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.
Highlights
Invasive video-assisted thoracoscopic surgery for small-sized pulmonary nodules is challenging, and image-guided preoperative localisation is required
Ground-glass nodule (GGN) lesions do not alter the surface of the visceral pleura, and the elevation of tumours cannot be perceived in the deflated lung during video-assisted thoracic surgery (VATS); ground-glass nodule (GGN) are difficult to localise
We have previously reported the concept of electromagnetic navigation bronchoscopy (ENB)-guided bronchoscopic injection of indocyanine green (ICG) and localisation of infrared ICG-fluorescence (ICG-FL) to localise small-sized pulmonary nodules using a porcine model [19]
Summary
Invasive video-assisted thoracoscopic surgery for small-sized pulmonary nodules is challenging, and image-guided preoperative localisation is required. In cases where lung lesions are small in size, present in the periphery of the lung, or close to the visceral pleura, thoracoscopic biopsy may be performed [3]. There is an increasing need for wedge resection of small-sized pulmonary nodules by means of video-assisted thoracic surgery (VATS) for both the diagnosis and treatment of lung cancer. Small-sized pulmonary nodules are often marked prior to VATS by using a VATS marker such as a hook-thread [4], spiral wire needle [5], microcoil [6], fiducial marker [7], or colour dyes such as methylene blue [8]; each of these is injected into the lung near the target using a CT-guided percutaneous injection approach. Gamma-ray emission signals can be detected intraoperatively using a gamma probe
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