Dye Marking Research Articles

Preoperative localization of pulmonary nodules by electromagnetic navigation bronchoscopy combined with methylene blue injection.

Electromagnetic navigation bronchoscopy (ENB) can help to accurately locate pulmonary nodules using a minimally invasive approach. This study sought to evaluate the clinical efficacy and safety of dye marking localization under the guidance of ENB followed by surgery. A retrospective analysis was performed of 61 patients who underwent ENB localization using methylene blue dye marking before surgery at Shanghai General Hospital from October 2021 to February 2022. The clinical efficacy and safety of ENB localization and the related factors affecting the navigation time of ENB location were analyzed. ENB was performed on 170 pulmonary nodules in 61 patients with a median age of 60 [interquartile range (IQR), 18] years. The majority of patients (70.69%) had more than two pulmonary nodules. The median maximum nodule diameter was 10 (IQR, 8) mm, and 48.21% of the nodules were mixed ground-glass nodules. Median time for ENB navigation was 10.5 (IQR, 6) min. The navigation success rate was 92.96%, and the ENB location success rate was 95.89%. The rate of complications related to ENB localization was 1.64% (there was only one case of pulmonary hemorrhage). The multivariate analysis showed that the factors related to the navigation time included the node location (P=0.001) and location mode (P=0.04). ENB-guided methylene blue injection is an effective and safe tool for localizing and marking pulmonary nodules, and can be used to assist the diagnosis and treatment of early lung cancer. The node location and location mode had significant effects on navigation time.

Robot-Assisted Bronchoscopy for Identification of Lung Nodules During Minimally Invasive Pulmonary Resection.

Small pulmonary nodules can be difficult to identify during minimally invasive surgical (MIS) resection. Previous investigators have reported using standard bronchoscopy with electromagnetic navigation to identify small pulmonary nodules. Robot-assisted bronchoscopy has been introduced into clinical practice and has shown utility for the biopsy of small lesions. We report our experience using robot-assisted bronchoscopy with dye marking to aid in minimally invasive pulmonary resection. Patients with peripheral pulmonary nodules underwent robot-assisted bronchoscopy before a planned minimally invasive resection. Indocyanine green or methylene blue was injected directly into the targeted lesion. Surgical resection was then immediately performed. Success was defined as dye visualization leading to sublobar resection of the target nodule without the need for lobectomy or thoracotomy. Thirty patients with a single targeted nodule underwent robot-assisted bronchoscopy followed by MIS resection. The median lesion size was 9 mm (4 to 25 mm), and the median distance from the pleura was 5 mm (1 to 32 mm). The success rate was 83.3% (25 of 30). There were 3 cases in which the dye was not visualized, and in 2 cases there was free extravasation of dye. The targeted nodule was identified in these 5 patients without the need for thoracotomy or lobectomy. Pathology revealed non-small cell lung cancer (n = 13, 43.3%), metastatic disease (n = 11, 36.7%), and benign disease (n = 6, 20%). There were no complications related to the use of robot-assisted bronchoscopy. Robot-assisted bronchoscopy with dye marking is safe and effective for guiding minimally invasive resection of small peripheral pulmonary nodules.

Evaluation of local movement of Bemisia tabaci MEAM1 and tomato severe rugose virus transmission to tomato plants using marked and unmarked whiteflies

AbstractTomato golden mosaic disease, caused by the tomato severe rugose virus (ToSRV), is one of the most serious tomato diseases. ToSRV is transmitted by the whitefly Bemisia tabaci MEAM1, from a wide range of hosts. Introducing ToSRV in commercial fields probably can occur by transporting the virus from distant locations. However, our hypothesis is that the inoculum causing epidemic development might be related to nearby sources. This study evaluated the short‐range flight distance of B. tabaci MEAM1 (marked with detectable proteins and powder dye), through recaptures in yellow sticky traps, and the transmission of ToSRV by viruliferous B. tabaci MEAM1 to tomato plants placed at increasing distances from a release point. Evaluated whiteflies reached a maximum of 30 m from the release point, and no ToSRV‐infected tomato plants were detected at greater distances. These findings reinforce the suspicion that the epidemic‐supporting source of ToSRV inoculum must be close to commercial cultivation areas. About the efficacy of the type of markers used, of the two protein sources tested (pasteurized chicken egg‐white albumin and commercial soy‐based extracts as sources of albumin and lecithin, respectively), albumin was considered easier to detect. Marking with these proteins or with two dyes (blue or pink) did not affect B. tabaci MEAM1 mortality, although field tests showed that fewer marked than unmarked insects were recaptured. Dye marking was considered more practical because of the ease of detection. The study validates a new tool to understand the movement of B. tabaci MEAM1, based on different marking methods.

EP07.02-08 Comparison of ICG and Methylene Blue in Preoperative Dye Marking Localization of Pulmonary Nodules Under the Guidance of ENB

EP07.02-08 Comparison of ICG and Methylene Blue in Preoperative Dye Marking Localization of Pulmonary Nodules Under the Guidance of ENB

EP07.02-16 Localization of Lung Nodules by Electromagnetic Navigation Bronchoscopy-Guided Dye Marking: Procedural Outcomes and Learning Curve

EP07.02-16 Localization of Lung Nodules by Electromagnetic Navigation Bronchoscopy-Guided Dye Marking: Procedural Outcomes and Learning Curve

Uniportal thoracoscopic extended right apical segmentectomy with virtual-assisted lung mapping: a case report

BackgroundPulmonary extended segmentectomy is an optional surgical treatment for early-stage non-small cell lung cancer that helps to achieve optimal surgical margins. Here, we describe a challenging instance of extended segmentectomy via uniportal video-assisted thoracic surgery with virtual-assisted lung mapping, a preoperative bronchoscopic dye marking procedure.Case presentationA 72-year-old woman presented with two tumors that were clinically diagnosed as early-stage lung cancer; extended right apical segmentectomy was indicated. Because the tumors had appeared unidentifiable intraoperatively, we performed virtual-assisted lung mapping for tumor localization and delineation of the optimal resection area. Surgery was conducted through a single port. All virtual-assisted lung mapping markings were visible. After dissection of the apical vessels and bronchi, a putative intersegmental line was determined using collateral ventilation. Based on the putative intersegmental plane identified by collateral ventilation and the virtual-assisted lung mapping markings, the resection line was delineated. Extended apical segmentectomy along the resection line was successfully performed via uniportal video-assisted thoracic surgery. The postoperative course was uneventful. The pathological diagnosis was minimally invasive adenocarcinoma and adenocarcinoma in situ.ConclusionsVirtual-assisted lung mapping can help to achieve optimal extended segmentectomy via uniportal video-assisted thoracic surgery.

Percutaneous Computed Tomography (CT)-Guided Localization with Indocyanine Green for the Thoracoscopic Resection of Small Pulmonary Nodules.

The identification of small lung nodules is challenging during mini-invasive thoracic surgery. Unable to palpate them directly, surgeons have developed several methods to preoperatively localize pulmonary nodules, including the computed tomography-guided positioning of coils or metallic landmarks (hook wire) or bronchoscopic marking. We present a series of patients scheduled for the video-assisted thoracoscopic sublobar resection of small pulmonary nodules, in which we performed preoperative percutaneous computed tomography (CT)-guided nodule localization through the injection of a mixture of indocyanine green and human albumin. A total of 40 patients underwent a preoperative CT-guided injection of indocyanine green followed by VATS resection within 24 h. Patients tolerated the procedure well, no pain medication was administrated, and no complications were observed during the marking procedure. All pulmonary nodules were easily detected and successfully resected. the near-infrared dye marking solution of indocyanine green (ICG) with diluted human albumin was safe, effective, and easy to perform. The ICG solution has the potential to facilitate the accurate localization and resection of pulmonary nodules during VATS surgery, avoiding the risk of marker displacement/migration.

Ten-Year Outcome and Development of Virtual-Assisted Lung Mapping in Thoracic Surgery

Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multispot dye-marking technique used in sublobar lung resection of barely palpable lung nodules. This review summarizes the history and outcomes of the VAL-MAP procedure. VAL-MAP was developed in 2012, and long-term outcomes of lung resection using VAL-MAP have recently been verified. Problems associated with conventional VAL-MAP include a prerequisite of post-mapping computed tomography (CT), occasional inability to see dye marks during surgery, and infrequent resection failure due to deep resection margins; various techniques have been developed to address these issues. VAL-MAP using electromagnetic navigation bronchoscopy with on-site adjustment can omit post-mapping CT. The use of indocyanine green in VAL-MAP has increased the success rate of marking detection during surgery without causing additional complications. VAL-MAP 2.0-a three-dimensional mapping technique that involves the intrabronchial placement of a microcoil-has increased the accuracy of sublobar resection, particularly for deeply located tumors. Although these promising new techniques have some limitations, they are beneficial for sublobar lung resection.

Lung Nodule Marking With ICG Dye–Soaked Coil Facilitates Localization and Delayed Surgical Resection

BackgroundWhereas diagnosis and treatment of pulmonary nodules may be combined during a surgical resection, this approach may lead to excision of benign lesions and excessive healthy lung tissue if the lesion is difficult to localize. Bronchoscopy-guided marking of pulmonary nodules before surgery may facilitate this process, but it is limited by current technologies and often challenging as dye marking may dissipate if surgery is performed days later. We present a novel method to address this problem that allows surgery multiple days after lesion marking with accurate localization. MethodsFour patients with newly identified lung nodules underwent robot-assisted navigation bronchoscopy with lesion marking with a fiducial coil saturated for 10 minutes with indocyanine green (ICG) dye and subsequent thoracic surgery. ResultsThe novel approach to soaking the fiducial in ICG allowed the lesions to be seen multiple days (0-9 days) later at the time of da Vinci robotic surgery with the Firefly fluorescence imaging system. No evidence of dye dispersion was visualized, and all surgeries were completed without complications. ConclusionsMethods to improve peripheral pulmonary nodule marking to facilitate surgical resection are imperative as more asymptomatic, smaller lesions continue to be identified. In our initial experience, placement of ICG dye–soaked fiducial coils for lung nodule marking multiple days before thoracic surgery appears to be a viable option to facilitate surgical resection.

Stability and safety of transbronchial dye mixture for preoperative localization in a porcine model.

For thoracoscopy, the usefulness of a dye mixture of indigo carmine and Lipiodol for localizing lung lesions has been reported. However, little is known about the stability and safety of this dye mixture injected on the visceral pleura through a bronchoscope. Porcine models were divided into three groups according to the detection time of the dye mixture: group A with a detection time of 4h; group B, 8h; and group C, 24 h. A dye mixture of indigo carmine and Lipiodol (0.5mL each) was sprayed onto the visceral pleura both in the ventral and dorsal regions via a spray catheter. Twelve markings were created on the visceral pleura of the porcine lung (six ventral and six dorsal) in the six porcine models. At predetermined detection times, all 12 dye markings (100%) were visible on the visceral pleura. The mean longest diameter of the dye marking in the ventral and dorsal regions was 18.8 mm and 24.3 mm, respectively. In groups B and C, pathological changes in the lymphatic system, such as lymphatic dilatations, were found; minimal changes were found in group B, however, these changes with oval-shaped lymphatic cysts and Lipiodol accumulation, were more evident in group C. The dye mixture of indigo carmine and Lipiodol had reliable stability and visibility. In terms of safety, it may be necessary to check the dye mixture on the lung surface within 8h.

Using Visual Observations to Compare the Behavior of Previously Immobilized and Non-Immobilized Wild Polar Bears

During 17 field seasons between 1973 and 1999, we conducted a long-term study of the behavior of undisturbed wild polar bears in Radstock Bay, southwest Devon Island, Nunavut. In a subset of 11 seasons (6 spring and 5 summer) between 1975 and 1997, we used three different drug combinations to chemically immobilize a small number of adult and subadult polar bears on an opportunistic basis and applied a temporary dye mark so that individual bears could be visually reidentified. We then used multinomial logistic regression to compare the behavior of 35 previously immobilized bears of five different demographic classes (sex, age, and reproductive status) to the behavior of non-immobilized bears of the same demographic classes in the same years and seasons. During the first two days after immobilization, bears slept significantly more and spent less time hunting than did bears that had not been immobilized. However, previously immobilized bears returned to the same behavioral patterns and proportion of total time spent hunting as non-immobilized bears within two days and no further negative behavioral effects were detected in the following 21 d. We visually confirmed successful hunting by three adult bears within 0.4 to 2.1 d of being immobilized, all of which went on to make additional kills within the following 24 h. The return to normal behavior patterns, including the ability to hunt successfully, within 48 h of immobilization appears consistent with the hypothesis that polar bears do not experience longer-term behavioral effects following brief chemical immobilization for conservation and management purposes.

Number of dye marks required in virtual-assisted lung mapping.

Virtual-assisted lung mapping is a preoperative bronchoscopic multi-spot dye-marking technique used in sublobar lung resection for hardly palpable lung nodules. However, the number of marks required per nodule remains unknown. Therefore, we examined the correlation between the number of intraoperative visible marks and the successful resection rate. We retrospectively examined 210 consecutive patients with 256 lesions who underwent virtual-assisted lung mapping during January 2014-December 2020 at our hospital. When a nodule was not resected at the initial attempt, or when a nodule was very close to the cut margin in the resected specimen and required additional resection, we categorized it as unsuccessful resection. We divided 256 lesions into successful and unsuccessful groups and compared the numbers of intraoperative visible marks between the two groups. Of 797 attempted marks, 738 (92.4%) were visible during the surgery. Fourteen (5.4%) of 256 lesions were determined to be unsuccessful according to the study criteria. There was a remarkable difference in the average numbers of intraoperative visible marks between both groups (3 [interquartile range: 2-4] vs. 2 [interquartile range: 1-2.8]; p < 0.01). Multivariable logistic analysis revealed a significant difference in the number of intraoperative visible marks (odds ratio: 0.28, 95% confidence interval: 0.14-0.57; p < 0.001) between both groups. Successful sublobar lung resection requires three or more intraoperative visible marks established using virtual-assisted lung mapping per lung nodule.

Availability of virtual-assisted lung mapping affects procedure selection for early-stage lung cancer: a web-based cross-sectional study

The availability of new techniques may affect surgeons' procedure selection and thereby affect clinical outcomes. This study aimed to evaluate the effect of the availability of virtual-assisted lung mapping (VAL-MAP) on the selection of lung resection methods. Members of the Japanese Association for Chest Surgeons were invited to participate in a web-based survey. Participants were divided into those who had never used VAL-MAP (group 0), those who had used only VAL-MAP 1.0 (multiple dye marks on the pleural surface; group 1) and those who had used VAL-MAP 2.0 (multiple dye marks and intrabronchial microcoils for three-dimensional mapping; group 2). Participants were shown chest computed tomography images of 6 ground-glass opacity nodules and asked to choose surgical procedures to resect the nodules with sufficient resection margins greater than the lesion diameter or 2 cm. There were 197 surgeons in group 0, 49 in group 1 and 26 in group 2. All groups showed a similar trend of avoiding wedge resection for deeply located nodules. However, group 1 showed a trend of disagreeing with the selection of wedge resection compared with group 0 as measured by a Likert scale (1-5) by -0.21 points (95% confidence interval, -0.41 to -0.008 points, P = 0.042). This tendency disappeared in group 2. The availability of VAL-MAP 1.0 led to the selection of segmentectomy, while the availability of VAL-MAP 2.0 led to aggressive deep wedge resection.

EP02.03-008 Combined Robotic Assisted Thoracic Surgery (CRATS)

Robotic assisted thoracic surgery (RATS) is an effective treatment for early stage lung cancer and for diagnosis of small lung nodules. The Ion robotic bronchoscopy system allows for more accurate biopsy and dye marking of smaller peripheral lung nodules. We have combined these two robot systems along with endobronchial ultrasound (EBUS) to create a single anesthesia procedure for the diagnosis, staging and resection of suspicious lung nodules: Combined Robotic Assisted Thoracic Surgery (CRATS).

The role of virtual-assisted lung mapping 2.0 combining microcoils and dye marks in deep lung resection.

Virtual-assisted lung mapping 2.0 is a novel preoperative bronchoscopic lung mapping technique combining the multiple dye marks of conventional virtual-assisted lung mapping with intrabronchial microcoils to navigate thoracoscopic deep lung resection. This study's purpose was to evaluate the feasibility of virtual-assisted lung mapping 2.0 in resecting deeply located pulmonary nodules with adequate margins. A multicenter, prospective single-arm study was performed from 2019 to 2020 in 8 institutions. The selection criteria were barely identifiable nodules requiring sublobar lung resections, nodules requiring resection lines reaching the inner 2/3 of the pulmonary lobe on computed tomography images in wedge resection, or the nodule center located in the inner 2/3 of the pulmonary lobe in wedge resection or segmentectomy. Resection margins larger than 2cm or the nodule diameter were considered successful resection. Bronchoscopic placement of multiple dye marks and microcoil(s) was conducted 0 to 2days before surgery. We analyzed 65 lesions in 64 patients. The diameter and depth of the targeted nodules and the minimum required resection depth reported as median (interquartile range) were 9 (7-13) mm, 11 (5-15) mm, and 30 (25-35) mm, respectively. Among 60 wedge resections and 5 segmentectomies, successful resection was achieved in 64 of 65 resections (98.5%; 95% confidence interval, 91.7-100). Among 75 microcoils placed, 3 showed major displacement after bronchoscopic placement. There were no severe adverse events associated with the virtual-assisted lung mapping procedure. This study demonstrated that virtual-assisted lung mapping 2.0 can facilitate successful resections for deep pulmonary nodules, overcoming the limitations of conventional virtual-assisted lung mapping.

Commentary: Practicing the philosophy of continuous improvement with virtual-assisted lung mapping 2.0

Lung cancer screening programs have led to an increase in detection of small, semisolid or ground glass nodules concerning for malignancy.1,2 Without the ability to palpate these nodules, thoracic surgeons require precise intraoperative localization methods to perform sublobar resections with clear oncologic margins. One such method is virtual-assisted lung mapping (VAL-MAP). Now routine in Japan, VAL-MAP uses preoperative bronchoscopic placement of multiple dye marks on the lung surface to localize the nodule and guide the direction of the staple line to obtain adequate margins.

Robotic Assisted-Bronchoscopy With Cone-Beam CT ICG Dye Marking for Lung Nodule Localization: Experience Beyond USA.

Electromagnetic navigation bronchoscopy (ENB)-guided indocyanine green (ICG) fluorescence dye marking of subsolid, small and deep lung lesions facilitates subsequent minimally invasive lung resection surgeries. The novel robotic-assisted bronchoscopy (RAB) platform can improve the accuracy and yield of ENB biopsy, and the use of RAB has been extended to ICG dye marking. However, performing this procedure in the hybrid operating room guided by cone-beam CT (CBCT) with immediate proceed to lung surgery has not been well reported. We studied the safety, feasibility and clinical outcomes of 5 consecutive cases performed between December 2021 and March 2022. Navigation success was 100% while localization success using ICG was 80%. The benefits and pitfalls of robotic bronchoscopy procedures, and challenges of combining with hybrid operating room CBCT were discussed in detail. In conclusion, robotic-assisted bronchoscopy is a promising and useful tool for ICG fluorescence dye-marking, providing accurate navigation, superior maneuverability and improved ergonomics compared to conventional bronchoscopy-guided ENB procedures. Learning curve is reasonable, but meticulous system set up to incorporate the robotic system into existing CBCT platform may be required to ensure a smooth procedure.

How Bronchoscopic Dye Marking Can Help Minimally Invasive Lung Surgery.

In the era of increasing availability of high-resolution chest computed tomography, the diagnosis and management of solitary pulmonary nodules (SPNs) has become a common challenging clinical problem. Meanwhile, surgical techniques have improved, and minimally invasive approaches such as robot- and video-assisted surgery are becoming standard, rendering the palpation of such lesions more difficult, not to mention pure ground-glass opacities, which cannot be felt even in open surgery. In this article, we explore the role of bronchoscopy in helping surgeons achieve successful minimally invasive resections in such cases.

Cryobiopsy and dye marking guided by electromagnetic navigation bronchoscopy before resection of pulmonary nodule

BackgroundOur aims were to explore the feasibility, safety, and efficacy of peroperative transbronchial lung cryobiopsy (TBLC) guided by electromagnetic navigation bronchoscopy (ENB) and ENB-guided methylene blue marking of presumably non-palpable pulmonary nodules, and to assess its impact on video-assisted thoracoscopic surgery (VATS) and postoperative lung function. MethodsThis approach was applied to 16 consecutive patients (Group A, mean age 64 years) who were compared retrospectively to a historical group of 49 patients (Group B, mean age 62 years) with similar nodules resected without guidance. The usefulness of dye marking was graded. The success rates of both ENB-guided TBLC and nodule localization through dye marking were computed. The type of resection, volume of resected parenchyma, duration of procedures, and postoperative lung function were compared between groups. Unpaired t-test, chi-square test, unpaired Wilcoxon test, and exact Fisher test were used when appropriate. ResultsMalignancy was pathologically proven in all patients. TBLC revealed malignancy in 9 patients in Group A. The success rate of ENB-guided dye marking was 94%. Lobectomy was less frequently performed in Group A than in Group B (p = 0.022). Forced expiratory volume in 1 s and total lung capacity were significantly less reduced in Group A than in Group B (p = 0.006 and p = 0.019, respectively). Combined procedure was longer than surgery alone (p<0.001), but its surgical part was shorter than VATS without guidance (p < 0.001). ConclusionPeroperative ENB-guided TBLC with methylene blue marking of non-palpable lung nodules is feasible. A sparing lung parenchyma procedure could be achieved thanks to the ENB-guided dye marking before VATS.

The oncologic safety and accuracy of indocyanine green fluorescent dye marking in securing the proximal resection margin during totally laparoscopic distal gastrectomy for gastric cancer: a retrospective comparative study

BackgroundSecuring the proximal resection margin in totally laparoscopic distal gastrectomy for gastric cancer is related to curability and recurrence, while reducing the operation time is related to patient safety. This study aimed to investigate the role of indocyanine green (ICG) fluorescent dye marking in totally laparoscopic distal gastrectomy, whether it is an oncologically safe and accurate procedure that can be conducted in a single centre.MethodsThe data of 93 patients who underwent laparoscopic-assisted distal gastrectomy (non-ICG group) or totally laparoscopic distal gastrectomy using ICG (ICG group) between 2010 and 2020 were retrospectively reviewed. To correct for confounding factors, a propensity score matching was performed.ResultsProximal resection margin did not vary with the ICG injection site after the propensity score matching (lower ICG, 3.84 cm vs. lower non-ICG, 4.42 cm, p = 0.581; middle ICG, 3.34 cm vs. middle non-ICG, 3.20 cm; p = 0.917), while the operation time was reduced by a mean of 34 min in the ICG group (ICG, 239.3 [95% confidence interval, 220.1–258.5 min]; non-ICG, 273.0 [95% confidence interval, 261.6–284.4] min; p = 0.006).ConclusionsICG injection for securing the proximal resection margin in totally laparoscopic distal gastrectomy is an oncologically safe and accurate procedure, with the advantage of reducing the operation time of gastric cancer surgery while it has the benefit of locating the tumour or clips when it is impossible to locate the tumour during surgery due to the inability to perform an endoscopic examination or when it is hard to directly palpate the tumour or clips in the operating theatre; this can be performed at a single centre.