Initial experience of virtual-assisted lung mapping utilizing both indocyanine green and indigo carmine

Virtual-assisted lung mapping is a bronchoscopic multiple dye marking technique that facilitates sublobar lung resections for unidentifiable pulmonary tumors. Marking failure reportedly occurs in 10% of cases. To overcome this limitation, we developed indocyanine green virtual-assisted lung mapping that uses indocyanine green in addition to indigo carmine. Here, we report our initial experience of indocyanine green virtual-assisted lung mapping.

Hybrid technique of virtual-assisted lung mapping and systemic indocyanine green injection for extended segmentectomy

Background Various approaches have been used to assist and facilitate segmentectomy with favorable oncological outcomes. We describe a hybrid approach comprising virtual-assisted lung mapping (VAL-MAP), which is a preoperative bronchoscopic dye-marking technique, combined with systemic indocyanine green (ICG) injection. Clinical presentation An asymptomatic 64-year-old man was referred to our department because of a lung nodule detected during his annual medical checkup. The chest computed-tomography image revealed a 16-mm, partly solid, ground-glass nodule in the left segment 4. Because the nodule was hardly palpable and deeply located between the left upper division segment and the left lingular segment, we performed VAL-MAP to facilitate extended left lingulectomy. Five dye markings were undertaken preoperatively. Surgery to remove the nodule was then conducted via complete three-port video-assisted thoracic surgery. The VAL-MAP markings were easily identified intraoperatively and helped locate the nodule. The intersegmental plane was identified by the ICG injection. The resection line was determined based on the intersegmental plane identified by the ICG injection and the site of the nodule suggested by the VAL-MAP markings. Following the resection line, we thoracoscopically achieved extended lingulectomy with sufficient surgical margins. The patient was discharged with no complications. The pathological diagnosis was adenocarcinoma in situ. Conclusion The hybrid technique of VAL-MAP and systemic ICG injection can be useful for accomplishing successful extended segmentectomy.

Ciliated muconodular papillary tumor with a growing cavity shadow that mimicked colorectal metastasis to the lung: a case report

Background Ciliated muconodular papillary tumor (CMPT) is a rare papillary nodule tumor with benign and malignant characteristics that occurs in the peripheral lung. Case presentation A 70-year-old woman who underwent right hemicolectomy for colorectal cancer (CRC; pT3N0M0, p-stage II) 2 years prior, presented with a sub-centimeter growing cavity shadow on chest computed tomography (CT), which was suspected to be a CRC metastasis. Because positron emission tomography CT suggested there was no other site suspicious of recurrence, thoracoscopic resection with preoperative pleural dye marking was planned to remove the small lesion, which seemed to be hardly palpable on CT. Immediately after pleural dye marking adjacent to the lesion using cone beam CT in the hybrid operating room, thoracoscopic wedge resection was performed and the tumor was finally diagnosed as CMPT, characterized by the papillary growth of mucus-producing cells in the alveoli. Conclusion We resected the non-palpable small lung lesions following preoperative marking using cone-beam CT in the hybrid operating room. This case highlights a rare cavitary CT image of a CMPT mimicking a metastatic lung tumor from colorectal cancer.

A meta-analysis of preoperative bronchoscopic marking for pulmonary nodules

OBJECTIVES Recent studies have suggested the usefulness of preoperative bronchoscopic marking techniques for the localization of pulmonary nodules in thoracic surgery. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of preoperative bronchoscopic marking. METHODS The PubMed and Cochrane Library databases were searched for clinical studies evaluating preoperative bronchoscopic marking for pulmonary resection. Non-comparative and random effects model-based meta-analyses were conducted to calculate the pooled success and complication rates of bronchoscopic marking. RESULTS Twenty-five eligible studies were included. Among these, 15 studies conducted dye marking under electromagnetic navigation bronchoscopy, 4 used virtual-assisted lung mapping and 7 used other marking methods. The overall pooled successful marking rate, successful resection rate and complete resection rate were 0.97 [95% confidence interval (CI) 0.95–0.99], 0.98 (95% CI 0.96–1.00) and 1.00 (95% CI 1.00–1.00), respectively. The overall pooled rates of pleural injury and pulmonary haemorrhage were 0.02 (95% CI 0.01–0.05) and 0.00 (95% CI 0.00–0.00), respectively. CONCLUSIONS This meta-analysis demonstrated that bronchoscopic marking is very safe and effective. Bronchoscopic marking should be considered, especially if there are concerns about the safety of other localization methods.

Strategies to improve the accuracy of lung stapling in uniportal and multiportal thoracoscopic sublobar lung resections

The challenges in video-assisted thoracic surgery for sublobar lung resection include difficulty in tumour localization by palpation and difficulty in determining appropriate resection lines. Virtual-assisted lung mapping (VAL-MAP), a bronchoscopic preoperative multispot lung dye-marking technique, allows for both tumour localization and determination of resection lines. To facilitate stapler-based resection, the AMAGAMI or ‘incomplete grasping’ stapler technique is useful to adjust the alignment of the stapler and resection lines. However, when the lung tissue to be stapled is thick, there is unavoidable uncertainty in the staple line inside the lung. We experimentally demonstrated that up to 1 cm of slippage of lung parenchyma occurs at stapling when the stapled lung tissue is >1 cm thick. VAL-MAP 2.0 is a new generation of VAL-MAP combining multispot dye markings with intrabronchial microcoil placement, allowing for 3-dimensional lung mapping and intraoperative navigation using fluoroscopy. The uncertainty of stapling in the lung parenchyma can be partly overcome by VAL-MAP 2.0.

Electromagnetic navigational bronchoscopy-directed dye marking for locating pulmonary nodules

BackgroundSmall 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).MethodsThe 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.ResultsStudy 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.ConclusionENB can be used to safely and accurately locate small peripheral pulmonary nodules and guide surgical resection.Trial registration numberChiCTR1900021963.