Tailored intraoperative localization of non-palpable pulmonary lesions for thoracoscopic wedge resection using hybrid room technology

[Comparison of Four-hook Needle and Memory Alloy Coil in Localization of Pulmonary Nodules]

背景与目的

随着肺结节微创手术的广泛开展，术前定位变得愈发关键。传统定位方式存在一定的缺陷，定位方式的改进很有必要。本研究旨在对比分析两种新型定位方式即四钩定位针和记忆合金弹簧圈在肺结节定位中应用的安全性和有效性。

方法

回顾性分析152例患者的资料，76例为四钩定位针组，76例为记忆合金弹簧圈组，术前均行肺结节定位，后行电视胸腔镜辅助肺结节楔形切除术，统计平均定位时间、定位并发症、结节切除时间等。

结果

两组患者均成功切除目标肺结节，四钩定位针组76例患者术中均找到定位装置，肺结节全部成功切除，1例因严重胸腔粘连而中转开胸行肺结节楔形切除术。记忆合金弹簧圈组76例患者肺结节均成功切除，1例因术中切除标本后未找到病灶而行妥协性扩大切除术。两组气胸、肺内出血发生率、定位成功率、结节楔形切除时间无统计学差异。四钩定位针组平均定位时间为（13.66±3.11）min，低于记忆合金弹簧圈组的（15.51±3.65）min，二者有统计学差异（P=0.001）。记忆合金弹簧圈组当结节至胸膜距离≥1.5 cm和 < 1.5 cm时，平均定位时间分别为（17.20±4.46）min、（14.91±3.15）min，二者有统计学差异（P=0.044）。

结论

四钩定位针和记忆合金弹簧圈两种新型肺结节定位方式均有较好的安全性及有效性，四钩定位针定位操作用时更短。在使用记忆合金弹簧圈定位时，对于到胸膜距离 < 1.5 cm的肺结节效果可能更佳。

Three-Dimensional Computed Tomography Bronchography and Angiography-Guided Thoracoscopic Segmentectomy for Pulmonary Nodules

BACKGROUND

Three-dimensional computed tomography bronchography and angiography (3D-CTBA) provides detailed imaging information for pulmonary segmentectomy. This study was performed to verify the feasibility of 3D-CTBA-guided thoracoscopic segmentectomy for the treatment of pulmonary nodules.

METHODS

A retrospective analysis was performed on all patients who underwent 3D-CTBA-guided uniport thoracoscopic segmentectomies or subsegmentectomies for pulmonary nodules in the period from May 2019 to May 2020. All of the information related to perioperative management and surgical operations was retrieved from the medical records and operating notes for detailed analysis.

RESULTS

A total of 104 eligible operations involving the resection of 110 nodules with diameters in the range of 5-20 mm were included. Under 3D-CTBA guidance, the pulmonary nodules were located with an accuracy of 100% (110/110) and the median resection margin was 24.3 mm (17-33 mm). Additionally, the segmental (subsegmental) bronchi, arteries, and veins were identified with accuracy rates of 100% (104/104), 96.2% (100/104), and 94.2% (98/104), respectively. The postoperative complications consisted of 3 cases of pulmonary infection (2.9%), 6 cases of arrhythmia (5.8%), 2 cases of hemoptysis (1.9%), 4 cases of air leak (3.8%), and 2 cases of subcutaneous emphysema (1.9%). No perioperative death occurred.

CONCLUSION

3D-CTBA-guided thoracoscopic segmentectomy is an effective surgical approach for the management of pulmonary nodules.

Single-Stage Localization and Thoracoscopic Removal of Nonpalpable Pulmonary Nodules in a Hybrid Operating Room

OBJECTIVE

We report our experience with simultaneous localization and thoracoscopic removal for nonpalpable undiagnosed pulmonary nodules.

METHODS

All patients with nonpalpable lesions requiring video-assisted thoracoscopic surgery (VATS) wedge resection underwent localization of the targets and surgical removal in a hybrid operating room. Lesions were considered nonpalpable if they were small (<1 cm), deep (>1 cm from the surface), subsolid, or located within a dystrophic area. In all cases, intraoperative cone-beam computed tomography was performed for nodule localization and targeting, metal hookwires, or coils were alternatively used for intraoperative marking.

RESULTS

From April 2016 to November 2019, 39 image-guided VATS (iVATS) were performed. The mean lesion size was 12 ± 6 mm. The mean distance from the deep edge of the lesion to the pleural surface was 24 ± 9 mm. The localization was performed with 20 hookwires and 19 coils. iVATS localization was successful in 36 patients (92.3%). Thirty-seven wedge resections were completed by VATS, 2 (5%) required conversion to thoracotomy. In 9 patients with intraoperative diagnosis of lung cancer, a lobectomy was performed (7 VATS and 2 thoracotomies). Mean length of iVATS localization was 30 ± 13 minutes. Median postoperative length of stay was 4 days (IQR 3 to 5).

CONCLUSIONS

iVATS seems to be a helpful tool for simultaneous localization and removal of nonpalpable nodules. A versatile approach using different devices seems advisable for the removal of targets in every clinical scenario reducing VATS conversion rate. Future research is required to compare iVATS with traditional preoperative localization techniques.

Use of the hybrid room for thoracic surgery procedures: single-stage localization and removal of non-palpable nodules

With the widespread availability of lung cancer screening programs, the number of small lung nodules requiring histological characterization has dramatically increased. Because computed tomography-guided fine-needle aspiration may frequently yield false-negative results, excisional biopsy using thoracoscopy is frequently required. Although thoracoscopic procedure has been known to be ideal for nodule resection, the identification of very small, subsolid and deep pulmonary nodules may still be challenging. Precise lesion localization is a key prerequisite to avoid conversion to an unplanned thoracotomy. In the traditional workflow, the localization procedure is performed in the radiology suite, after which the patient is moved to an operating room. With the availability of hybrid operating rooms, a new approach encompassing simultaneous localization and removal of non-palpable lung nodules has become feasible. In this article, we review the procedural workflow of this new technique and discuss its indications and results.

Three-dimensional printed navigational template for localizing small pulmonary nodules: A case-controlled study

Background

Localization of small pulmonary nodules is an inevitable challenge for the thoracic surgeon. This study aimed to investigate the accuracy of three‐dimensional (3D) printing technology for localizing small pulmonary nodules, especially ground‐glass nodules (GGNs).

Methods

This study enrolled patients with peripheral small pulmonary nodules (≤ 2 cm) who required preoperative localization. In the comparison period, patients underwent both computed tomography‐guided (CT‐G) and 3D‐printing template guided (3D‐G) localization to compare the accuracies of the two methods. In the testing period, the 3D‐printing technique was implemented alone. The 3D‐printing physical navigational template was designed based on data from perioperative CT images. Clinical data, imaging data, surgical data, and evaluation index were collected for further analysis. The learning curve of the 3D‐printing localization technique was assessed using cumulative sum (CUSUM) analysis and multiple linear regression analysis.

Results

In the comparison period (n = 14), the success rates of CT‐G and 3D‐G were 100% and 92.9% (P = 0.31), respectively; in the testing period (n = 23), the success rate of 3D‐G was 95.6%. The localization times of CT‐G, 3D‐G (comparison), and 3D‐G (testing) were 23.6 ± 5.3, 19.3 ± 6.8, and 9.8 ± 4.6 minutes, respectively. The CUSUM learning curve was modeled using the equation: Y = 0.48X²− 0.013X − 0.454 (R² = 0.89). The learning curve was composed of two phases, phase 1 (the initial 20 patients) and phase 2 (the remaining 17 patients).

Conclusions

3D printing localization has adequate accuracy and is a feasible and accessible strategy for use in localizing small pulmonary nodules, especially in right upper lobe. The use of this technique could facilitate lung nodule localization prior to surgery.

Precise sublobar lung resection for small pulmonary nodules: localization and beyond

Early-stage primary lung cancer is increasingly detected by computed tomographic (CT) screening and the radicality of sublobar lung resection (wedge resection and segmentectomy) has been suggested. However, identification of a tumor intraoperatively becomes more difficult, the earlier a nodule is detected. A solution to this challenge is localization techniques. There are many techniques to localize small pulmonary nodules, including that replacing surgeon's tactile sensation, visualizing the tumor using ultrasound, and various types of lung markings that are placed percutaneously under CT guidance or bronchoscopically. The most commonly used technique is CT-guided placement of a hookwire, but there are concerns about potentially fatal air embolism. Bronchoscopic localization, especially using electromagnetic navigation bronchoscopy with or without intraoperative cone-beam CT imaging, has been increasingly reported. Beyond localization, the concept of lung "mapping" is emerging. In sublobar lung resection, in addition to localization of the targeted tumor, acquisition of sufficient resection margins is critical to prevent local recurrence. Virtual-assisted lung mapping (VAL-MAP) has evolved from bronchoscopic dye localization, but by placing multiple dye marks, it provides two-dimensional geometric information on the lung. Moreover, to ensure deep resection margins, the newly developed technique of VAL-MAP 2.0 combining dye marks and intrabronchial placement of a microcoil enables three-dimensional lung mapping. This allows for intraoperative navigation of lung resection under a fluoroscope. Development of this field, such as using a new technology of augmented reality, will further enhance the accuracy and convenience of lung resection in the near future.

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.

Imaging techniques for minimally invasive thoracic surgery-Korea University Guro Hospital experiences

In this paper, we described our clinical experiences with respect to image-guided thoracic surgery, including procedures involving percutaneous injection of fluorescent dye, radiotracers, and hook wires, guided by preoperative computed tomography (CT); and transbronchial injection of fluorescent dye by using electromagnetic navigational bronchoscope technology. Our recent experience with the intravenous systemic injection of fluorescent dye for the intraoperative detection of pulmonary lesions and intersegmental planes are also described in this review.