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

Percutaneous Computed Tomography (CT)-Guided Localization with Indocyanine Green for the Thoracoscopic Resection of Small Pulmonary Nodules

BACKGROUND

The identification of small lung nodules is challenging during mini-invasive thoracic surgery. Unable to palpate them directly, surgeons have developed several methods to preoperatively localize pulmonary nodules, including the computed tomography-guided positioning of coils or metallic landmarks (hook wire) or bronchoscopic marking.

METHODS

We present a series of patients scheduled for the video-assisted thoracoscopic sublobar resection of small pulmonary nodules, in which we performed preoperative percutaneous computed tomography (CT)-guided nodule localization through the injection of a mixture of indocyanine green and human albumin.

RESULTS

A total of 40 patients underwent a preoperative CT-guided injection of indocyanine green followed by VATS resection within 24 h. Patients tolerated the procedure well, no pain medication was administrated, and no complications were observed during the marking procedure. All pulmonary nodules were easily detected and successfully resected.

CONCLUSION

the near-infrared dye marking solution of indocyanine green (ICG) with diluted human albumin was safe, effective, and easy to perform. The ICG solution has the potential to facilitate the accurate localization and resection of pulmonary nodules during VATS surgery, avoiding the risk of marker displacement/migration.

A new preoperative localization of pulmonary nodules guided by mixed reality: a pilot study of an animal model

Background

With the popularity of high-resolution computed tomography (HRCT), more and more pulmonary nodules are being discovered. Video-assisted thoracoscopic surgery (VATS) has become the first choice for surgical treatment of pulmonary nodules. The use of accurate preoperative localization is crucial for successful resection in VATS. At present, there are many kinds of preoperative localization methods, but there are certain disadvantages. This study aimed to evaluate the feasibility and safety of mixed reality (MR)-guided pulmonary nodules localization, which is a new method that can benefit patients to a greater extent.

Methods

By constructing an animal model of pulmonary nodules localization, 28 cases of pulmonary nodules were located by MR-guided localization. We recorded the localization accuracy, localization time, insertion attempts, and incidence of complications related to localization under MR-guidance.

Results

All 28 nodules were successfully located: the deviation of MR-guided localization was 5.71±2.59 mm, localization time was 8.07±1.44 min, and insertion attempts was 1. A pneumothorax and localizer dislodgement occurred in 1 case, respectively.

Conclusions

Since preoperative localization is critical for VATS resection of pulmonary nodules, we investigated a new localization method. As indicated by our study, MR-guided localization of pulmonary nodules is feasible and safe, which is worthy of further research and promotion. We have also registered corresponding clinical trials to further investigate and help to improve our understanding of this technique.

Preoperative Localization for Small Pulmonary Nodules Using Anchor with Scaled Suture System

PURPOSES

This study aimed to describe a new localization technique developed using an anchor with a scaled suture (AWSS) system and to characterize the localization results and post-operative outcomes to evaluate its safety and effectiveness.

METHODS

This retrospective study was conducted at our centre from October 2020 to December 2021. In total, 328 small pulmonary nodules (sPNs) who underwent pre-operative computed tomography (CT)-guided AWSS system localization followed by wedge resection by video-assisted thoracoscopic surgery (VATS) were enrolled in this study.

RESULTS

CT-guided AWSS system implantations targeting 328 sPNs were successfully performed. The time spent performing localization was 12.4 ± 4.9 min. After puncture localization, the incidences of pneumothorax, pulmonary haemorrhage, and chest pain were 19.2% (63/328), 25.9% (85/328), and 0.9% (3/328), respectively. The incidence of overall complications was 42.7%. According to the CIRSE classification, there were no major complications. The median localization-VATS interval time was 7 h (range, 1-75 h). In 328 cases (100%), the location of the lesion was determined by palpation of the four-paw anchor in the lung and was successfully resected by VATS, and the correct diagnosis was obtained.

CONCLUSION

In this series, CT-guided pre-operative localization of pulmonary nodules with the AWSS system was safe and had a high positioning accuracy and success rate.

Comparison of hook-wire and medical glue for CT-guided preoperative localization of pulmonary nodules

Background

Preoperative localization is challenging due to the small diameter of pulmonary nodules or their deep location in the lung parenchyma during VATS surgery. The purpose of this study was to compare the efficacy and safety of both hook-wire and medical glue for pre-operative localization of pulmonary nodules.

Methods

In the current study, 158 patients were retrospectively analyzed (January 2019 and January 2020). The patients underwent hook-wire or medical glue for pre-operative localization of pulmonary nodules. Among them, 74 patients in the hook-wire group and 84 patients in the medical glue group underwent VATS anatomic segmentectomy or wedge resection after localization of pulmonary nodules. Pre-operative localization data from all patients were compiled. Moreover, the efficacy and safety of the two methods were evaluated according to localization success rates and localization-related complications.

Results

The success rate of localization in the medical glue group was 100% while 97.3% in the hook-wire group. After localization of the pulmonary nodules, the incidence of minor pneumothorax in the medical glue group (11.9%) was lower than that in the hook-wire group (37.8%) (p=0.01). The incidence of mild pulmonary parenchymal hemorrhage in the medical glue group (13.1%) was also lower than that in the hook-wire group (24.3%) (p=0.000). The mean time from the completion of localization to the start of surgery was also longer in the medical glue group than in the hook-wire group (p=0.000). The mean visual analog scale (VAS) scores after localization were higher in the hook-wire group than in the medical glue group (p=0.02). In both groups, parenchymal hemorrhage was significantly associated with the needle length in hook-wire localization and the depth of the medical glue in the lung parenchyma (p = 0.009 and 0.001, respectively).

Conclusion

These two localization methods are safe and effective in pre-operative pulmonary nodule localization. The medical glue localization method had a lower risk of complications, a higher localization success rate, less pain after localization and more flexibility in the arrangement of operation time.

Targeted Near-Infrared Fluorescence Imaging With Iodized Indocyanine Green in Preoperative Pulmonary Localization: Comparative Efficacy, Safety, Patient Perception With Hook-Wire Localization

Background

Precise preoperative localization is of great importance to improve the success rate and reduce the operation time of VATS surgery. This study aimed to assess the efficacy, safety, patient perception between CT-guided indocyanine green (ICG) preoperative localization of lung nodule and hook-wire localization.

Methods

65 patients with 85 clinically suspicious pulmonary nodules underwent ICG preoperative localization in this study, and 92 patients with 95 nodules localized by conventional hook-wire served as controls. Both hook-wire localization and ICG injection were performed under CT guidance. Successful targeting rate, success rate in the operative field, incidence rate of complications and respiratory pain score were recorded and compared.

Results

The successful targeting rate for both groups is 100%, however, due to hook-wire dislodgement, the success rate in the VATS operation field of the hook-wire group (95.6%) is lower than that of the ICG group (100%), with no significant difference(p=0.056). The overall complication rate of the hook-wire group (37.0%) is significantly higher than the ICG group (35.4%) (p=0.038). The mean respiratory pain score of the hook-wire group is 3.70 ± 1.25, which is significantly higher than that of the ICG group (2.85 ± 1.05) (p<0.001).

Conclusions

ICG composed with contrast mixture are superior to the conventional hook-wire preoperative lung nodule localization procedure, with a lower complication rate, lower pain score, and relatively higher success rate. ICG is a promising alternative method for pulmonary nodule preoperative localization.

Dopamine-Modified Alginate Hydrogel with Effectiveness and Safety for Preoperative Localization of Lung Nodules

It is important to mark an early lung tumor manifested with small nodules during computed tomography-guided and minimally invasive surgery. The aim of this study is to develop an injectable hydrogel for clinical lung nodule localization. Dopamine, a typical catechol-containing compound, was used to modify alginate for better gel formation and performance needed for localization application. Through the addition of an adequate oxidant and catalase, the catechol-conjugated alginate (C-ALG) hydrogel showed rapid gelation for less than 5 min, similar mechanical properties to lung tissue, slight swelling degree, good cell compatibility, and enough tissue adhesion for localization around the lung tissue. In addition, the C-ALG hydrogel increased the bursting pressure of lung tissue up to 266 ± 15-385 ± 13 mm-H₂O that could prevent hydrogel rupture and migration during localizing surgery, suggesting the injectable hydrogel with effectiveness and safety for clinical applications.

A novel technique for preoperative localization of pulmonary nodules using a mixture of tissue adhesive and iohexol under computed tomography guidance: A 140 patient single-center study

Background

The increase in the incidence of pulmonary nodules has made computed tomography (CT) screening a requirement for diagnosis and treatment. Small pulmonary nodule detection during video‐assisted thoracoscopic surgery (VATS) or thoracotomy is frequently challenging; however, accurate and efficient localization of nodules is critical for precise resection. Herein, we introduce and evaluate the feasibility and safety of a novel technique for preoperative pulmonary nodule localization.

Methods

From March 2018 to December 2019, 140 patients with 153 pulmonary nodules measuring <2 cm in diameter were enrolled in this study. Preoperative, CT‐guided localization was performed on each nodule with an injected mixture of tissue adhesive and iohexol. Patient and nodule characteristics, localization data, complications, surgical data, and pathological results were analyzed.

Results

All 153 nodules in 140 patients were successfully marked preoperatively and detected during surgery (n = 153/153). Mean nodule size was 8.7 ± 2.6 mm, and mean distance from nodule to pleura was 7.9 ± 8.2 mm. The mean procedural time was 8.7 ± 1.0 min. Nine patients (6.4%) underwent two simultaneous nodule localizations and two patients (1.4%) underwent three simultaneous nodule localizations. Pneumothorax (17/140, 12.1%), pain (6/140, 4.3%), and pungent odor (5/140, 3.6%) were the major complications. No patient required further treatment, and no allergic reactions or embolisms were observed.

Conclusions

Preoperative CT‐guided nodule localization using a mixture of tissue adhesive and iohexol is an efficient technique for localizing small and impalpable pulmonary lesions, including multiple pulmonary nodules. Our study demonstrates that this novel method is safe and straightforward to implement.

Contralateral pulmonary resection using selective bronchial blockade in postpneumonectomy patients

BACKGROUND

Pulmonary resection is occasionally performed in postpneumonectomy patients with contralateral lung lesions, such as metachronous or metastatic lung cancer. Careful intraoperative respiratory management is essential in such patients. This study evaluated the respiratory management of postpneumonectomy patients who underwent contralateral pulmonary resection with selective bronchial blockade of the lobe or segment to be resected.

METHODS

We retrospectively analyzed the surgical findings and safety of surgery in six patients who underwent contralateral pulmonary resection with selective bronchial blockade after pneumonectomy for non-small cell lung cancer (NSCLC).

RESULTS

The percutaneous oxygen saturation did not decrease in any of the patients during bronchial blockade under high oxygen concentration. The median blockade time was 57.5 minutes. The operative field was tolerable secured under conditions of partial lung collapse, and partial pulmonary resection was performed as planned. Postoperatively, one patient developed acute respiratory distress syndrome due to acute exacerbation of interstitial pneumonia; however, no patients died within one month postoperatively. Two patients underwent pulmonary resection in order to obtain adequate tissue specimens to evaluate the biomarkers of multiple lung metastases. On histopathology, one patient tested positive for anaplastic lymphoma kinase (ALK) and was subsequently administered an ALK inhibitor, which prolonged survival.

CONCLUSIONS

In all patients, intraoperative respiratory condition under partial lung collapse remained stable, and all partial pulmonary resections were safely performed. However, surgical indications should be carefully reviewed preoperatively in patients with interstitial pneumonia.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: Contralateral partial pulmonary resection was performed using selective bronchial blockade in postpneumonectomy patients. Percutaneous oxygen saturation did not decrease during the bronchial blockade under high oxygen concentration, and the operative field was tolerable secured under conditions of partial lung collapse.

WHAT THIS STUDY ADDS

Oxygen concentration can be set to the minimum level, sufficient to maintain oxygenation, during contralateral partial pulmonary resection with selective bronchial blockade.

[Value of preoperative localization techniques for solitary pulmonary nodules in singleport thoracoscopic surgery]

ObjectiveTo evaluate the value and clinical effect of different preoperative localization techniques for solitary pulmonary nodules (SPN) before single-port thoracoscopic surgery.MethodFrom January 2018 to June 2019, 54 patients diagnosed with solitary pulmonary nodules received single-port thoracoscopic surgery in Thoracic Department of General Hospital of Southern Theater Command of PLA. Based on the location methods of the nodules, the patients were divided into group A (34 cases) with preoperative CT-guided Hook-wire (a common positioning needle usually using in mammary gland) positioning and group B (20 cases) with preoperative CT-guided methylene blue location.ResultsThe success rate of localization in group A was 94.18% (32/34), significantly higher than that in group B [85% (17/20), P < 0.05). No intraoperative conversion to thoracotomy occurred in group A, while the conversion rate was 10% (2/20) in group B (P < 0.05). The average positioning cost was significantly higher in group A than in group B (1715±109 vs 1021±86 RMB yuan, P < 0.05), but the total hospitalization cost was similar between the two groups (50 114±3788 vs 47871±5902 RMB yuan, P>0.05). The length of hospital stay was significantly shorter in group A than in group B (6.71±1.23 vs 8.19±2.61 days, P < 0.05).ConclusionCompared with the traditional methylene blue localization method, Hook-wire localization positioning can significantly increase the success rate of localization, and can be used as the standard preoperative localization method in patients undergoing single-port thoracoscopic pulmonary nodule resection, especially in those with deep nodule location from the visceral pleura.

Computed tomography-guided localization for lung nodules: methylene-blue versus coil localization

PURPOSE

To compare the relative clinical efficacy of preoperative computed tomography (CT)-guided methylene-blue (MB) and coil localization for lung nodules (LNs).

MATERIAL AND METHODS

Between January 2013 and December 2018, a total of 89 patients with LNs underwent CT-guided MB or coil localization and subsequent video-assisted thoracoscopic surgery (VATS)-guided wedge resection in our hospital. We compared the technical success of localization and wedge resection between two groups.

RESULTS

In MB group, 47 LNs in 39 patients were localized, with successful localization and wedge resection rates of 97.9% and 97.9%, respectively. In the coil group, 64 LNs in 50 patients were localized, with successful localization and wedge resection rates of 96.9% and 96.9%, respectively. There were no significant differences in technical success rates of localization and wedge resection between the two groups (p = 1.000 and 1.000). The coil group sustained a longer duration between localization and VATS relative to the MB group (14.4 h vs. 1.6 h, p = .001).

CONCLUSION

Both MB and coil localization were safe and effective techniques to establish a high success rate of VATS-guided wedge resection for LNs. Relative to MB localization, coil localization might be compatible with a longer delay between localization and VATS.