CT-guided percutaneous hookwire localization increases the efficacy and safety of VATS for pulmonary nodules

Comparison between one-stage and two-stage CT-guided localization of lung nodules with surgical resection: a single medical center experience

BACKGROUND

This retrospective study aimed to compare the efficacy and safety of one-stage computed tomography (OSCT)- to that of two-stage computed tomography (TSCT)-guided localization for the surgical removal of small lung nodules.

METHODS

We collected data from patients with ipsilateral pulmonary nodules who underwent localization before surgical removal at Veteran General Hospital Kaohsiung between October 2017 and January 2022. The patients were divided into the OSCT and TSCT groups.

RESULTS

We found that OSCT significantly reduced the localization time and risky time compared to TSCT, and the success rate of localization and incidence of pneumothorax were similar in both groups. However, the time spent under general anesthesia was longer in the OSCT group than in the TSCT group.

CONCLUSIONS

The OSCT-guided approach to localize pulmonary nodules in hybrid operation room is a safe and effective technique for the surgical removal of small lung nodules.

Impact of CT-guided hookwire localization on tumor spread through air spaces in stage IA lung adenocarcinoma

Background

It remains undetermined whether preoperative computed tomography (CT)-guided hookwire localization would result in elevated risk of tumor spread through air spaces (STAS) in stage IA lung adenocarcinoma.

Methods

A total of 1836 patients who underwent lobectomy were included. To eliminate the potential impact of confounding factors on producing STAS, propensity score-matching (PSM) was used to create two balanced subgroups stratified by implementation of hookwire localization. We also introduced an external cohort including 1486 patients to explore the effect of hookwire localization on the incidence of STAS and patient survival after sublobar resection (SR). For proactive simulation of hookwire localization, 20 consecutive lobectomy specimens of p-stage IA lung adenocarcinoma were selected.

Results

Ex vivo tests revealed that mechanical artifacts presenting as spreading through a localizer surface (STALS) could be induced by hookwire localization but be distinguished by CD68 and AE1/3 antibody-based immunohistochemistry. The distance of STALS dissemination tended to be shorter compared with real STAS (P = 0.000). After PSM, implementation of hookwire localization was not associated with elevated STAS incidence, nor worse survival in p-stage IA patients undergoing lobectomy irrespective of STAS.

Conclusions

CT-guided hookwire localization might induce mechanical artifacts presenting as STALS which could be distinguished by immunohistochemistry, but would not affect survival in p-stage IA disease. Surgeons can be less apprehensive about performing hookwire localization in relation to STAS on stage IA disease suitable for SR.

Evaluation of pain levels treated by the distal end of the hook-wire positioning needle: A randomized controlled study

BACKGROUND

Severe pain can be expected among adult patients undergoing hook-wire CT-guided localization of pulmonary nodules. We compared varying pain degrees between two different treatment techniques.

METHODS

Data from 100 patients who underwent hook-wire puncture localization under preoperative CT between May 2022 and October 2022 were prospectively reviewed. Using the random number table method, the patients were assigned to an observation and control group in a 1:1 ratio. In the observation group (n = 50), the external part of the hook-wire positioning needle was cut off; in the control group (n = 50), the external portion of the needle was bent. Static pain scores were measured using the visual analog scale (VAS) at 30 min, 1, and 2 h post localization for patients.

RESULTS

No significant differences were present between the two groups in terms of patient age, sex, nodule size, and nodule location. The observation group had lower VAS scores at 30 min (2.57 ± 1.38 vs. 3.51 ± 1.87 p = 0.005), 1 h (2.43 ± 1.14 vs. 3.33 ± 1.76 p = 0.003), and 2 h (2.41 ± 1.12 vs. 3.17 ± 1.74 p = 0.011) after localization. Moreover, the pain level did not gradually worsen in either group. Both groups had a 100% localization success rate. There was no statistically significant difference (p = 0.431) in the localized complication incidences between the two groups.

CONCLUSIONS

We found both approaches for handling the hook-wire extending outside the chest to be safe and effective. However, cutting off the hook-wire extending outside the chest is associated with lesser pain. Moreover, pain severity does not worsen with time after localization.

Accurate and non-invasive localization of multi-focal ground-glass opacities via electromagnetic navigation bronchoscopy assisting video-assisted thoracoscopic surgery: a single-center study

Background

Accurate localization of multi-focal ground-glass opacities (GGOs) is crucial for successful video-assisted thoracoscopic surgery (VATS). Electromagnetic navigation bronchoscopy (ENB) provides a minimally invasive and dependable approach for precise localization. This study assessed the accuracy and safety of ENB-guided localization in cases involving multi-focal GGOs.

Methods

This retrospective study presents a single-center investigation into ENB-guided localization, utilizing methylene blue, for multi-focal GGOs assisting VATS. Clinical, surgical, and pathological data were collected from patients who underwent ENB-guided localization between 23 December 2019 and 31 August 2022.

Results

The study examined 57 patients with multi-focal GGOs who underwent ENB-guided localization and VATS. A total of 150 GGOs were treated, with ENB-guided localization taking a median time of 65 min. Following localization, all patients proceeded to VATS, with a median duration of 170 min. The median lesion size measured 7.8 mm, with a 5-mm distance between GGO and pleura or fissure. When the distance between GGO and pleura/fissure exceeded 1 cm, an additional location point was introduced below the pleura or fissure based on GGO location. No complications related to localization were observed. The overall malignancy rate stood at 66%. Location precision was confirmed by measuring the marker-to-GGO lesion distance, resulting in a 94% (141/150) accuracy rate for GGO localization.

Conclusion

ENB-guided methylene blue injection is a safe and precise method to treat multi-focal GGOs, potentially minimizing operation time and simplifying lesion detection.

Implementation of Individualized Low-Dose Computed Tomography-Guided Hook Wire Localization of Pulmonary Nodules: Feasibility and Safety in the Clinical Setting

Background: CT-guided hook-wire localization is an essential step in the management of small pulmonary nodules. Few studies, however, have focused on reducing radiation exposure during the procedure. Purpose: This study aims to explore the feasibility of implementing a low-dose computed tomography (CT)-guided hook wire localization using tailored kVp based on patients' body size. Materials and Methods: A total of 151 patients with small pulmonary nodules were prospectively enrolled for CT-guided hook wire localization using individualized low-dose CT (LDCT) vs. standard-dose CT (SDCT) protocols. Radiation dose, image quality, characteristics of target nodules and procedure-related variables were compared. All variables were analyzed using Chi-Square and Student's t-test. Results: The mean CTDIvol was significantly reduced for LDCT (for BMI ≤ 21 kg/m2, 0.56 ± 0.00 mGy and for BMI > 21 kg/m2, 1.48 ± 0.00 mGy) when compared with SDCT (for BMI ≤ 21 kg/m2, 5.24 ± 0.95 mGy and for BMI > 21 kg/m2, 6.69 ± 1.47 mGy). Accordingly, the DLP of LDCT was significantly reduced as compared with that of SDCT (for BMI ≤ 21 kg/m2, 56.86 ± 4.73 vs. 533.58 ± 122.06 mGy.cm, and for BMI > 21 kg/m2, 167.02 ± 38.76 vs. 746.01 ± 230.91 mGy.cm). In comparison with SDCT, the effective dose (ED) of LDCT decreased by an average of 89.42% (for BMI ≤ 21 kg/m2) and 77.68% (for BMI > 21 kg/m2), respectively. Although the images acquired with the LDCT protocol yielded inferior quality to those acquired with the SDCT protocol, they were clinically acceptable for hook wire localization. Conclusions: LDCT-guided localization can provide safety and nodule detection performance comparable to SDCT-guided localization, benefiting radiation dose reduction dramatically, especially for patients with small body mass indexes.

Predicting pleural invasion of invasive lung adenocarcinoma in the adjacent pleura by imaging histology

The aim of the present study was to develop a non-invasive method based on histological imaging and clinical features for predicting the preoperative status of visceral pleural invasion (VPI) in patients with lung adenocarcinoma (LUAD) located near the pleura. VPI is associated with a worse prognosis of LUAD; therefore, early and accurate detection is critical for effective treatment planning. A total of 112 patients with preoperative computed tomography presentation of adjacent pleura and postoperative pathological findings confirmed as invasive LUAD were retrospectively enrolled. Clinical and histological imaging features were combined to develop a preoperative VPI prediction model and validate the model's efficacy. Finally, a nomogram for predicting LUAD was established and validated using a logistic regression algorithm. Both the clinical signature and radiomics signature (Rad signature) exhibited a perfect fit in the training cohort. The clinical signature was overfitted in the testing cohort, whereas the Rad signature showed a good fit. To combine clinical and radiomics signatures for optimal performance, a nomogram was created using the logistic regression algorithm. The results indicated that this approach had the highest predictive performance, with an area under the curve of 0.957 for the clinical signature and 0.900 for the Rad signature. In conclusion, histological imaging and clinical features can be combined in columnar maps to predict the preoperative VPI status of patients with adjacent pleural infiltrative lung carcinoma.

The additional diagnostic value of virtual bronchoscopy navigation in patients with pulmonary nodules - The NAVIGATOR study

BACKGROUND

The number of solitary pulmonary nodules to be evaluated is expected to increase and therefore we need to improve diagnostic and therapeutic tools to approach these nodules. To prevent patients from futile invasive procedures and receiving treatment without histological confirmation of cancer, we evaluated the value of virtual bronchoscopy navigation to obtain a diagnosis of the solitary pulmonary nodule in a real-world clinical setting.

METHODS

In the NAVIGATOR single center, prospective, observational cohort study patients underwent a virtual bronchoscopy navigation procedure with or without guide sheet tunnelling to assess a solitary pulmonary nodule. Nodules were considered not accessible if a diagnosis could not be obtained by either by CT-guided transthoracic biopsy or conventional bronchoscopy.

RESULTS

Between February 2021 and January 2022 35 patients underwent the virtual bronchoscopy navigation procedure. The overall diagnostic yield was 77% and was dependent on size of the nodule and chosen path, with highest yield in lesions with an airway path. Adverse events were few and manageable.

CONCLUSION

Virtual bronchoscopy navigation with or without sheet tunnelling is a new technique with a good diagnostic yield, also in patients in whom previously performed procedures failed to establish a diagnosis and/or alternative procedures are considered not feasible based on expected yield and/or safety. Preventing futile or more invasive procedures like surgery or transthoracic punctures with a higher complication rate is beneficial for patients, and allowed treatment adaptation in two-third of the analyzed patient population.

CT-guided percutaneous transthoracic needle biopsy (PTNB): A thoracic surgeon's learning curve and experience summary

BACKGROUND

Few studies have investigated the learning process of percutaneous transthoracic needle biopsy (PTNB). Here, we aimed to evaluate the number of cases required to achieve proficiency by plotting the learning curve of PTNB.

METHODS

Data were collected from 94 consecutive patients who underwent computed tomography-guided PTNB by a thoracic surgeon at the Affiliated Hospital of Xuzhou Medical University between May 2021 and February 2022. The data collected included patient information, relevant examination results, intraoperative parameters, postoperative complications, and diagnostic results.

RESULTS

The inflection points of the cumulative sum curve were around cases 13 and 24, according to which three phases were identified, including phase I, phase II, and phase III. A significant downtrend was observed regarding operative time (phase I, 26.53 ± 9.13 min vs. phase III, 18.42 ± 4.29 min, p < 0.05), rate of false-negative (phase I, 15.4% vs. phase III, 5.7%; p < 0.05), rate of pneumothorax (phase I, 30.8% vs. phase III, 12.9%; p < 0.05), and rate of hemoptysis (phase I, 15.4% vs. phase III, 2.9%; p < 0.05).

CONCLUSIONS

Thirteen cases were accumulated to lay the technical foundation, and 24 cases were required to achieve proficiency. In this study we summarize our own experience and provide specific guidance for young doctors with no experience in biopsy.

Marking ground glass nodules with pulmonary nodules localization needle prior to video-assisted thoracoscopic surgery

OBJECTIVES

To evaluate the efficacy and safety of marking ground glass nodules (GGNs) with pulmonary nodules localization needle (PNLN) prior to video-assisted thoracoscopic surgery (VATS).

MATERIALS AND METHODS

From June 2020 to February 2021, all patients with GGNs who received CT-guided localization using PNLN before VATS were enrolled. Clinical and imaging data were retrospectively analyzed.

RESULTS

A total of 352 consecutive patients with 395 GGNs were included in the study. The mean diameter of GGNs was 0.95 ± 0.48 cm, and the shortest distance from nodules to the pleura was 1.73 ± 0.96 cm. All 395 GGNs were marked using PNLNs. The time required for marking was 7.8 ± 2.2 min. The marking success rate was 99.0% (391/395). The marking failure of four nodules was all due to the unsatisfactory position of PNLNs. No marker dislocation occurred. Marking-related complications included pneumothorax in 63 cases (17.9%), hemorrhage in 34 cases (9.7%), and hemoptysis in 6 cases (1.7%). All the complications were minor and did not need special treatment. Localization and VATS were performed on the same day in 95 cases and on different days in 257 cases. All GGNs were successfully removed by VATS. No patient converted to thoracotomy. Histopathological examination revealed 74 (18.7%) benign nodules and 321 (81.3%) malignant nodules.

CONCLUSIONS

It is safe and reliable to perform preoperative localization of GGNs using PNLNs, which can effectively guide VATS to remove GGNs.

KEY POINTS

• Preoperative localization of GGNs could effectively guide VATS to remove GGNs. • PNLN was based on the marking principle of hook-wire, through the improvement of its material, specially designed to mark pulmonary nodules. • The application of PNLN to mark GGNs had high success rate, good patient tolerance, and no dislocation. Meanwhile, VATS could be performed 2 to 3 days after marking GGNs with PNLN.

Clinical value and application of preoperative CT-guided hookwire localization of solitary pulmonary nodules for video-assisted thoracic surgery

BACKGROUND

Video-assisted thoracic surgery (VATS) is a minimally invasive technique for the diagnosis and management of small pulmonary nodular lesions However, the identification of some lung nodules remains difficult.

OBJECTIVE

This research aimed to investigate the clinical value of preoperative computed tomography (CT)-guided hookwire localization of solitary pulmonary nodules (SPNs) for thoracoscopic resection.

METHODS

Seventy-one patients with 74 SPNs underwent VATS wedge resection after CT-guided hookwire localization. The mean diameter of the SPNs was 8.50 ± 4.53 mm,,besides, the mean distance from the SPNs to the parietal pleura was 16.81 ± 5.23 mm.

RESULTS

Sixty-nine of the 74 nodules were successfully localized using a CT-guided hookwire. The success rate of CT-guided localization was 93.2%. The average localization time was 15.23 ± 7.21 min per lesion. Seven patients (9.5%) had asymptomatic pneumothorax and 10 (13.5%) had minimal needle tract parenchymal hemorrhages after localization no clinical intervention was required for these patients. The rate of success for VATS wedge resection of the SPNs was 100%. Histological analysis of the SPNs revealed malignant disease in 67.4% of the patients.

CONCLUSIONS

Preoperative CT-guided hookwire localization for thoracoscopic resection is a safe and effective operation for the identification and stable fixation of SPNs.

CT-guided microcoil localization of pulmonary nodules: the effect of the position of microcoil proximal end on the incidence of microcoil dislocation

OBJECTIVES

To evaluate the effect of the position of microcoil proximal end on the incidence of microcoil dislocation during CT-guided microcoil localization of pulmonary nodules (PNs).

METHODS

This retrospective study included all patients with PNs who received CT-guided microcoil localization before video-assisted thoracoscopic urgery (VATS) resection from June 2016 to December 2019 in our institution. The microcoil distal end was less than 1 cm away from the nodule, and the microcoil proximal end was in the pleural cavity (the pleural cavity group) or chest wall (the chest wall group). The length of microcoil outside the pleura was measured and divided into less than 0.5 cm (group A), 0.5 to 2 cm (group B) and more than 2 cm (group C). Microcoil dislocation was defined as complete retraction into the lung (type I) or complete withdrawal from the lung (type II). The rate of microcoil dislocation between different groups was compared.

RESULTS

A total of 519 consecutive patients with 571 PNs were included in this study. According to the position of microcoils proximal end on post-marking CT, there were 95 microcoils in the pleural cavity group and 476 in the chest wall group. The number of microcoils in group A, B, and C were 67, 448 and 56, respectively. VATS showed dislocation of 42 microcoils, of which 30 were type II and 12 were type I. There was no statistical difference in the rate of microcoil dislocation between the pleural cavity group and the chest wall group (6.3% vs 7.6%, x² = 0.18, p = 0.433). The difference in the rate of microcoil dislocation among group A, B, and C was statistically significant (11.9%, 5.8%, and 14.3% for group A, B, and C, respectively, x² = 7.60, p = 0.008). In group A, 75% (6/8) of dislocations were type I, while all eight dislocations were type II in group C.

CONCLUSIONS

During CT-guided microcoil localization of PNs, placing the microcoil proximal end in the pleura cavity or chest wall had no significant effect on the incidence of microcoil dislocation. The length of microcoil outside the pleura should be 0.5 to 2 cm to reduce the rate of microcoil dislocation.

ADVANCES IN KNOWLEDGE:

CT-guided microcoil localization can effectively guide VATS to resect invisible and impalpable PNs. Microcoil dislocation is the main cause of localization failure. The length of microcoil outside the pleura is significantly correlated with the rate and type of microcoil dislocation. Placing the microcoil proximal end in the pleura cavity or chest wall has no significant effect on the rate of microcoil dislocation.

Thoracoscopic segmentectomy and lobectomy assisted by three-dimensional computed-tomography bronchography and angiography for the treatment of primary lung cancer

BACKGROUND

Anatomical segmentectomy has been proposed as a substitution for lobectomy for early-stage lung cancer. However, it requires technical meticulousness due to the complex anatomical variations of segmental vessels and bronchi.

AIM

To assess the safety and feasibility of three-dimensional computed-tomography bronchography and angiography (3D-CTBA) in performing video-assisted thoracoscopic surgery (VATS) for lung cancers.

METHODS

In this study, we enrolled 123 patients who consented to undergo thoracoscopic segmentectomy and lobectomy assisted by 3D-CTBA between May 2017 and June 2019. The image data of enhanced computed tomography (CT) scans was reconstructed three-dimensionally by the Mimics software. The results of preoperative 3D-CTBA, in combination with intraoperative navigation, guided the surgery.

RESULTS

A total of 59 women and 64 men were enrolled, of whom 57 (46.3%) underwent segmentectomy and 66 (53.7%) underwent lobectomy. The majority of tumor appearance on CT was part-solid ground-glass nodule (pGGN; 55.3%). The mean duration of chest tube placement was 3.5 ± 1.6 d, and the average length of postoperative hospital stay was 6.8 ± 1.8 d. Surgical complications included one case of pneumonia and four cases of prolonged air leak lasting > 5 d. Notably, there was no intraoperative massive hemorrhage, postoperative intensive-care unit stay, or 30-d mortality. Preoperative 3D-CTBA images can display clearly and vividly the targeted structure and the variations of vessels and bronchi. To reduce the risk of locoregional recurrence, the application of 3D-CTBA with a virtual 3D surgical margin help the VATS surgeon determine accurate distances and positional relations among the tumor, bronchial trees, and the intersegmental vessels. Three-dimensional navigation was performed to confirm the segmental structure, precisely cut off the targeted segment, and avoid intersegmental veins injury.

CONCLUSION

VATS and 3D-CTBA worked in harmony in our study. This combination also provided a new pattern of transition from lesion-directed location of tumors to computer-aided surgery for the management of early lung cancer.

Preoperative non-invasive visual localization of synchronous multiple lung cancers using three-dimensional computed tomography lung reconstruction

BACKGROUND

Synchronous multiple primary lung cancers are becoming more common with increasing use of computed tomography for screening. Intraoperative localization and resection of ill-defined pulmonary ground-glass opacities during thoracoscopic resection is challenging. This study aimed to determine the clinical feasibility of non-invasive visual localization of these nodules by three-dimensional computed tomography lung reconstruction before sublobar resection.

METHODS

Forty-four patients with synchronous multiple primary lung cancers underwent thoracoscopic pulmonary resection at our institution between June 2017 and August 2019. Preadmission computed tomography images were downloaded and reconstructed into a three-dimensional model. Small nodules (< 15 mm) were localized non-invasively by three-dimensional computed tomography lung reconstruction before surgery. Patient demographics, nodule characteristics, procedural details, pathological data, and outcomes were obtained from the medical records.

RESULTS

One hundred and twenty-one pulmonary nodules from the 44 patients were scheduled for video-assisted thoracic surgery; 54 (44.6%) were pure ground-glass opacities and 57 (47.1%) were mixed ground-glass opacities. One hundred and seventeen nodules were localized preoperatively. The mean nodule diameter was 7.67 ± 3.87 mm. The mean distance from the nodule to the pleura was 14.84 ± 14.43 mm. All nodules were removed successfully by wedge resection (27 patients), lobectomy (26 patients), or segmentectomy (25 patients). Most lesions (85.1%) were malignant. Paraffin pathology revealed 12 cases of atypical adenomatous hyperplasia (9.92%), 13 of adenocarcinoma in situ (10.74%), 16 of minimally invasive adenocarcinoma (13.22%), and 73 of invasive adenocarcinoma (60.33%).

CONCLUSIONS

Three-dimensional computed tomography lung reconstruction is a feasible and alternative method of visual localization for small lung nodules before sublobar resection in some suitable patients.

Medical adhesive vs hookwire for computed tomography-guided preoperative localization and risk factors of major complications

OBJECTIVE

To compare the efficacy of medical adhesive and hookwire as CT-guided non-palpable pulmonary nodule (NPN) localization methods before video-assisted thoracoscopic surgery (VATS) resection, and determine the risk factors for common complications during localization.

METHODS

This was a single-center non-randomized retrospective study. 102 consecutive patients with 109 NPNs were divided into Group A (medical adhesive, 66 patients, 72 nodules) and Group B (hookwire, 36 patients, 37 nodules) before VATS. Patient- and nodule-based characteristics were compared. Logistic regression was performed to identify the risk factors for complications.

RESULTS

Localization was successfully performed in all the NPNs. For Group A, the rate of pneumothorax immediately after localization was lower (p = 0.049) and the localization-to-surgery interval was longer (p = 0.011) than Group B. There was no significant difference in rates of hemorrhage after needle withdrawal between the two groups (p = 0.198). Hookwire ( vs medical adhesive) (β = 1.12, p = 0.018), total insertion depth (β = -0.41, p = 0.013), pleura-needle angle (β = -0.04, p = 0.025) and grade of hemorrhage after needle withdrawal (β = -0.96, p = 0.030) were independently associated with pneumothorax, while age (β = -0.94, p = 0.018), tumor size (β = 0.29, p = 0.007) and its distance from the pleural surface (β = 0.14, p = 0.004) were associated with higher grade hemorrhage after needle withdrawal.

CONCLUSION

Compared with hookwire, localization with medical adhesive excelled in lower risk of pneumothorax, a more flexible localization-to-surgery interval, and had similar rates of hemorrhage after needle withdrawal. Hookwire is an independent risk factor of pneumothorax immediately after localization.

ADVANCES IN KNOWLEDGE

This study added new clinical evidence to the efficacy of medical adhesive in pre-operative CT-guided NPN localization.

CT-guided preoperative localization of ground glass nodule: comparison between the application of embolization microcoil and the locating needle designed for pulmonary nodules

OBJECTIVES

To compare the efficacy and safety of pre-operative localization of ground glass nodule (GGN) using embolization microcoils and the locating needles designed for pulmonary nodules.

METHODS

From June 2019 to December 2020, 429 patients who received CT-guided localization of single GGN before video-assisted thoracoscopic surgery (VATS) were enrolled. The diameter and depth of GGNs were 0.84 ± 0.39 cm and 1.66 ± 1.37 cm. Among 429 cases, the first 221 GGNs were marked with microcoils (the microcoil group), and the remaining 208 GGNs were marked with the locating needles designed for pulmonary nodules (the locating needle group). SPSS 17.0 statistical software was used to compare the marking success rate, marking time, marking-related complications between two groups. p values < 0.05 were considered statistically significant.

RESULTS

The marking time in the microcoil group was longer than that in the locating needle group (11.1 ± 3.9 vs 8.2 ± 2.0 min, t = -7.87, p = 0.000). The marking success rate in the microcoil group was lower than that in the locating needle group (91.4% vs 98.6%, χ² = 11.27, p = 0.001). In the microcoil group, marking failures included 16 cases of microcoil dislocation and 3 cases of unsatisfactory microcoil position, while all 3 cases of marking failure in the locating needle group were due to unsatisfactory anchor position. No significant differences in the incidence of total complications (23.1% vs 22.1%), pneumothorax (18.1% vs 19.2%), hemorrhage (9.5% vs 9.1%), and hemoptysis (1.8% vs 1.4%) were observed between the two groups. All the complications were minor and did not need special treatment. Except for one case in the microcoil group, which was converted to thoracotomy, the remaining 428 GGNs were successfully resected by VATS.

CONCLUSIONS

It is safe and effective to perform pre-operative localization of GGN using either embolization microcoil or the locating needle designed for pulmonary nodules. The locating needle is superior to microcoil for marking GGN in terms of procedure time and the success rate. The complication rate of both methods is similar.

ADVANCES IN KNOWLEDGE

The locating needle designed for pulmonary nodules has recently been used to mark pulmonary nodule. Its structure can effectively avoid dislocation after localization, and the marking process is simple and quick. Compared with localization using microcoil, it takes less time and has higher success rate to mark GGNs using the locating needle. The complication rate of both methods is similar.

Planting Seeds into the Lung: Image-Guided Percutaneous Localization to Guide Minimally Invasive Thoracic Surgery

Image-guided localization materials are constantly evolving, providing options for the localization of small pulmonary nodules to guide minimally invasive thoracic surgery. Several preoperative methods have been developed to localize small pulmonary lesions prior to video-assisted thoracic surgery. These localization techniques can be categorized into 4 groups according to the materials used: localization with metallic materials (hook-wire, microcoil, or spiral coil), localization with dye (methylene blue or indigo carmine), localization with contrast agents (lipiodol, barium, or iodine contrast agents), and radiotracers (technetium-99m). However, the optimal localization method has not yet been established. In this review article, we discuss the various localization techniques and the advantages and disadvantages of localization techniques as well as the available safety and efficacy data on these techniques.

CT-guided microcoil implantation for localizing pulmonary ground-glass nodules: feasibility and accuracy of oblique approach for lesions difficult to access on axial images

Objective:

(1) To evaluate the value of CT-guided microcoil implantation for localizing pulmonary ground-glass nodules (GGNs) before video-assisted thoracoscopic surgery (VATS). (2) To evaluate the feasibility, safety and accuracy of cephalic-caudal oblique approach for lesions difficult to access on axial images owing to overlying bony structures, large vessels or interlober fissures.

Methods:

From June 2016 to March 2019, all patients with GGNs resected by VATS after marking using CT-guided microcoil implantation in China-Japan friendship hospital were enrolled and clinical and imaging data were retrospectively analyzed. According to the microcoil marked path, the GGNs were divided into cephalic-caudal oblique group (oblique group) and non-oblique group. The success rate of marking, the time required for marking and the incidence of complications between the two groups were compared.

Results:

258 GGNs from 215 consecutive patients were included in this study. The diameter of GGNs was 1.22 ± 0.50 cm, and the shortest distance from GGNs to the pleura was 1.56 ± 1.09 cm. All 258 GGNs were successfully resected by VATS under the guidance of implanted microcoils, and no case was converted to thoracotomy. During CT-guided microcoil implantation, cephalic- caudal oblique approach was taken in 56 GGNs (oblique group) to avoid bone, interlobar fissure and blood vessels. The time required for marking was significantly longer for oblique group compared with non-oblique group (16.6 ± 2.4 vs. 13.1 ± 1.9 min, p<0.01). No significant differences in the success rate of marking (94.6% vs 91.6%), the incidence of pneumothorax (19.6% vs 17.8%), the bleeding rate (10.7% vs 8.9%), and the hemoptysis rate (1.8% vs 1.5%) were observed between the two groups.

Conclusion:

CT-guided microcoil implantation can effectively guide VATS to resect GGNs. For GGNs difficult to access on axial images, CT-guided cephalic-caudal oblique approach is feasible, safe, and accurate.

Advances in knowledge:

CT-guided microcoil implantation can effectively guide VATS to resect GGNs. The marked path with cephalic-caudal obliquity can effectively avoid bone, interlobar fissure and blood vessels, successfully mark GGNs difficult to access on axial images, while keeping the distance from the pleura to the lesion on the marked path as short as possible at the same time.

Preoperative versus intraoperative image-guided localization of multiple ipsilateral lung nodules

OBJECTIVES

Computed tomography (CT)-guided localization of multiple ipsilateral pulmonary nodules remains challenging. Hybrid operating rooms equipped with cone-beam CT and laser navigation systems have the potential for improving clinical workflows and patient outcomes.

METHODS

Patients with multiple ipsilateral pulmonary nodules requiring localization were divided according to the localization method [preoperative CT-guided (POCT group) localization versus intraoperative CT-guided (IOCT group) localization]. The 2 groups were compared in terms of procedural efficacy, safety and radiation exposure.

RESULTS

Patients in the IOCT (n = 12) and POCT (n = 42) groups did not differ in terms of demographic and tumour characteristics. Moreover, the success and complication rates were similar. Notably, the IOCT approach allowed multiple nodules to be almost simultaneously localized-resulting in a shorter procedural time [mean difference (MD) -15.83 min, 95% confidence interval (CI) -7.97 to -23.69 min] and lower radiation exposure (MD -15.59 mSv, 95% CI -7.76 to -23.42 mSv) compared with the POCT approach. However, the total time under general anaesthesia was significantly longer in the IOCT group (MD 34.96 min, 95% CI 1.48-68.42 min), despite a similar operating time. The excess time under anaesthesia in the IOCT group can be attributed not only to the procedure per se but also to a longer surgical preparation time (MD 21.63 min, 95% CI 10.07-33.19 min).

CONCLUSIONS

Compared with the POCT approach, IOCT-guided localization performed in a hybrid operating room is associated with a shorter procedural time and less radiation exposure, albeit at the expense of an increased time under general anaesthesia.

Accuracy of a 3-Dimensionally Printed Navigational Template for Localizing Small Pulmonary Nodules: A Noninferiority Randomized Clinical Trial

Importance

Localization of small lung nodules are challenging because of the difficulty of nodule recognition during video-assisted thoracoscopic surgery. Using 3-dimensional (3-D) printing technology, a navigational template was recently created to assist percutaneous lung nodule localization; however, the efficacy and safety of this template have not yet been evaluated.

Objective

To assess the noninferiority of the efficacy and safety of a 3-D-printed navigational template guide for localizing small peripheral lung nodules.

Design, Setting, and Participants

This noninferiority randomized clinical trial conducted between October 2016 and October 2017 at Shanghai Pulmonary Hospital, Shanghai, China, compared the safety and precision of lung nodule localization using a template-guided approach vs the conventional computed tomography (CT)-guided approach. In total, 213 surgical candidates with small peripheral lung nodules (<2 cm) were recruited to undergo either CT- or template-guided lung nodule localization. An intention-to-treat analysis was conducted.

Interventions

Percutaneous lung nodule localization.

Main Outcomes and Measures

The primary outcome was the accuracy of lung nodule localization (localizer deviation), and secondary outcomes were procedural duration, radiation dosage, and complication rate.

Results

Of the 200 patients randomized at a ratio of 1:1 to the template- and CT-guided groups, most were women (147 vs 53), body mass index ranged from 15.4 to 37.3, the mean (SD) nodule size was 9.7 (2.9) mm, and the mean distance between the outer edge of target nodule and the pleura was 7.8 (range, 0.0-43.9) mm. In total, 190 patients underwent either CT- or template-guided lung nodule localization and subsequent surgery. Among these patients, localizer deviation did not significantly differ between the template- and CT-guided groups (mean [SD], 8.7 [6.9] vs 9.6 [5.8] mm; P = .36). The mean (SD) procedural durations were 7.4 (3.2) minutes for the template-guided group and 9.5 (3.6) minutes for the CT-guided group (P < .001). The mean (SD) radiation dose was 229 (65) mGy × cm in the template-guided group and 313 (84) mGy × cm in CT-guided group (P < .001).

Conclusions and Relevance

The use of the 3-D-printed navigational template for localization of small peripheral lung nodules showed efficacy and safety that were not substantially worse than those for the CT-guided approach while significantly simplifying the localization procedure and decreasing patient radiation exposure.

Trial Registration

ClinicalTrials.gov identifier: NCT02952261.

Electromagnetic navigational bronchoscopy-directed dye marking for locating pulmonary nodules

BACKGROUND

Small peripheral pulmonary nodules, which are usually deep-seated with no visual markers on the pleural surface, are often difficult to locate during surgery. At present, CT-guided percutaneous techniques are used to locate pulmonary nodules, but this method has many limitations. Thus, we aimed to evaluate the accuracy and feasibility of electromagnetic navigational bronchoscopy (ENB) with pleural dye to locate small peripheral pulmonary nodules before video-associated thoracic surgery (VATS).

METHODS

The ENB localisation procedure was performed under general anaesthesia in an operating room. Once the locatable guide wire, covered with a sheath, reached the ideal location, it was withdrawn and 0.2-1.0 mL of methylene blue/indocyanine green was injected through the guide sheath. Thereafter, 20-60 mL of air was instilled to disperse the dye to the pleura near the nodules. VATS was then performed immediately.

RESULTS

Study subjects included 25 patients with 28 nodules. The mean largest diameter of the pulmonary nodules was 11.8 mm (range, 6.0-24.0 mm), and the mean distance from the nearest pleural surface was 13.4 mm (range, 2.5-34.9 mm). After the ENB-guided localisation procedure was completed, the dye was visualised in 23 nodules (82.1%) using VATS. The average duration of the ENB-guided pleural dye marking procedure was 12.6 min (range, 4-30 min). The resection margins were negative in all malignant nodules. Complications unrelated to the ENB-guided localisation procedure occurred in two patients, including one case of haemorrhage and one case of slow intraoperative heart rate.

CONCLUSION

ENB can be used to safely and accurately locate small peripheral pulmonary nodules and guide surgical resection.

TRIAL REGISTRATION NUMBER

ChiCTR1900021963.

Computed tomography-guided coil localization for video-assisted thoracoscopic surgery of sub-solid lung nodules: a retrospective study

BACKGROUND

Wedge resection via video-assisted thoracoscopic surgery (VATS) is the best choice for the diagnosis of sub-solid lung nodules. Preoperative localization is utilized to increase the success rate of this procedure. We aimed to evaluate the effectiveness of preoperative coil localization in VATS wedge resection for sub-solid lung nodules.

METHODS

From October 2015 to August 2018, 42 patients with 55 sub-solid lung nodules underwent computed tomography-guided coil localization with subsequent VATS wedge resection in our centre. Data regarding visible coil rates, technical success of the wedge resection and pathological results were collected and analysed retrospectively.

RESULTS

A total of 55 sub-solid lung nodules were localized in 42 patients. Thirty-three patients had one nodule and nine patients had multiple nodules. Fifty-two coils (52/55, 94.5%) were visible during the VATS. The mean duration of each coil localization was 14.3 ± 4.8 min (range 7-40 min). Three patients (7%) experienced pneumothorax after coil localization. VATS wedge resection was successfully performed for 53 nodules (53/55, 96.4%). The remaining two nodules were treated directly with lobectomy. The nine patients who had multiple nodules underwent one-stage VATS wedge resection of all nodules. The mean duration of the VATS in the 42 patients was 159.3 ± 83.4 min (range 60-360 min) while the mean blood loss was 119.3 ± 115.3 mL (range 10-700 mL).

CONCLUSION

Preoperative computed tomography-guided coil localization is a safe and effective method to facilitate high success rates for diagnostic VATS wedge resection for sub-solid nodules.

Ultralow dose computed tomography protocol for hook-wire localization of solitary pulmonary nodules prior to video-assisted thoracoscopic surgery

BACKGROUND

This study prospectively investigated the efficacy and radiation dose of ultralow dose computed tomography (CT)-guided hook-wire localization (HWL) at 100 kV with tin filtration (100Sn kV) for small solitary pulmonary nodules.

METHODS

All HWL procedures were performed on a third generation dual-source CT system. Eighty-eight consecutive patients undergoing CT-guided HWL were randomly assigned to standard dose CT (Group A: n = 44; reference 110 kV and 50 mA) or ultralow dose CT (Group B: n =44; ¹⁰⁰ Sn kV and 96 mA) protocols. The technical success rate, complications, subjective image quality, and radiation dose were compared between the groups.

RESULTS

The mean volume CT dose index and total dose-length product were significantly lower in Group B compared to Group A (0.32 mGy vs. 3.2 ± 1.1 mGy and 12.1 ± 0.97 mGy-cm vs. 120 ± 40.6 mGy-cm; P < 0.001). The effective dose in Group B was significantly lower than in Group A (0.17 ± 0.01 mSv vs. 1.68 ± 0.57 mSv, -89.8%; P < 0.001). The technical success rates were 100% for both groups. There were no significant differences in complication rates between the protocols (P > 0.05). The image quality of ultralow dose CT met the requirements for HWL procedure.

CONCLUSION

Ultralow dose CT-guided HWL of solitary pulmonary nodules performed at ¹⁰⁰ Sn kVp spectral shaping significantly reduced the radiation dose compared to standard dose CT, with high technical success and acceptable patient safety.

Preoperative computed tomography-guided coil localization of lung nodules

Purpose: To evaluate the usefulness of preoperative computed tomography (CT)-guided coil localization in patients with lung nodules who underwent video-assisted thoracoscopic surgery (VATS) for lung resection.Material and methods: From October 2015 to January 2018, 76 patients with lung nodules underwent CT-guided coil localization and subsequent VATS in our center. The tail of the coil remained above the visceral pleura. Data regarding the technical success of coil localization and wedge resection were analyzed.Results: A total of 96 lung nodules in 76 patients were localized. The technical success rate of CT-guided coil localization was 97.9% (94/96). Among the 94 localized nodules, 88 coils were visible and six coils were palpated during VATS. Nine patients experienced pneumothorax and two patients experienced hemoptysis after coil localization. Two patients underwent VATS beyond 24 h after coil localization. The technical success rate of wedge resection of lung nodules was 97.9%. Seventeen patients with multiple target lung nodules underwent one-stage video-assisted resection of all target nodules after coil localization.Conclusion: Preoperative CT-guided coil localization is a safe and convenient method to facilitate a high success rate of diagnostic VATS wedge-resection of lung nodules. Coil localization can also facilitate one-stage VATS wedge-resection of multiple nodules.

Computed tomography-guided percutaneous hook wire localization of pulmonary nodular lesions before video-assisted thoracoscopic surgery: Highlighting technical aspects

OBJECTIVE

Confirming the histologic diagnosis of small pulmonary nodules or Ground-glass opacity nodules (GGNs) of unknown origin is difficult. These nodules are not always appropriate for percutaneous transthoracic needle biopsy. Preoperative localization of pulmonary lesions provides more precise target points to ensure complete surgical excision. The goal of the present study was to evaluate the validity and effectiveness of computed tomography-guided preoperative hook wire localization with our technique for video-assisted thoracoscopic surgery (VATS).

METHODS

We retrospectively investigated 113 patients who had undergone preoperative hook wire localization before VATS resection for newly present or growing pulmonary nodular lesions between May 2007 and December 2016. Procedural and perioperative outcomes were assessed to evaluate the safety and efficacy of preoperative localization technique.

RESULTS

A total of 113 pulmonary nodules were localized and successfully resected in all 113 patients. The mean diameter of nodules was 10.8 ± 6.1 mm (range, 3-28). The mean distance from the pleural surface was 20.2 ± 12.4 mm (range, 5-55). The mean procedure time of localization was 23.7 ± 6.3 min. Asymptomatic minimal pneumothorax and mild parenchymal hemorrhage occurred in 26 (23.0%) and 8 (7.1%) patients, respectively. There were 32 (28.3%) deep lung nodules, in which the distance to pleural surface was more than 25 mm. Wire dislodgement occurred in 4 (3.5%) patients. Complete resection of all lung lesions was achieved, and definite histological diagnosis was obtained in all patients. Pathologic examination revealed 42 (37.2%) primary lung cancers, 2 (1.8%) lymphomas, 53 (46.9%) metastases, 16 (14.1%) benign lesions.

CONCLUSIONS

Preoperative percutaneous hook wire localization is a dependable and useful technique to facilitate positioning small and deep pulmonary nodules for thoracoscopic complete excision and accurate diagnosis.

Fiducial marker placement with electromagnetic navigation bronchoscopy: a subgroup analysis of the prospective, multicenter NAVIGATE study

BACKGROUND

Fiducial markers (FMs) help direct stereotactic body radiation therapy (SBRT) and localization for surgical resection in lung cancer management. We report the safety, accuracy, and practice patterns of FM placement utilizing electromagnetic navigation bronchoscopy (ENB).

METHODS

NAVIGATE is a global, prospective, multicenter, observational cohort study of ENB using the superDimension™ navigation system. This prospectively collected subgroup analysis presents the patient demographics, procedural characteristics, and 1-month outcomes in patients undergoing ENB-guided FM placement. Follow up through 24 months is ongoing.

RESULTS

Two-hundred fifty-eight patients from 21 centers in the United States were included. General anesthesia was used in 68.2%. Lesion location was confirmed by radial endobronchial ultrasound in 34.5% of procedures. The median ENB procedure time was 31.0 min. Concurrent lung lesion biopsy was conducted in 82.6% (213/258) of patients. A mean of 2.2 ± 1.7 FMs (median 1.0 FMs) were placed per patient and 99.2% were accurately positioned based on subjective operator assessment. Follow-up imaging showed that 94.1% (239/254) of markers remained in place. The procedure-related pneumothorax rate was 5.4% (14/258) overall and 3.1% (8/258) grade ⩾ 2 based on the Common Terminology Criteria for Adverse Events scale. The procedure-related grade ⩾ 4 respiratory failure rate was 1.6% (4/258). There were no bronchopulmonary hemorrhages.

CONCLUSION

ENB is an accurate and versatile tool to place FMs for SBRT and localization for surgical resection with low complication rates. The ability to perform a biopsy safely in the same procedure can also increase efficiency. The impact of practice pattern variations on therapeutic effectiveness requires further study.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02410837.

Safety and efficacy of computed tomography-guided dye localization using patent blue V for single lung nodule for video-assisted thoracoscopic surgery: a retrospective study

Background

For invisible or impalpable lung nodules, video-assisted thoracoscopic surgery (VATS) has some limitations; some preoperative localization has been developed to overcome this limitation. This study aimed to assess the safety and efficacy of preoperative computed tomography (CT)-guided localization with patent blue V dye.

Methods

In this retrospective study, we examined patients with solitary pulmonary nodule undergoing preoperative CT-guided patent blue V dye localization from 2013 to 2015. We analyzed patients' demographic data, nodular features, and procedures undergone.

Results

We enrolled 282 patients (282 lung nodules; mean age: 56.6±11.6 years, with female preponderance) in this study. The mean size of nodules was 0.9±0.5 cm, and mean time of localization was 24 min. The leading complications after localization were asymptomatic pneumothorax (48 patients, 17%) and localized pulmonary hemorrhage (51 patients, 18%). Other rare complications included subcutaneous emphysema and hematoma. We noted two cases with intraoperative poor or fail dye localization. Most patients underwent wedge resection (221 patients, 78.4%) and segmentectomy (36 patients, 12.8%), whereas 25 patients underwent lobectomy (8.9%) after the intraoperative frozen histopathological study confirmed malignancy. Furthermore, postoperative hospital stay was 4.8±2.0 days. Few patients experienced postoperative complications such as empyema (n=1), air leakage (n=3), and chylothorax (n=1).

Conclusions

This study establishes that CT-guided dye localization is a safe and efficient method with rare severe complications and high success rate.

A novel CT-guided technique using medical adhesive for localization of small pulmonary ground-glass nodules and mixed ground-glass nodules (≤20 mm) before video-assisted thoracoscopic surgery

PURPOSE

We aimed to evaluate the success rate and complication occurrence of CT-guided localization of small pure ground-glass nodules (pGGNs) and mixed ground-glass nodules (mGGNs) with medical adhesive injection before video-assisted thoracoscopic surgery (VATS).

METHODS

From March 2015 to May 2017, 41 patients with 44 small pGGNs and mGGNs underwent CT-guided percutaneous localization with medical adhesive prior to wedge resection by VATS.

RESULTS

Localization with medical adhesive was successful in all patients (100%). The nodules (13 pGGNs, 31 mGGNs) had a mean maximal long-axis diameter of 9±4 mm and a mean distance of 10±7 mm from the most superficial edge of the nodule to the visceral pleura. The localization time was 16±8 minutes. There was a moderate inverse relationship between localization time and the nodule diameter (r= -0.42, P = 0.005). Thirty-three nodules with primary lung cancer were pathologically confirmed. There were 3 cases of pneumothorax (7%), 3 cases of parenchyma hemorrhage (7%) and 2 cases of irritable cough (5%), respectively. No conversion to thoracotomy was necessary in any patient.

CONCLUSION

CT-guided percutaneous localization with medical adhesive can label small pGGNs and mGGNs prior to VATS, with high success and low complication rates.

Computed tomography-guided hook wire localization facilitates video-assisted thoracoscopic surgery of pulmonary ground-glass nodules

BACKGROUND

This retrospectively study was conducted to assess the efficiency and safety of computed tomography (CT)-guided hook wire localization of pulmonary ground-glass nodules (GGNs) prior to video-assisted thoracoscopic surgery (VATS).

METHODS

From 2015 to 2018, a total of 86 patients with 86 pulmonary GGNs underwent preoperative CT-guided hook wire localization before VATS. The technical details and clinicopathological findings were analyzed.

RESULTS

All 86 pulmonary GGNs (25 pure GGNs and 61 part-solid GGNs) were successfully located and resected. The mean diameter of the GGNs was 1.4 ± 0.4 cm (range 0.6-2.2) and the mean lesion distance to the pleural surface was 7.3 ± 4.3 mm (range 2-19). Complications of hook wire marking included asymptomatic minor pneumothorax in 21 patients (24%) and focal pulmonary hemorrhage in 18 (21%). The median hook wire localization time was 19.1 minutes (range 10-30) and the median VATS time was 49 minutes (range 28-89). Pathology revealed 72 precancerous lesions or primary lung adenocarcinomas, 5 metastatic tumors, and 9 benign lesions.

CONCLUSIONS

Preoperative localization of small pulmonary GGNs using CT-guided hook wire was efficient and safe prior to VATS resection.

Thoracoscopic Resection of Congenital Cystic Adenomatoid Malformation in a Patient With Fused Lung Fissure Using Hookwire

Thoracoscopic resection is being used more commonly for the treatment of congenital cystic adenomatoid malformation in neonates and infants. However, in the rare case of congenital cystic adenomatoid malformation with congenital absence of lung fissure, thoracoscopic lobectomy cannot be performed safely. Moreover, if the lung lesion is deep-seated and cannot be visualized on the pleural surface, wedge resection may result in residual lesion. Here, we reported our approach of thoracoscopic resection under hookwire guidance to tackle this problem.

A single-center experience of 100 image-guided video-assisted thoracoscopic surgery procedures

Background

The advent of image-guided video-assisted thoracoscopic surgery (iVATS) has allowed the simultaneous localization and removal of small lung nodules. The aim of this study is to detail, in a retrospective review, one institution's experience using iVATS in this clinical setting, with a special attention to efficacy, safety, and procedural details.

Methods

This study was a retrospective analysis of prospectively collected data. Between October 2016 and January 2018, a total of 95 patients with 100 small lung nodules underwent iVATS. All procedures were performed in a hybrid operating room (HOR) in which a cone-beam computed tomography (CT) apparatus and a laser navigation system were present.

Results

The mean size of the 100 lung nodules was 7.94 mm, with their mean depth from the visceral pleura being 10 mm. A total of 98 nodules were successfully localized; of them, 94 were resected through a marker-guided procedure. There were four resection failures [wire dislodgement (n=2) or dye spillage (n=2)]). A significant inverse association was found between localization time (mean: 21.19 min) and the surgeon's experience (Pearson's r=-0.632; P<0.001). The mean length of hospital stay was 4.87 days and there were no perioperative deaths.

Conclusions

In the current context of an increase in early diagnosis of lung cancer by screening programs, iVATS performed in a HOR offers a safe and efficient option for simultaneous localization and removal of small pulmonary nodules.

Coil Localization-Guided Video-Assisted Thoracoscopic Surgery for Lung Nodules

PURPOSE

To determine the clinical efficacy of preoperative coil localization-guided video-assisted thoracoscopic surgery (VATS) for lung nodules.

MATERIALS AND METHODS

Between November 2015 and July 2017, 56 patients with lung nodules underwent coil localization-guided VATS procedure. The coil implantation was performed under the guidance of computed tomography (CT). The end tail of the coil remained above the visceral pleura. The target lung nodules were removed by VATS wedge resection. Data on the technical success of coil localization and wedge resection, procedure-related complications, and pathological results were collected and analyzed.

RESULTS

Sixty-seven lung nodules in 56 patients (1.2 nodules/case) were localized. The technical success rate of coil localization was 89.6% (60/67). Sixty-three nodules were localized with one coil and four nodules with two coils. The mean time taken to perform CT-guided coil implantation was 15.7 ± 5.3 (range: 8-40) minutes. Six patients (9.0%) experienced pneumothorax after coil implantation. The technical success rate of wedge resection was 97.0% (65/67). Two nodules were removed directly by video-assisted lobectomy. Nine patients with multiple target lung nodules underwent single-stage resection. The mean total operating time was 147.2 ± 79.1 (range: 50-360) minutes. The mean volume of blood loss was 113.2 ± 113.0 (range: 10-700) mL. Postoperative complications included prolonged air leak (n = 2) and pleural effusion (n = 5).

CONCLUSIONS

Preoperative coil localization is a safe and effective method to facilitate a high successful rate of VATS wedge-resection for lung nodules.