Uniportal video-assisted thoracic surgery resection of small ground-glass opacities (GGOs) localized with CT-guided placement of microcoils and palpation

Abstract

Although uniportal video-assisted thoracic surgery (VATS) is becoming more popular, it's still very challenging to conduct a wedge resection of small pulmonary ground-glass opacities (GGOs), especially deeply situated subpleural GGOs, via uniportal VATS. We successfully performed thirteen uniportal VATS wedge resections through an approach that combines radiologically guided microcoil localization with palpation, and we encountered no complications related to the new approach. Based on our experience, a combination of CT-guided microcoil localization with palpation in uniportal VATS for deeply situated subpleural GGOs is a safe and effective procedure for accurate diag¬nosis and resection of indeterminate The core of a 150-mm-long Chiba biopsy needle was removed. A 30-mm-long, 0.035-inch-diameter fiber-coated stainless steal microcoil was pushed into the Chiba needle by using the stiff end of a 40-cm-long, 0.018-inch-diameter guidewire from a micropuncture catheter introducer set. After the microcoil was loaded into the needle, a hemostat was used to mark the pusher wire at one point-the length necessary to eject the entire 30-mm-long microcoil from the Chiba needle.All microcoil localizations were performed or closely supervised by one interventional chest radiologist with 20 years' experience. With CT guidance, the loaded Chiba needle was pushed through and 5 mm deep to the suspicious nodule. The premeasured guidewire was advanced into the Chiba needle up to the mark at which the hemostat was placed, and the 30-mmlong microcoil was deployed into the lung parenchyma, where it assumed a tightly coiled ball configuration just beyond the tip of the needle. A localizer CT scan was obtained to confirm the microcoil deployment. The empty needle and guidewire assembly were then withdrawn (Figure 1). During the localization, we preferred a relatively longer travel from entry point of visceral pleura to the lesion to prevent microcoil displacement to the cavity. To avoid dislocation, we push in the guiding wire when retrieving the Chiba needle to keep the microcoil relatively immobilized. When Chiba needle is retrieved and not in contact with the microcoil, we then pull out the guiding wire.A postprocedural larger-volume CT scan was obtained to assess the final position of the microcoil relative to the nodule and the pleural space and to test for the presence of postprocedural hemorrhage, as indicated by new airspace consolidation and pneumothorax. The patient was then transferred to the preoperative area, where he or she waited for 1-4 hours before undergoing surgical resection of the nodule in the operating room. There were two pneumothoraxes and one intrapulmonary hemorrhage, post-procedurally. Surgical techniqueAfter being placed under general anaesthesia with double lumen endotracheal intubation, the patient is positioned in a lateral position. The surgeon stands anterior to the patient with the assistant and scrub nurse opposite to him, and the screen at the patient's head. The incision is made on the an...

Computed tomography‐guided coil localization for video‐assisted thoracoscopic surgery of sub‐solid lung nodules: a retrospective study

“…Malignancies appear to be more frequent in sub‐solid nodules than in solid nodules . Most sub‐solid lung nodules tend to correspond to early‐stage lung cancer or precancerous lesions . Surgical resection may provide nearly 100% disease‐free survival for patients with sub‐solid lung nodules .…”

“…To overcome this shortcoming, several preoperative localization techniques (coils, hook‐wires, radiolabelling and methylene blue injection) have been used to increase the success rate of VATS wedge resection . Although preoperative localization for lung nodules has been reported several times to date, few studies have focused on the preoperative localization of sub‐solid lung nodules …”

Single-stage nonintubated uniportal thoracoscopic resection of synchronous bilateral pulmonary nodules after coil labeling

“…Hookwire may cause tearing of the lung parenchyma with hemorrhage risk, and fail to localization if pneumothorax develops. [23] CT-guided patent blue vital dye localization is more accurate, and it could be utilized for synchronous multiple nodules. [8] It is hard to decide the proper margin of deeply located pulmonary nodules during the operation, thus, preoperative simulation using 3-dimensional CT and rapid prototyping of pulmonary vessels could be considered.…”

Surgical management of ground glass opacities of the lung

“…However, non‐surgical biopsy may have variable accuracy (as low as 50% for small, pure GGOs) and are not without risk of morbidity (pneumothorax rates of up to 33%) . It is unclear why surgery is not given preference in evaluating these patients despite its better diagnostic accuracy and similar (if not lower) morbidity …”

“…However, GGO incidence already appears to be higher in Asia, and preliminary evidence from many Asian case series also seem to suggest a possibly higher rate of malignancy or malignant potential in GGOs from that continent . Management of GGOs in East Asia also tend to be slightly more aggressive in terms of offering surgery, with good clinical results reported . Clearly, current GGO guidelines have not considered geographical or racial patterns of pathology and surgery.…”