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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 54  |  Issue : 5  |  Page : 165-170

The application of image-guided video-assisted thoracoscopic surgery to bilateral pulmonary nodules resection


Division of Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan

Date of Submission14-Sep-2020
Date of Decision16-Dec-2020
Date of Acceptance31-May-2021
Date of Web Publication12-Oct-2021

Correspondence Address:
Bing-Yen Wang
Department of Surgery, Division of Thoracic Surgery, Changhua Christian Hospital, No. 135, Nanxiao St., Changhua City, Changhua County 500
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_175_20

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  Abstract 


Background: In tradition, bilateral small pulmonary nodules are localized in a computed tomography room and operation twice for fear of complications. In contrast, image-guided video-assisted thoracoscopic surgery (iVATS) is applied to localize small pulmonary nodules and resect these nodules in a single stage. The application of iVATS for bilateral pulmonary nodule localization and resection has not been explored. This study describes the methods and outcomes of bilateral small pulmonary nodule localization and resection in a single-staged method.
Materials and Methods: This study is a retrospective analysis in our institute (Changhua Christian Hospital, Changhua, Taiwan). Patients with bilateral small pulmonary nodules who received single-staged iVATS from July 2018 to May 2020 were included in the study. The outcome measurements include operative time, localization time of one side, nodule pathologies, operative method, presence of complications, chest tube duration, and length of hospital stay (LOS).
Results: Twenty-one patients with bilateral pulmonary nodules were included in this study, and a total of 50 pulmonary nodules were resected. The average operative time for a procedure was 203 min (95% confidence interval [CI]: 160–246 min), which included 18 min (95% CI: 13–23 min) of localization time for each side. Eight of 21 patients (38.10%) showed different pathologies among their bilateral nodules. There was only one complication noted; it was due to prolonged air leakage at the left side.
Conclusion: There were about 40% different pathologies for synchronous bilateral lung nodules. Single-staged iVATS is feasible and efficient for bilateral small lung nodules resection.

Keywords: Lung cancer diagnosis, lung cancer treatment, minimally invasive surgery, surgical equipment, thoracoscopy/video-assisted thoracoscopic surgery


How to cite this article:
Cheng YF, Liang CC, Chen HC, Ke PC, Hung WH, Cheng CY, Wang BY. The application of image-guided video-assisted thoracoscopic surgery to bilateral pulmonary nodules resection. Formos J Surg 2021;54:165-70

How to cite this URL:
Cheng YF, Liang CC, Chen HC, Ke PC, Hung WH, Cheng CY, Wang BY. The application of image-guided video-assisted thoracoscopic surgery to bilateral pulmonary nodules resection. Formos J Surg [serial online] 2021 [cited 2021 Nov 28];54:165-70. Available from: https://www.e-fjs.org/text.asp?2021/54/5/165/327882




  Introduction Top


In this decade, the popularity of low-dose computed tomography (CT) for lung cancer screening leads to the growing detection of small lung nodules. A new method called image-guided video-assisted thoracoscopic surgery (iVATS) is applied to localize these small lung nodules. There have been several studies reporting that iVATS is a feasibility way to remove solitary pulmonary nodules (SPNs) and improve patient care.[1],[2] It can also provide a shorter global time and similar perioperative and postoperative outcomes compared with traditional localization in a CT room.[3]

To develop the technique and application of iVATS, several studies discussed the experience of iVATS with cone-beam CT. The patient's position, learning curve, single incision, material for localization, and dual-marker technique were reported.[4],[5] Furthermore, the application of single-staged VATS to resect bilateral SPNs was a feasible option.[6] However, the application of iVATS for bilateral SPNs localization and resection has not been explored.

After we localized more than 300 patients with iVATS, we generalized that patients with bilateral pulmonary nodules might extremely benefit from an iVATS technique. In the past, we localized bilateral pulmonary nodules in a CT room at separate times for fear of bilateral pneumothorax and hemothorax. Patients with bilateral SPNs had to admit to the hospital and receive VATS surgery twice. The prolonged hospital stay and treatment coarse lead to more cost and delayed cancer treatment.

The application of iVATS provides localization and operation at a single stage in a hybrid operating room. The shorter time from localization to surgery in a hybrid operating room makes bilateral SPNs localization more feasible and safer.

In this study, we retrospectively analyze the outcomes of iVATS for patients with bilateral SPNs in our institution. We describe the methods and outcomes of bilateral SPNs localization in a hybrid operating room.


  Materials And Methods Top


Database

This study is a retrospective analysis in our institute (Changhua Christian Hospital, Changhua, Taiwan). All patients over 18 years of age undergoing removal of small lung nodules with iVATS in a hybrid operating room from July 2018 to May 2020 were included in the study. Patients who did not receive bilateral localization were excluded. This study was approved by the institutional review board in our institution (IRB-191201), and written informed consent was obtained from all participants. We analyzed the age, gender, number of nodules, nodule pattern, nodule size, distance to the pleura, and nodule location.

Indications of bilateral pulmonary nodule resection with iVATS are as following:

  1. Nodule side <2 cm
  2. Tolerable pulmonary function (forced expiratory volume in 1 s >1.6)
  3. Nodule number <5
  4. Suspect different pathology of bilateral lesion. The outcome measurements include operative time, localization time of one side, nodule pathologies, operative method, presence of complications, chest tube duration, and length of hospital stay (LOS).


Image-guided video-assisted thoracoscopic surgery procedure

All patients were admitted 1 day before surgery. After induction of general anesthesia, patients were placed in the lateral decubitus position in a hybrid operating room. We chose the easier side or expected smaller resection side first to maintain the saturation during the other side's procedure. We used robotic C-arm cone-beam CT (Artis Pheno; Siemens Healthcare GmbH, Forchheim, Germany) for the scanning. Localization was performed by the attending surgeon. Before the scanning, a test-C-arm-movement was performed to ensure that the scanner would not collide with the patient. Another scan was performed with breath-hold at end inspiration. We laid out the needle path under the syngo needle guidance of a syngo X-Workplace with a three-dimensional view. After measuring the depth, a cross laser beam for incision location is projected onto the patient's skin. An 18-gauge marker needle was inserted into the thorax with the cross-laser guidance after holding the breath at end inspiration [Figure 1]. After another scan for confirmation of the appropriate needle location [Figure 2], diluted methylene blue dye (0.2 ml) plus normal saline (0.3 ml) were injected. The operation started after sterilization.
Figure 1: Patients were placed in lateral decubitus position. Robotic C-arm cone-beam computed tomography (Artis Pheno; Siemens Healthcare GmbH, Forchheim, Germany) guided the entrance of the marker needle

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Figure 2: (a) Right side localization, which was done later due to the deeper lesion. The black arrow points to an 18-gauge marker needle. The white arrow points to the small pulmonary nodule. Methyl blue was then inserted. (b) Left side localization, which was done first due to resection being easier. The black arrow points to an 18-gauge marker needle. The white arrow points to the small pulmonary nodule. Methyl blue was then inserted

Click here to view


During the operation, all of the procedures were performed with single-incision VATS. The methylene blue dye could be seen clearly on the surface of the lung when needle insertion 5–10 mm into lung parenchymal [Figure 3]a. If needle was inserted <5 mm, the dye would spill out and hard to distinguish [Figure 3]b. On the contrary, merely a small puncture hole could be seen when the needle inserted more than 10 mm [Figure 3]c. We performed wedge resections for the peripheral nodules. On the other hand, we performed segmentectomies for the central nodules to ensure safe margins.
Figure 3: The needle must insert to 5–10 mm deep of parenchymal to make good localization (a) Good localization (b) Too superficial localization (c) Too deep localization

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After the end of the first side's operation, we placed the patient to a more difficult side in a lateral decubitus position. The same steps of scanning and localization were done. We then started the more difficult side's operation. A frozen section examination was also performed after resection of the nodules.

Statistical analysis

We used Statistical Package for the Social Sciences version 22.0 for Windows (IBM, Armonk, NY, USA) to perform the statistical analysis for this study. Categorical data were expressed as counts and percentages. Continuous data were delivered as means with their 95% confidence intervals (CIs).


  Results Top


Between July 2018 and May 2020, there were 312 patients receiving iVATS procedures in a hybrid operating room. Among these, 21 patients with bilateral pulmonary nodules were included in this study [Table 1]. A total of 50 pulmonary nodules were resected. The mean age was 58.93-year-old. The study sample consisted of 10 males and 11 females. Thirteen of the 21 patients received two-nodule resections, and the other eight patients received three-nodule resections.
Table 1: Clinical demographic data of patients presenting for bilateral nodule localization

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Most of the nodules were solid with Ground-glass nodule (GGN) >50% (32/50, 64%). The mean nodule size was 9.12 mm (95% CI: 4.41–13.83 mm), and the mean distance to the pleura was 12.75 mm (95% CI: 4.90–20.60 mm). The distribution of the 50 nodules was as follows: right upper lobe, n = 11; right middle lobe, n = 5; right lower lobe, n = 12; left upper lobe, n = 10; and left lower lobe, n = 12.

[Table 2] summarizes the outcomes of bilateral nodule resection with iVATS. This procedure took an average operative time of 203 min (95% CI: 160–246 min), which included 18 min (95% CI: 13–23 min) of localization time for each side. A patient's bilateral nodules were not necessarily of the same pathology. There were eight patients (38.10%) whose bilateral nodules differed in pathology. Most of the pulmonary nodules showed metastatic lesions (n = 30, 60%), followed by infection or inflammation (n = 6, 12%), adenocarcinoma in situ (AIS) (n = 5, 10%), primary adenocarcinoma (n = 5, 10%), atypical adenomatous hyperplasia (n = 3, 6%), and primary squamous cell carcinoma (n = 1, 2%).
Table 2: Outcomes of bilateral nodule localization and resection

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When a nodule was at peripheral area (distance to the pleura <15 mm), we performed a wedge resection (n = 41; 82%). On the other hand, segmentectomy was performed for the other 9 nodules (n = 9; 18%) due to the nodules being central lesions. Among these patients, there was only one complication noted; it was prolonged air leakage at the left side. The patient with the complication is female and is the first patient in our bilateral pulmonary nodule resection study. We removed her right-side chest tube on postoperative day 3. The air leakage of the left side did not need any further intervention. We successfully removed her chest tube on postoperative day 8. The mean chest tube placement duration was 2.87 days (95% CI: 1.10–4.58 days). The mean LOS was 5.17 days (95% CI: 3.26–7.08 days).


  Discussion Top


Patients with bilateral SPNs are challenging to operate on due to the difficulty of localizing and resecting at a time. Our previous study reported a retrospective single institute case series report and claimed that the iVATS procedure seems to be a feasible and cost-effective approach for bilateral pulmonary nodules.[7] In this study, we successfully extended to 21 patients for bilateral SPNs resection. We also analyzed the data for nodule distribution, pattern, number, size, and pathology. The pathology of synchronous bilateral lung nodules is quite different. Our study is the first study to analyze outcomes of bilateral SPNs resection with iVATS localization.

Preoperative biopsy is difficult to perform and the complication rate is significantly higher when the pulmonary nodule is <12 mm.[8] Most of the patients directly received VATS surgery for tissue proofing. To find these small nodules during an operation, preoperative localization is essential to identify the resection area. In the past, we localized these small nodules in a CT room. It was very difficult to localize bilateral small pulmonary nodules in the CT room at one time for fear of hemothorax, pneumothorax, wire dislodgment, and hemoptysis. The complication rates of CT-guided localization of pulmonary nodules in a CT room differ between 9.7% and 15.1%.[9],[10] The first iVATS procedure was introduced in 2013 with the advanced multimodal image-guided operating suite. Nowadays, iVATS is proven to have less time from localization to skin incision. The localization time ranges from 20 to 33 min with the help of cone-beam CT.[3],[11] We were able to localize at a steady pace after a learning curve of 15 patients.[5] This advantage makes it possible for bilateral small pulmonary nodules resection at the same time. In our study, we only took an average of 18 min to localize one side with the help of Artis Pheno and an average of 203 min from localization to bilateral small pulmonary nodule resection.

It is not guaranteed that a patient's resected bilateral small pulmonary nodules have identical pathologies. In one study, more than 10% of sets of resected pulmonary nodules had nodules with differing pathologies.[12] About 40% of patients revealed different pathologies in this study. If we choose to resect from only one side for tissue proofing, the rate of misdiagnosis or over-staging would be high. The iVATS technique for bilateral nodule resection plays an important role in this situation. Single-staged bilateral surgical treatment provides fast diagnosis and tumor staging. Patients can benefit from less surgery time, a shorter LOS, and accurate treatment.

We performed wedge resection for peripheral pulmonary nodules. On the other hand, we chose segmentectomies if the nodule was located over 15 mm distance to the pleura. In our study, 18% of the resected nodules were central nodules, and they provided another challenge during resection. Several techniques have been proposed to deal with the central pulmonary nodules. Dual marker techniques and electromagnetic navigation bronchoscopy (ENB) in a hybrid theater were recently discussed. The dual marker procedure involves inserting an 18-gauge coaxial needle with guidance from cone-beam CT scanning. One microcoil is placed at the deep lesion, and then diluted indocyanine green is injected at the pleural surface. The ENB procedure involves putting a 21-gauge biopsy needle at the target lesion via a flexible bronchoscope. If the position is wrong, the biopsy needle is redeployed under guidance from Dyna-CT.[13],[14]

In our study, we localize the central lesion at the spot on the peripheral lung surface that is closest to the nodule. Then, we identify the segment of the localization area. Direct segmentectomy is done to make sure the central lesion is included. Further research is still needed to find the optimal way to resect these central nodules.

We believe that the breakthrough of iVATS can provide easier pulmonary resection and make some difficult resections possible. The advanced intraoperative imaging-guided techniques decrease the risk period of complications developments associated with needle insertion.[15] In future, iVATS may provide real-time pulmonary nodule resection, allow for resection of smaller nodules, or be combined with interventional bronchoscopy. The low physical discomfort and emotional stress to the patient make it possible to introduce iVATS worldwide.[1] However, there are some limitations of iVATS to overcome. First, the high cost of a hybrid operating room makes it not widely available. Second, surgeons must have good chemistry with the anesthetist during perioperation to ensure a smooth procedure.

Some caveats of this study merit consideration. First, we need more patients undergoing bilateral small nodule resection to have better proof of the advantages of iVATS. The cost difference between two-stage bilateral small nodule localization/resection and one-stage iVATS resection does not evaluate well. Further cost-effectiveness analyses involving larger sample sizes are essential in the future.


  Conclusion Top


There were about 40% different pathologies for synchronous bilateral lung nodules. Single-staged iVATS is feasible and efficient for bilateral small lung nodules resection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hsieh MJ, Fang HY, Lin CC, Wen CT, Chen HW, Chao YK. Single-stage localization and removal of small lung nodules through image-guided video-assisted thoracoscopic surgery. Eur J Cardiothorac Surg 2018;53:353-8.  Back to cited text no. 1
    
2.
Zhao ZR, Lau RW, Yu PS, Wong RH, Ng CS. Image-guided localization of small lung nodules in video-assisted thoracic surgery. J Thorac Dis 2016;8 Suppl 9:S731-7.  Back to cited text no. 2
    
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Chen PH, Hsu HH, Yang SM, Tsai TM, Tsou KC, Liao HC, et al. Preoperative dye localization for thoracoscopic lung surgery: Hybrid versus computed tomography room. Ann Thorac Surg 2018;106:1661-7.  Back to cited text no. 3
    
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Hsieh MJ, Wen CT, Fang HY, Wen YW, Lin CC, Chao YK. Learning curve of image-guided video-assisted thoracoscopic surgery for small pulmonary nodules: A prospective analysis of 30 initial patients. J Thorac Cardiovasc Surg 2018;155:1825-32.e1.  Back to cited text no. 5
    
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Han KN, Kang CH, Park IK, Kim YT. Thoracoscopic approach to bilateral pulmonary metastasis: Is it justified? Interact Cardiovasc Thorac Surg 2014;18:615-20.  Back to cited text no. 6
    
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Liang CC, Liao CH, Cheng YF, Hung WH, Chen HC, Huang CL, et al. Bilateral lung nodules resection by image-guided video-assisted thoracoscopic surgery: A case series. J Cardiothorac Surg 2020;15:203.  Back to cited text no. 7
    
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Heerink WJ, de Bock GH, de Jonge GJ, Groen HJ, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: Meta-analysis. Eur Radiol 2017;27:138-48.  Back to cited text no. 8
    
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Ichinose J, Kohno T, Fujimori S, Harano T, Suzuki S. Efficacy and complications of computed tomography-guided hook wire localization. Ann Thorac Surg 2013;96:1203-8.  Back to cited text no. 9
    
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Poulou LS, Tsagouli P, Ziakas PD, Politi D, Trigidou R, Thanos L. Computed tomography-guided needle aspiration and biopsy of pulmonary lesions: A single-center experience in 1000 patients. Acta Radiol 2013;54:640-5.  Back to cited text no. 10
    
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Chao YK, Wen CT, Fang HY, Hsieh MJ. A single-center experience of 100 image-guided video-assisted thoracoscopic surgery procedures. J Thorac Dis 2018;10 Suppl 14:S1624-30.  Back to cited text no. 11
    
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Yao F, Yang H, Zhao H. Single-stage bilateral pulmonary resections by video-assisted thoracic surgery for multiple small nodules. J Thorac Dis 2016;8:469-75.  Back to cited text no. 12
    
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Ng CS, Yu SC, Lau RW, Yim AP. Hybrid DynaCT-guided electromagnetic navigational bronchoscopic biopsy†. Eur J Cardiothorac Surg 2016;49 Suppl 1:i87-8.  Back to cited text no. 13
    
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Zhao ZR, Lau RW, Ng CS. Electromagnetic navigation bronchoscopy in Hybrid Theater. Front Surg 2019;6:10.  Back to cited text no. 14
    
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Zhao ZR, Lau RW, Yu PS, Ng CS. Devising the guidelines: The techniques of pulmonary nodule localization in uniportal video-assisted thoracic surgery-hybrid operating room in the future. J Thorac Dis 2019;11:S2073-8.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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