Near-infrared dye marking for thoracoscopic resection of small-sized pulmonary nodules: comparison of percutaneous and bronchoscopic injection techniques

Abstract

BackgroundMinimally invasive video-assisted thoracoscopic surgery for small-sized pulmonary nodules is challenging, and image-guided preoperative localisation is required. Near-infrared indocyanine green fluorescence is capable of deep tissue penetration and can be distinguished regardless of the background colour of the lung; thus, indocyanine green has great potential for use as a near-infrared fluorescent marker in video-assisted thoracoscopic surgery.MethodsThirty-seven patients with small-sized pulmonary nodules, who were scheduled to undergo video-assisted thoracoscopic wedge resection, were enrolled in this study. A mixture of diluted indocyanine green and iopamidol was injected into the lung parenchyma as a marker, using either computed tomography-guided percutaneous or bronchoscopic injection techniques. Indications and limitations of the percutaneous and bronchoscopic injection techniques for marking nodules with indocyanine green fluorescence were examined and compared.ResultsIn the computed tomography-guided percutaneous injection group (n = 15), indocyanine green fluorescence was detected in 15/15 (100%) patients by near-infrared thoracoscopy. A small pneumothorax occurred in 3/15 (20.0%) patients, and subsequent marking was unsuccessful after a pneumothorax occurred. In the bronchoscopic injection group (n = 22), indocyanine green fluorescence was detected in 21/22 (95.5%) patients. In 6 patients who underwent injection marking at 2 different lesion sites, 5/6 (83.3%) markers were successfully detected.ConclusionEither computed tomography-guided percutaneous or bronchoscopic injection techniques can be used to mark pulmonary nodules with indocyanine green fluorescence. Indocyanine green is a safe and easily detectable fluorescent marker for video-assisted thoracoscopic surgery. Furthermore, the bronchoscopic injection approach enables surgeons to mark multiple lesion areas with less risk of causing a pneumothorax.Trial RegistrationUMIN-CTR R000027833 accepted by ICMJE. Registered 5 January 2013.

Image-guided Preoperative Localization of Pulmonary Nodules for Video-assisted and Robotically Assisted Surgery

“…The first type involves the injection of a liquid material through a fine needle. Injected materials include methylene blue (10)(11)(12), india ink (13), barium (14), lipiodol (15)(16)(17), indocyanine green (18,19), and radionuclides (20). The second type of localization technique involves percutaneous placement of a metallic marker.…”

Simultaneous cone beam computed tomography‐guided bronchoscopic marking and video‐assisted thoracoscopic wedge resection in a hybrid operating room

“…A transbronchial aspiration cytology (TBAC) needle (Fig b) is inserted near the target by X‐ray fluoroscopic guidance (Fig c). The TBAC needle tip is pierced into the lung parenchyma (Fig d) and 0.05 mL of a 0.025 mg/mL (100 times diluted from the original concentration) ICG/Iopamidol mixture is injected (Fig e) using a method reported previously . The second CBCT is performed to confirm that the VATS marker has been injected in the vicinity of the lesion (Fig f).…”

“…The TBAC needle tip is pierced into the lung parenchyma ( Fig 1d) and 0.05 mL of a 0.025 mg/mL (100 times diluted from the original concentration) ICG/Iopamidol mixture is injected (Fig 1e) using a method reported previously. 12 The second CBCT is performed to confirm that the VATS marker has been injected in the vicinity of the lesion (Fig 1f ). In a representative case that had three multiple pulmonary nodules in rt.…”

“…Factors defining marking accuracy include the positional relationship between the bronchial branch and the lesion, the accuracy of the bronchoscopic examination technique of the operator, and the accuracy of the image guidance technique. On the basis of CT data, a bronchial route closest to the target lesion was created as a virtual bronchoscopy movie using the dedicated software Synapse Vincent (Fuji Film, Tokyo, Japan) . If the target lesion cannot completely be reached by the bronchoscope, a VATS marker is placed at a point as close as possible to the target, and the surgeon is able to localize the target by confirming the relative positional relationship by 3DCT (Fig g).…”

“…On the basis of CT data, a bronchial route closest to the target lesion was created as a virtual bronchoscopy movie using the dedicated software Synapse Vincent (Fuji Film, Tokyo, Japan). 12 If the target lesion cannot completely be reached by the bronchoscope, a VATS marker is placed at a point as close as possible to the target, and the surgeon is able to localize the target by confirming the relative positional relationship by 3DCT (Fig 2g).…”