a very important role in management of airway for especially for the intervention people who are practicing the interventions and the practice of airway stenting should be patient centric then looking for an ideal stent or talking about the complications of airway stents and decision making mainly depends on the operator's experience, availability and training there is a lot of scope and interest in research and development especially in the coming 3 to 5 years so there should be a forum that needs to sit and discuss on possibilities of new concepts in airway stenting and there are a lot to do in that and as I said ideal stenting can never be developed and there are some areas where lung transplantation and post intubation process is so before surgery stents will remain an important factor and biodegradable airway stenting the airway stents are going to play a very important role in philistinosis and lung cancer again there will be a debate between stent and silicone but usual practice is stent but once you get experience and start putting silicone stents in this way you will understand the use of the patients so with this I would like to end my welcome all of you to bronchus 2023 in January 28 and 29 at Hyderabad so any questions I have to answer just now for your nice innovative talk on the future of stenting in between and I hope with the 3D printing and all these things and the biodegradable airway will be available I think in the way he has going forward I think we should come up with some answers for this Parvita Thao, he is all known as all known as the treatment pulmonist at Naseh Chants over 30 years exposure in the philistinosis personality he was past president of the world association of international pulmonology 20 and 22 and he is the president of intervention bronchus and he is the field of research and nutrition and it is a pleasure to invite him and listen to him of manipulation last session for the live series thank you for inviting me to your course on international pulmonology and what to say in the master of my Indian colleagues and well I remember when you stayed in my unit you and Shiba another Indian colleague you particularly like one of my editorial sorry I have to define your editorial that I wrote with David Fila Pogman David Fila Pogman is also famous American medical physician in Baltimore and I'm happy that you like it because I like to write editorial so editorial is not really scientific it's not very science but for me it's very important to because it's a way for me to give my vision of my activities my work and the role that getting older and so you like this work which is called international pulmonology between ambition and wisdom and I'm going to summarize what are the ideas behind this title this is the editorial that was published in Europe and as part of the review in 2020 again with David Fila Pogman and so in this editorial we emphasize the fact that since I started pulmonology more than 30 years ago I have seen granted changes in our specialty a lot of new technologies came to our practice like mainly I would say mainly in diagnosis of pulmonology which are focuscopy electromagnetic navigation retrosome demographic even now, robotic focuscopy we treat now patients like COPD patient as a patient after the patient and when I started pulmonology now it's 30 years ago asthma for instance was almost a contra-education to contra-education to focuscopy and now it's not an indication that we are going inside of the area of vision so I told you few interactive focuscopy few maybe I could have prior evaluation of cetrolymer absorption by malignancies that can be done with prior products but one of the most important are the relation in standing it's really the second part of my talk in standing we have different way of evolution and one I would insist on is a 3D printed stance but also we are buying the valuable step and not really now in our practice but people are working on active stance so stance cover these pharmaceutical drugs not only have mechanical properties but also pharmaceutical properties eventually also in the training of patients of physicians it's much more structured than in the past with a lot of insulation and also not changing the scientific communication when I started with my mentor at that time almost on the case report where in which you had 3D post-imaging so the author would say look it's better after so it works it works at least in picture but it wasn't proven scientific so we have a lot of retrospective students and now we evolve to more more scientific prospective and modernized scientific students that's a big change also in our knowledge Daiso wisdom why wisdom wisdom in the way that any new technology is not always sure to be successful in the in the future so we have to be very careful with this new innovation we have to prove that it changed the course of the disease or at least to improve quality of life of patients to imagine survival but this innovation are very costly and they require a dedicated and guaranteed and very well organized infrastructures which is generally seen in tertiary reference so unique, very good organization and this innovation are very costly so many innovations in terms of diagnosis of post-imaging patients and if I just mention them for instance Kotlin City which is around 5,000 euros and I don't even speak about disposable and materials that has to be had as the robotic is also 500 1,000 euros again you have to have more disposable things etc and this is the clearly issues that cannot be ignored and the very only economically aware countries can afford this kind of technology and sometimes even before they are clinically in school or have impact on the course of some diseases for instance I can use an example of the solitary peripheral module which is suspect of malignancy again isolated to the scan and the question is do we really need to have diagnosis of this module do we really need it so do we have to buy a robot or Kotlin City to get diagnosis and if the diagnosis is positive for malignancy then the second step will be surgery for patients that can be operated if you cannot have the diagnosis because even with the robot with the U.S. pro you can reach only 80% of positive diagnosis so imagine if the diagnosis is negative what will be the next step generally next step is to again surgery because you cannot let the patient with a suspect in the module without diagnosis so surgery with the diagnosis is an achievement so what I mean is that when you consider starting a biological terminology taking into account all these steps and taking into account also your surroundings I give you the example of Marseille a location that knows quite well here in Marseille we are and it's not a new world it's a reality we are very close to all specialties like to the surgeon we are friends we are very close to the international radiologist so in fact in Marseille we have decided that we won't spend money for expensive technologies to diagnose peripheral modules because we are surrounded by very good international radiologist who can do neither in the this kind of course in a 5mm module with quite close 100% of diagnosis and this is very important so if in your institution you have very good colleagues of other specialties take that into account this is what we have done in Marseille and in each case this is my last sentence it's like it's really part of this is pretty routine approach in which we frankly want our colleagues for the best of the patient and not for the best of international radiologist and I don't know if you notice if you are interested in the world of international radiologist we have different kind of colleagues we have colleagues international radiologist who claim that in the future we won't need any more disorders that international radiologist have diagnosis of radiomania is a kind of treatment you know the treatment so non cancer, non state non cancer I have this kind of international radiologist I don't claim that we can do everything alone we really have to work as a team and a multidisciplinary team again for the good of the patient is the best option for someone ok let's go to surgery let's say if again one of our colleagues can reach more easily let's go I don't want to do everything because when you do everything I don't think you're doing good so don't forget to trust your colleagues but that doesn't mean that we we have to be ambitious of course we have to improve our techniques we have to innovate like our new ones and we also have to be confident in sharing strong data without colleagues so like changing practice from this is the way we have always done it the way we do it now international radiologist take into account the strengths weaknesses and needs from other institutions is what I was saying before considering which techniques and technologies should be required this is I'm going now to show you the history of the history of international epidemiology for those who are interested in all of those famous names the first physician who was performing in 1819 then she went to to study the microscope in the 16th of the previous century my mentor, Dr. Dumont in 1982 was one of the first pioneering to do at the nuclear laser therapy so if you see all these names the one who was invented the transformation the emotion from the years for the therapy again my mentor, Dr. Dumont in 1990 is a silicon stand but also a metallic stand it's not nothing but it was a physician who was a surgeon that came with a new probe and a delegation combined in both the US target information all this information but really when I look at that at this timeline I realize that for me the only technology who has really really changed our practice about all these techniques is a double-coil ultrasound not for instance total fluorescence is almost no longer used but even as now actually dramatically changed the approach of the diagnosis of the ultrasound and even the TVA is now almost abandon even yes this has really changed the practices in the national community so just to say that you will see a lot of new technologies you will be probably obsessive to use them but at the end only a few of them will remain as a tradition I would say and I would say that a tradition is an innovation that has been successful it's a progress that has been successful and it has become successful it becomes tradition and this is the process of being a part of timeline but still we are using re-proposcoping to treat central brain function as you can see on this timeline I have a picture here with this physician he collected there he collected there from France which is my best place France is now the president of the French speaking group of the national community but he is also a very smart guy very nice guy and he is one of the pioneers in 3D printing stand and this is my second part of my talk is about 3D printing stand but before that I would like to illustrate how the wisdom of 30 years of regular standard aerospace printing has evolved to an innovation which is 3D printing stand so another editorial again I love to write a tutorial because I can summarize a lot of things and this one is particularly special for me I have published an index that I have written with my manager so it was in 2017 and in 2017 it was the 30th birthday of Airways printing because the first Airways stand placement was achieved in Marseille in 1987 so in 2017 I will show you all this name from Kiva told me to write an editorial and in this editorial I have summarized all the experience we have acquired with Airways printing and first I want to start with this slide that shows the evolution of Airways printing in Marseille from 1987 to 2017 so look at that look at the curve it started so the number of standplates in Marseille increased a lot to reach the plateau of 600 standplates imagine that 600 standplates in France in a small country compared to India so 600 standplates in India means almost 3 tenths place in the day in total case when I was at the time with Dr. Dumont I have seen almost 3 tenths place in the day why? because of course Marseille at that time was the only centre you were to do that so a lot of French patients were referred to Marseille and all around Europe even from other countries outside Europe and as a good technology also Dr. Dumont has told me over in Marseille it's a new technology so you won't try it to any type of such a railway pathology and generally I call this Carpet Barrier why Carpet Barrier? it's because when you clean your house and when you have dust you know where to put the dust you put it below the carpet and in a certain way because any abnormality in the airway were covered by the stand at that time like simple idea that just by hiding the pathology it was true and of course it's not the truth so the second period started and this second period you see the decrease of the stand in numbers in place in Marseille also because a lot of centres in France but in Europe and in the world we know from some our experience and from disease we have told just to give you some example of the stand freckle recombination at that time someone who had a collapse especially collapsed at the stand place and the direction now is 3M on the fact that even if you face a stand short-term improvement but mid-term you have a lot of complications so freckle recombination for instance is no more limited in Marseille another indication freckle recombination b9 freckle recombination b9 freckle recombination in Marseille so how to do the procedure first, see the scale of the patient then reconstruction 3D reconstruction and same to the 3D reconstruction then design the stand according to the exact direction, exact angle of the patient the problem because of the sequence test a silicone set cannot be printed with liquid so you cannot print the stand directly with silicone so you have to print with mold you make the mold, print it with mold and then you inject the silicone inside and you see different kind of stand can be produced and then like something set to original purpose so the results 10 patients 4 are post-transplant recombination 2 patients have recombination from interstitial surgery 1 patient has access for recombination and 3 patients have post-transplant recombination so let's start with the post-transplant and with the business you see this is the case I showed you before that's the purpose of this which is closed here and you see on the prostration and at the end of the step you see a nice shooting step going to the right tutorial here and this is the purpose of this so this patient improve systematically and this can also improve after 3 months because after 3 months unfortunately this is the start of this patient this is the start of this and now this can still be done after 3 months so you see this is just the first case we realize that even if it's perfectly adapted to the airway stay in the front for the night then you see some complication of standing out second case it's left which was treated with this helipad system again the microscopic aspect is very nice after 3 months you almost never see the step almost but you see how it adapts when you prepare to do what there is a status on the left side of the calamity almost don't see so technically it's done it's a nice fitting on the surface then 2 patients with complication for intracerectal surgery one has a paortic aneurysm and one has a helipad so this patient you see images with standard steps in place and you see this can go back to the compression that's a paortic aneurysm you see a great direction here you see clearly the axis of the trachea and then with a free distance in place which I have very well that will be meant to curve the magnetic trachea to get improvement of the complication this one is simply it's a positive C-elementary so C-elementary is probably a re-platation of the focus to the right eye and again a nice fitting scan in the C-scan so and now one patient has extensive aneurysm but it's rather recombination while a system has been designed but this one is fake because of poor variance my understanding was they moved to a free mass so again remember regarding the regular standard step in tracheal recombination but even free distance in this don't seem to be the ideal solution to treat tracheal recombination and last, tracheal system is so you see the patient with the tracheal system to do free distance you have a simply the design perfect congruence and this patient is still standing in place with no complication what case it may be another one had a good numbers to be congruent but by virtue that they sent him to a new place and again removed the system so this one was a success one was a fail even after treatment the congruence was good but by way of two months after what I may be able to tell you you don't know is that tracheal system have a approval after the FDA approval of tracheal state that have approval in Europe but they are approved only for bifurcated states not for straight states because straight states seem to have the same rate of complication which is in a different respect to the states you cannot order but on the e-by-50 states in January in this kind of situation when you have false utility states so the conclusion of this table the serious the subject of high decompression proves the feasibility taking into clinical community that they are just complying with that congruence are very good the efficiency is 8 to 10 complication still is there to improve our technology we have had some breaking, migration and one curve because of that congruence so what will be in France we are going to take a new trail which is a prospecting to lose because we are one of the biggest centre to enforce the placement still in France and so we are doing a trail with more patients or with minor obstruction learning more on the congruence system thanks to 40 so consider that we collapse when we receive this test to reduce migration when we are forced after the test is always range with even three participants we prove with treatment surface of the test and this is not a job but one dream that in the future may be produced freely printed by another test for new strategic education in my mind we are going to think about the transfer of patients so this is my conclusion and I hope that I give you an interesting overview about future of the restency Congratulations the next session that is panel welcome Rad I think it will be a very good session so unlike the normal panel which we have we usually panel for ILD we hear about tumor board but today we have a stenosis board so we have five excellent people who manage area stenosis so we will request some of these things other than that we request Dr. Popal Dr. Mohan Vishwesh here is Dr. Vishwesh Dr. Hari Sathi come in the frame so we have designed this as a we have four cases which will be presented by Dr. Lokesh and we will take the opinion of the parades ask you how to go about with these cases I think we just wait for a couple of seconds for Dr. Vishwesh and Dr. Hari to join and then we can start the next session like in intervention program we started 30 years back so in literature if you see we have only case reports case series expert opinions and also retrospective observation studies but we don't have prospective randomized control studies to say this is correct and this is obviously from experts so we have a best of experts in the field sitting here so we listen to the case how to approach from them so let's start first case in this case little tough you can see the CT scan the coronal and surgical cuts is showing retrosthenal mass you can see it is extended beyond the sternum even if you for tracheology it is tough to do it and even though lumina is completely blocked apart from tempers the CT you can see here an intrinsic repression is here in this tumor the tumor completely up to 80-90% of the women a small phase with which flexible diagnostic, flexible bronchoscope could be able to negotiate beyond the tumor so I think at this point we have the opinion of the panelists so we have a lady with a malignant type of obstruction so first I would ask Dr. Bowman so what would be the indication of surgery in cases of such malignant type of obstruction in forward answering this question just I need to know the histopathology of the idea because probably the proglustigation and the decision actually may depend on so which kind of because this is a turret mass integrated with the trachea papillary CA follicular CA, anaphylastic CA but as we said it is a a huge long history of the gorilla so most probably it could be that the possible this is a papillary's carcuma thyroid although this patient has liver metastasis we do such regularly such kind of cases in association with our redundic oncology team the presence of liver metastasis is not an action or indication for any kind of for the quiet removal and also trachealization so it is showing that it is involving approximately as per the CT what the understanding is approximately 2-3 sentiments of trachea is involved and although it appears that this trachea was being compressed by the mass, I doubt it is actually infiltrating the trachea in that region so how am I going in this case the mass region bronchoscopy just debunk the intratracheal component study for the papacy we will wait for the papacy to see what kind of pathology it is because we have actually cross the emergency and then at one stage we can do the thyroidectomy with regular sessions I think this is for the general interest of everyone here so this is a thyroid medicine which probably has some good outcome after surgery so we will have other than thyroid we have other would you still recommend a such contraception Surgical contraception is the best mode of treatment if surgery can be performed surgery can be performed that is the best mode of management whether it is anodic acid or neocupyramide castuma if it can be performed that is the best way of management even the scum is the best way so again that comes to the component of 50% mark so if you are crossing the 50% mark then of course the thyroid so if it is less than that you can go ahead and get this I think this is an important point because most of us say that if it is a malignancy then the surgery cannot be done everything more important is a given in surgery if it is a resectomy lesion probably still the surgery may happen with a basic disease and there will be a problem now I will request Dr. I the prescription is there where we have to establish a loom in it just before just I need to add incorporate because this patient is also having a retrosanal kind of extension so thyroid to me along with him this patient may require a partial upper strenuous drift to remove the retrosanal I think even in our center sometimes for thyroid malignancies they do critical resections especially for thyroid malignancies now I will request Dr. Ihar so what modality would you would you prefer for the procedure here the extension looks very long for a surgeon the end of the improvement of the care that is already said what we are able to see is probably 2 to 3 second details but once you develop it you will probably have a better first will be the debulking and then probably if it can be done then it is the best one so now the next question is if we have to establish juvenile patency I am looking at the range in these cases in this case apart from this endocrine lesion beyond this lesion is inflicted with the tumour we will discuss that part also how to extend the sub-neucosal extent of see you can see the sub-neucosal completely interact with the tumour adding options to develop the tumour ventilation wise I don't think it's a difficult thing here you can just use your rigid barrel just to just rotate the barrel in such a way that the tumour will get off the wall usually thyroid tumours don't do much and when you are doing with the rigid barrel that scope also will act like a damper that is one option otherwise if you want to do with a simple this name would be a good option here so put a snail in the tumour lesion and then whatever this thing is doing in FTC depends on what you have on the day but establishing movement patency in this case would be very easy with any of the other things so in the end of the procedure usually what is superior that discussion you can see snail or legy from scope the finally you should be establishing patency what you use as a known doesn't really matter I think it's probably a very good point that what you use to achieve movement patency would depend more upon what you have as your centre and what your experience says so I think with this discussion this one is very important to us which is tumour it's how to actually how to determine the extent of involvement so what we are seeing is the obvious quality but many times we see this of mucosal so I will now ask Dr Vishwesh to comment on any role of NVI or any of this newer process of imaging techniques to try to watch the extent of the sub mucosal spread of movement patency because that might have an impact on the extent of surgical perception and again before you do a surgical perception for such cases would you also want to use these techniques to extend all of the visual inspection of the normal VITHAID process so what we are seeing is the VITHAID process so in this case I think it shouldn't matter much because if we are dealing with a metastatic disease already the patient is having a metastatic disease I think you can say even if there is small metastatic disease it wouldn't be a conflict not a conflict the point which is only do you also try to look at the sub mucosal extent to see if there is any impact definitely there are few studies which are done with these different narrow band imaging and even FICE and other things to look into increased vascularity being a marker of probably an abnormal tissue but when you have such and those are all done for cases with carcinoma in situ where you find a relatively normal because except in one spot you can obviously improve carcinoma in situ but in a case like this where there is an extensive involvement of the mucosa you cannot say with certainty even with the FICE that this is the margin at which we are moving from a normal tissue to a cancer tissue so I don't think in such an extensive mucosa involvement it is better to assume it to be a cancer rather than taking a FICE and saying that this is the point at which the cancer ends and beyond this it's normal this is my personal feeling I think these modalities are brought for early detection of lung cancer mostly as a screening rather than establishing the point of saying whether it is a medicancy or not maybe one thing which our oncology generally uses the frozen section but again that cannot be applied in this case because we are dealing with the case of a tracheal so you cannot take lot of these biopsies to say that the frozen section is negative so the section margin I agree with the one of the issues but I still like my heart really says is that the neurovascularization of the endemic valve of the trachea it can be due to the pressure effects may not be that actually yeah of course you cannot differentiate so there are so many non-flying flight biopascos not only what we see is the biopascos so most of the companies have this now newer technologies like ice cat technology and we also tend to identify this abnormal plastic part this has not yet been proven enough to be European use of infant pregnancy I think now we will ask Mr. how we manage that case this is the case so it came to us with the spider imagine she came to us with hypoxia so obviously we need to do a medicancy procedure there is two minutes to take up the test he didn't tell us what is the list of the I am more interested in that I don't know after doing the biopsy so that actually I am not revealing it we will just see when she was not done she came inside so we need to take her directly I can't forward directly so we intubated this patient with rigid bronchoscopy the first step was obviously after we placed the rigid bronchoscopy above the level of tumor and with the flexible bronchoscope I tried to snare that it was half cut then after that it was bleeding heavily so what we did obviously vision is gone after vision is not so clear so with the rigid bronchoscopy we code the tumor I don't have complete procedure video so I will record the system as it was not recording after placing, pouring placed the rigid bronchoscopy above the level of carrier to control the bleeding for 15 minutes then bleeding was stopped so after that what happened was bleeding and there were actions in combustion yes there is a question whether to stand or not this patient my thoughts of standing for this patient were one is that it was bleeding we had to put rigid bronchoscopy for 15 minutes to stop the bleeding you can see that such this video of the trachea after this was bleeding heavily because of in the anterior the trachea was you can see even after standing you can see this so much of bleeding from the surface the one reason for standing in this case and also one action is in operation so you want the patient once you do the procedure you want to come out of that procedure that is one reason we thought we will see to stand this case she is doing well to stand out of the procedure so she was doing well actually so in this case as Dr. Harid has suggested also a combination of peripheral photore and the rigid coring are used to initially to achieve local pregnancy in fact the rigid bronchoscopy the coring is not the fastest way wherein you can achieve a lumen and the barrel itself will act as an outlet so it also gets in the airway and also causes symptoms at the same time now the second question for the panel is this it is a family to see a thyroid and HP after that now the second thing is many times you come across these cases where you develop the tumor in the airway lumen now when would you want to stand a person with a malignant airway obstruction I think this is something which we will again take into account as Dr. Hopal so after the debugging procedure when would you want to place a sense or a silk constant to achieve or to maintain lumen once after debugging I will look the lumen once the lumen is ok there is no idea collapse of the airway so usually I don't prefer to go for standing so I will look after the biopsy report if it is susceptible tumor lumen patency is achieved and I can refer the case to the searcher suppose if it is patient is having some amount of creatio malacia we cannot be able to maintain the patency of airway lumen then we will prefer the stand since it is a malignancy so we will go for stand later we will send a case for airway lumen for the malignant airway if the airway lumen is adequate and it is not collapsing there is no special extension in compression it is not necessary then always we have to place a center I think in this case we will also send a significant extension in compression so probably a sense was placed so I will ask Dr. Lokesh what happened after this the HP was pampered we referred to such a long policy he advised that what Dr. Rangte said that was the plan to accept extension but unfortunately they were two families and they couldn't defer so in 10 states the CA also they couldn't defer to develop palliative chemotherapy palliative treatment only after that they will go for surgery I think we were able to give an initial palliation of our symptoms and the patient went home without that yes one of the important things whenever we have a patient coming to us to try to at least improve her symptoms for as long as we can if we can cure her then I think like that but if we cannot at least if she goes home it is a question to the states any role of positive in this case since I think you have done two cases we have only limited experience two cases we did but definitely there is a I don't know whether for this case it could be really helpful because already we know that the tumor is arising it is invading the trekking palliative and it is having an internal component also so even if you do an OCT in this case we we know that it is an infiltrating tumor but OCT what we use was the high quality is so good and if you have really good experience you can even differentiate the sub-leucosus layer you can clearly see the cartilage and even the expel beyond the cartilage and there are a lot of articles which has evaluated the role of the OCT as well as the role of a high frequency radial probe initially the radial probe when it started it was mainly used for the trekking now we are moving into the periphery so both have been used to the cartilages especially for such tumors which are higher so it plays an important role whether it can be a surgically removable tumors or not OCT yes would help but not in this case because in this case it is a clear bit that there has been a trekking formation and there has been an intra-rubinal extension but if we have a tumor which is without an intra-rubinal involvement then probably OCT can clearly say that whether the cartilages are infiltrated or not so this is the second case I think so this is the final discussion but if any audience has any question also you have to do more than to stop us and ask a wonderful case location just for the panelist and especially to the surgeon now what you said that probably it can be a congestion that is causing hypervascular issues so my question is so the next case if you see the congestion extending much beyond down so that means the length of the trekking probably infiltration or condition is more the surgical resection is going to be a challenging in this case if the length increases so would you recommend us to do a biopsies in that point to find out is there any infiltrative lesion there when you plan your resection or did you any time experience this kind of situation so I think it is a very valid question also so how exactly to determine the extent of when you plan your edges that is what I am saying so where you resected and how you plan your edges why I am saying this is congestion because if you go to the converse cooking over the kerain also there is this there is near oscillation even though so with all the kerain this is not right so it is very unlikely that the trekking, infiltration and the kerain are causing this so so should we do biopsies do we do biopsies you can do the second we don't go biopsies I think for lack of time we go on to the second case so it is a totally fair old bank manager had any fever with the air ds he was a ventilator for one month and wouldn't recluse me he was present with stride after one month after recanning the recluse me too very calm scenario we see in our daily practice groundless could be upper trekked so we do biopsies spying around 1 cm so this was the case it is shown showing stenosis and also probably around 1 cm so from the scope of the video close to the vocal cords we came to a strider can you also tell us the distance between the vocal cord and the approximately 4-5 cm now I request Dr. Rakesh to describe the stenosis and what would be your initial management strategy right so looking at the patient's history that it is a benign post-intubition tracheal stenosis and here so first of all we see that the length of this stenosis is 1 cm and the distance so it is critical stenosis in term of the symptomatic because the patient is strider second thing is there the good thing about because it is distilled to the subplotic part so and the segment is very short and third one is that it is the cartilage we need to look into really the cartilage is damaged or not it's a one thing and first we will offer the patient the bronchoscopic because the patient is symptomatic so we need to go for the bronchoscopic dilation of the segment once that we can use for that the cartilage along with the balloon bronchoplasty and later on the same thing with the bronchial variant corner once that this is achieved then I will refer this patient for the surgical part because it's a short segment and it's a small one so the surgery has a definite once the symptoms are resolved after that the surgical definitive treatment is done initially because the patient is symptomatic the initial irritation would be done and then he would be referred for surgery if the person remains symptomatic because this is a force to take care of some of the patients mostly the cartilage would have been involved and would not be as simple as the other nurses Harim would you like to apply on the management strategy yes money that has been practically we should think such a patient coming from the village is admitted in ICU with their BS all his money is gone the surgery will not agree so first what we do is bronchoplasty short segment very far away from vocal cord very easy for surgery to operate so for Dr Harim the first case also a CD to ventilate second case is also easy that is not in such cases I think it is partly correct because it is not very sublottic so you have 3-4 second meters below the vocal cord so doing the procedure is not as challenging as in an upper tracheal but a stenosis so would the panellists agree that when the first sitting you would only dilate and leave or how would you want to do you want to discuss with the patient we will see how the surgery will be you don't have to try to understand in this case you can just put the pressure column and dilate if the room is okay if he is willing for surgery he will wait for a few minutes if the room is okay you do the dilatation first and you wait for a few days at least 3-4 weeks and if it is wrong if necessary you can go for one more dilatation if it is a surgery or a surgery what would Dr Mohan say would he be comfortable with us doing one dilatation or would he want the surgery straight away one dilatation is okay I think he is very considerate he has let us do one dilatation so one dilatation alone if surgery because surgery what all surgery we have to take a minute now we have one chance with us before the patient goes and remains so the thing that I want to emphasize in this case is that so usually these patients are put on steroids to decrease the edema and all that maybe few days so in our study when we actually we analyzed the anastomotic complications the patients who are on steroids more traditional steroids at the time of surgery actually had post-operative complications so stopping steroids at least 2 weeks before 1-2 weeks before doing the surgery is the critical component of regular treatment one last question for all the steroids some patients usually don't have it last question we have to put the steroids so you have to take a needle and then you take steroids no that doesn't work because anyway we are going to remove it patients are actually we got referrals who are actually one month, two months steroids no Dr Mohan I would agree with you that many centers after dilatation give a course of steroids with a hope to if not if necessary the edema which is part because of the procedure maybe a little better last round of the wish page to comment on his practice of prescribing the course of steroids after a dilatation session how long would you give and if you give how long would you give we do give steroids course procedure so we generally anyway when on the day of surgery we put them on injected with steroids but the very next day general most of these patients go home once we have dilated adequately enough in their symptoms we put them on a tapering dose of steroids at least for 15 weeks that has been the practice till now but it is not a very heavy dose we start with methyl pretensivone 30 mg like 5 days then we taper it off very fast by 15 with the almost the steroids off this is mainly if you ask us for an evidence we don't have an evidence to say whether it really works or not but it has been the rationale which we follow even for any sort of an obstructive aggravated server where we have manipulated so I don't feel any problem in giving this short course duration of steroids in fact if let's say that we have manipulated so much and next day the patient presents with an edematous airway and again that is a more challenging thing for us rather than subjecting the patient to just a short course of steroids I think it should not harm the patient anyway provided if you are taking on for surgery yes you can wait for it would Rakesh Mohan give the comment on his practice and then maybe just summarise it for the benefit of the audience so as I agree with Dr. Nagar that the steroid for the paring procedure for 3 to 5 days is kind of a because to decrease the luma and the kind of the procedure but 2 week is so I think see so the point which I want to say is that there are so many gray zones when we talk about the prophesopic therapy for the there are so many questions that I can answer so our attempts to try to prevent osteoarthritis Dr. Hari was talking about interrelationsal steroids now we are talking about the short course of oral steroids none of these have been actually proven to say that you can prevent resealers I was talking about my talk by saying some people have used to try out relations so many things we do in an attempt to prevent resealers none of them are actually proven scientifically so each one will have their own preferences nothing is correct nothing is wrong but steroids as Dr. Bohan said 1 to 2 months ago somebody would practice how that person was taking but you have to tell them to stop so that is how probably the person would have come I would request Dr. Nagar to this case and whether the person responsible for that case I will start with that sir obviously we spoke to the family they are obviously terrified with this but they immediately came to home after suffering for 1 month of interrelation then we optioned what are the options available one option is through prophesied dilatation and stenting I have only dilatation dilatation plus stenting surgery so all three options we explained them what are the chances of frequency we explained them surgical 90% success rate related to 90% in best hand so only in best hands not in every hand and we don't have modern dilatation in our hospital in our city that was one problem second thing obviously we told balloon dilatation and in my experience usually if I grew one balloon dilatation I had experience of coming back very fast within 3 weeks again coming back with the same problem so I counseled him for this is the option 50 to 70% success rate if you keep it for 18 months if you keep longer terms for 18 months 70% success rate you can get so I told him 50 to 70% the lowest then 90% 80 to 90% highest chance of success rate with the tracheal surgery obviously I explained the complication I didn't want the procedure I want to do obviously we explained everything then he opted for the tracheal stenting because of his personal reasons then we proceed with the procedure that we play the video and since it is upper tracheal stenosis so there is a chance of migrations on the stent so after the after the placer stent we play the stitch to prevent migrations that was one of the most complication after doing the upper tracheal stenting we can migrate and so far it's been I think 12 months every one month he comes to the follow-up there is no migration and there is no migrations for his person the plan to remove the stent after 6 months later by God's grace if it heals on it's very good but doesn't heal one hundred days he is there I am saying that is the plan that's what we are thinking it happened to me in December 30th of last year we did this procedure it was like he came inside so I think the stent had to be beautifully placed I think it was discussed with the person so once the person leaves the inform concept then I think it's not wrong to place a stent and till 1 year there are no stent complication no stent complication so I have two questions for the analyst one is the it's stitch so I personally develop productivity of person because there is more signatures from the open course and we put it in the criteria of the so if at all you want I would request for the vocalist comments on when we would place a stent it's stitch if you know the teaching especially in the practical part of the criteria I go for stitch because there is a high chance of stent displacement you know we cannot place a stent so that is the one situation and you probably if I found the difference between the stent and the practical you will be with the stent the stent opens up too easily without manipulation that is also one indication that probably it might I have written about the hurry also what other techniques can we do to defend migration it's experience with our class stents because that is one thing which is also there now it's a very good candidate for our class because it shorts the but again you see Malaysia in the posterior beyond the stent so once you place our class sometimes the compression of the posterior starts pressing the distal area and then starts to granulate in the wall so you serially call the patient and they do cryo or something because this sometimes I have patients who got cured even without searching to place our class so that is one option I will try but again availability of our class is not everywhere so I am okay because I need to recommend this in this case so what do you do a big stitch for this case I usually my practice is I can patient and operator preference it's not like it goes to the idea you place a stitch for all it's never become like this so my practice is like I put a stent in send the patient there is a problem then you place a stitch I am little not pro towards putting stitches right if not here that is my own preference it's not like you should do like this there is no right thing I think again this is one area where we don't have any consensus so what Dr. Hari says is that if the stent you place it then you will be position and place is stitched I think that becomes on patient factors also like if your location is from far away place see what happens is after you place a stent it's not easy for you sometimes you get dreams also that water doesn't fit that's good seriously if you are because if you have a high volume of patients what happens is some this is life and death question because once you place a stent and this guy goes to a peripheral center if they have to do an emergency tracheostomy and there is a stent here which they don't want like it goes to pulmonary or some area so they are patient again who presents to strider you won't come to a visual order so they have to cut open and do a tracheostomy sometimes the doctors may not understand how to remove the stent in patients space so in a preventive aspect putting a stent in such patients is not wrong again it depends on many factors not just what we have learned so actually I have learned basically we are still conscious we expect for the person of migration in the head which are so when we place an upper trachea assume that it will migrate up for the person of the cases that's how I got trained I assume that it will migrate then I will put the stitches which is the system of counseling patients for this kind of because we take a sign that this fellow will come for review with me only so every 15 days we have a phone call recently only one patient missed that patient so we usually don't lose their contact every week our PG's or fellows they call them and ask how the patient is doing and if they don't have money also sometimes they call them for free from this call I think it brings out a very important point of following up stents that will end as we discussed in the morning talks also once you place a stent it is your responsibility more than the patient's responsibility to make sure that the patient is surviving when the stent and the stent is surviving when the patient so the same thing I agree with Dr. Ali that first of all you have memories of that patient and what happens because two patients and I have one patient I put a stent and then after one month and he died in a kind of a remote area he moved the stent and then it was kind of a small metallic stent part was there the family sent me the 14th photo and then he said that you charge me this much for this small thing and it stuck in my patient's and my patient died because of this one so at that he started using me so this is because and then he didn't come for the follow-up any kind of this bronchoscopy and two months and he got stuck here and he was not able to pay I think this is a very very important thing that you have to educate the patient before you place the stent so it is important that you have to educate them that if you are not able to the stent itself can cause more misery than the other stent so as Dr. Ali has said we also have a very strict protocol that we educate the patient and then we make sure that they come for regular surveillance so I will come to that so this one we keep on calling because one patient in 2019 I put a stent it was a large endoprotein tumor and then I called because you need a bronchoscopy and then you need to check it 3 months, 6 months, it didn't come again 9 months, 12 months and he said that I am doing fine what is your problem so ok what is your problem why you are calling me I have to pay for that suddenly after the 2 years of the metallic stent he called me and said I am not able to breathe so then what should I do