Target Bronchus Research Articles

Evaluation of radiofrequency identification tag accuracy using bronchoscopy with fluoroscopy and virtual navigation guidance before segmentectomy

BackgroundThe use of sublobar resection has increased with advances in imaging technologies. However, it is difficult for thoracic surgeons to identify small lung tumours intraoperatively. Radiofrequency identification (RFID) lung-marking systems are useful for overcoming this difficulty; however, accurate placement is essential for maximum effectiveness.MethodsWe retrospectively reviewed patients who underwent RFID tag placement via fluoroscopic bronchoscopy under virtual bronchoscopic navigation (VBN) guidance before our institution’s sublobar resection of lung lesions. Thirty-one patients with 31 lung lesions underwent RFID lung-marking with fluoroscopic bronchoscopy under VBN guidance. Results: Of the 31 procedures, 26 tags were placed within 10 mm of the target site, 2 were placed more than 10 mm away from the target site, and 3 were placed in a different area from the target bronchus. No clinical complications were associated with RFID tag placement, such as pneumothorax or bleeding. The contribution of the RFID lung-marking system to surgery was high, particularly when the RFID tag was placed at the target site and tumour was located in the intermediate hilar zone.ConclusionsAn RFID tag can be placed near the target site using fluoroscopic bronchoscopy in combination with VBN guidance. RFID tag placement under fluoroscopic bronchoscopy with VBN guidance is useful for certain segmentectomies.

Clinical observation of three-dimensional reconstruction in thoracoscopic segmental pneumonectomy.

Accurately identifying the branches of pulmonary segmental vessels and bronchi, as well as adjacent structures, and determining the spatial location of lesions within pulmonary segments, are major challenges for thoracic surgeons. The application of three-dimensional reconstruction technology holds promise in addressing this issue. To evaluate the clinical value of three-dimensional reconstruction in thoracoscopic segmental surgery. Seventy-seven patients who underwent thoracoscopic segmental surgery combined with three-dimensional reconstruction at our hospital from January 1, 2020, to August 31, 2023, were retrospectively analyzed. Preoperative chest enhanced CT scans were conducted, and MIMICS software aided in reconstructing DICOM format original data for patients with pulmonary nodules to facilitate intraoperative nodule localization. Accurate segmental pneumonectomy was performed by comparing preoperative anatomical identification of target segmental arteries, veins, and bronchi, with surgical details and postoperative outcomes recorded, including intraoperative pulmonary resection distribution, operation time, blood loss, chest tube drainage, extubation time, hospital stay, and complications. Following preoperative three-dimensional reconstruction, successful segmental lung surgeries were performed, predominantly with single segmental resection (92.2%), and a minority with combined segmentectomy (7.8%). Median operation time was 130225 minutes, with intraoperative blood loss at 70100 mL and postoperative chest tube drainage at 347 mL (159690mL). Median extubation time and hospital stay were 4 days and 7 days, respectively. Complications within the 3-month follow-up affected 11.7% of cases, including persistent pulmonary leakage (7.1%), pulmonary infection (4.3%), atelectasis (4.3%), and pleural effusion (1.4%), with no fatalities. Preoperative 3D reconstruction can help the operator to perform safe, efficient and accurate thoracoscopic segmental pneumonectomy, which is worth popularizing in clinic.

Using cryoprobes of different sizes combined with cone-beam computed tomography-derived augmented fluoroscopy and endobronchial ultrasound to diagnose peripheral pulmonary lesions: a propensity-matched study

BackgroundEndobronchial ultrasound (EBUS) and cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) are utilized for the diagnosis of peripheral pulmonary lesions (PPLs). Combining them with transbronchial cryobiopsy (TBC) can provide sufficient tissue for genetic analysis. However, cryoprobes of different sizes have varying degrees of flexibility, which can affect their ability to access the target bronchus and potentially impact the accuracy. The aim of this study was to compare the diagnostic efficacy of cryoprobes of varying sizes in CBCT-AF and EBUS for the diagnosis of PPLs.MethodsPatients who underwent endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) and TBC combined with CBCT-AF for PPLs diagnosis between January 2021 and May 2022 were included. Propensity score matching and competing-risks regression were utilized for data analysis. Primary outcome was the diagnostic accuracy of TBC.ResultsA total of 284 patients underwent TBC, with 172 using a 1.7-mm cryoprobe (1.7 group) and 112 using a 1.1-mm cryoprobe (1.1 group). Finally, we included 99 paired patients following propensity score matching. The diagnostic accuracy of TBC was higher in the 1.1 group (80.8% vs. 69.7%, P = 0.050), with a similar rate of complications. Subgroup analysis also revealed that the 1.1 group had better accuracy when PPLs were located in the upper lobe (85.2% vs. 66.1%, P = 0.020), when PPLs were smaller than 20 mm (78.8% vs. 48.8%, P = 0.008), and when intra-procedural CBCT was needed to be used (79.5% vs. 42.3%, P = 0.001). TBC obtained larger specimens than TBB in both groups. There is still a trend of larger sample size obtained in the 1.7 group, but there is no statistically different between our two study groups (40.8 mm2 vs. 22.0 mm2, P = 0.283).ConclusionsThe combination of TBC with CBCT-AF and EBUS is effective in diagnosing PPLs, and a thin cryoprobe is preferred when the PPLs located in difficult areas.

A novel method for the bronchial occlusion of prolonged air leakage using customized endobronchial plugs.

The management of prolonged air leakage (PAL) is a significant clinical challenge, particularly for patients who are unfit for surgical treatment. The use of endoscopic interventions with occlusive devices has been reported previously; however, local availability and cost may represent potential hurdles, especially in developing countries. In this study, we presented a conical endobronchial plug of our design and evaluated the efficacy of making use of that in the treatment of PAL as a novel method. This retrospective study included a total of 23 patients with PAL who were not suitable for surgery and underwent bronchial occlusion using customized plugs. The responsible bronchi were identified by the balloon occlusion test or by end-tidal carbon dioxide detection. In each case, the plug was grasped at the knot of the tip with forceps and then inserted into the target bronchus with a flexible bronchoscope. Of the 23 patients with intractable pneumothorax, 1 to 3 plugs (median =1) were successfully inserted into the affected bronchi of each patient for bronchial occlusion. Air leakage showed complete cessation in 13 patients (56.5%) and reduction in seven patients (30.4%). A total of 20 patients (87.0%) experienced successful removal of the drainage tube following plug occlusion or presented with additional pleurodesis. Complications included expectoration of the plug (n=1) and fever (n=1); no other severe complications were observed. Bronchial occlusion using customized endobronchial plugs appears to be an effective and simple option for the management of PAL in patients who are not suitable for surgery, especially in developing countries, as the customized plug is a cost-effective alternative.

Efficacy of Bronchial Artery Embolization for Clinically Suspected Bronchial Dieulafoy’s Disease

Background:: The efficacy of bronchial artery embolization (BAE) for bronchial Dieulafoy’s disease (BDD) has not been well established. Objective:: This study aimed to evaluate the safety and efficacy of BAE in patients with clinically suspected BDD presenting with major hemoptysis, and to describe angiographic findings. Methods:: 17 patients (all men; mean age, 53.5 years) diagnosed with clinically suspected BDD by bronchoscopy (n = 7) or CT angiography (CTA) (n = 10) and who underwent BAE after directional and segmental localization of the target bronchus were enrolled. BAE was performed at the culprit bronchial artery traveling toward the target bronchus, regardless of the pathologic angiographic findings. Angiographic findings and clinical outcomes of BAE, including technical and clinical success, complication, recurrent hemoptysis, and follow-up imaging, were retrospectively reviewed. Results:: Representative angiographic findings included parenchymal hypervascularity prominent in the lobe where the BDD was located (82.4%), bronchial artery hypertrophy (70.6%), and contrast extravasation into the bleeding bronchus (17.6%). BAE was technically successful in all patients. All hemoptysis ceased within 24 h. No procedure-related complications occurred. During a mean follow-up of 491.9 days, 1 (6%) patient experienced recurrent hemoptysis. Follow-up bronchoscopy or CT performed in 10 (58.8%) patients showed the disappearance of pre-existing lesions (n = 9) or glue cast within the target bronchial artery (n = 1). Conclusion:: Bronchial angiography showed pathologic findings in most patients with clinically suspected BDD. BAE assisted by bronchoscopy or CTA localization is a safe and effective treatment for patients with clinically suspected BDD with excellent short- to mid-term results.

Revaluation of a selected segmental insufflation technique in total thoracoscopic lung segmentectomy.

We report selected insufflation technique using direct bronchial insufflation to visualize the intersegmental plane during total thoracoscopic segmentectomy. Following the transection of the bronchus using a stapler, a small incision was created in the dissected target bronchus, and direct air insufflation was performed at the small incision site. The target segment was inflated, while the preserved segments appeared to collapse, and a demarcating line was visualized between the inflated and deflated lung parenchyma. This technique quickly identifies the anatomic intersegmental plane without warranting special equipment such as jet ventilation or ICG. Furthermore, this method saves time in creating inflation-deflation lines.

Cone-beam computed tomography-guided endobronchial ultrasound using an ultrathin bronchoscope for diagnosis of peripheral pulmonary lesions: a prospective pilot study.

Multimodal transbronchial biopsy (TBB) may have improved diagnostic yield for peripheral pulmonary lesions suspected as lung cancer. Radial endobronchial ultrasound (R-EBUS) provides real-time imaging and confirmation of the location of the lesions. Cone-beam computed tomography (CBCT) can confirm that the forceps tip has reached the lesion before biopsy. Patients with peripheral pulmonary lesions and a positive computed tomography (CT) bronchus sign (based on slice thickness of 1 mm) were prospectively enrolled. An ultrathin bronchoscope (UTB) and R-EBUS probe were advanced to the target bronchus. Thereafter, forceps were advanced, and CBCT was performed. R-EBUS was performed for re-navigation, if possible. The obtained EBUS and CBCT images were classified into "within" (type 1), "adjacent to" (type 2), or "far from" (type 3), based on the probe or forceps tip. For 20 lesions, the diagnostic yield was 85%. The primary EBUS images were of types 1, 2, and 3 in 12, 6, and 2 cases, respectively. The primary CBCT images were of types 1, 2, and 3 in 12, 6, and 2 cases, respectively. Primary EBUS and CBCT image types were equivalent in 14 cases. Of the 12 cases with type 1 primary EBUS image, 9 cases had a type 1 primary CBCT image, while 3 cases exhibited positional misalignment of the forceps tip. Re-navigation was required in 8 cases with types 2 and 3 primary CBCT images. CBCT-guided TBB using an UTB and EBUS may enable real-time positioning guidance and better re-navigation in the diagnosis of peripheral pulmonary lesions.

Analysis of predicted factors for bronchoalveolar lavage recovery failure: An observational study.

The bronchoalveolar lavage (BAL) recovery rate should generally be more than 30% for effective diagnosis. However, there have been no reports investigating a target bronchus for BAL, and the cause of BAL recovery failure is uncertain. Therefore, this study detected predictive factors for BAL recovery failure through investigations on a target bronchus for BAL by using a 3D image analysis system. Therefore, this study detected predictive factors for BAL recovery failure. We retrospectively collected data from 338 adult patients who underwent BAL procedures at Fukujuji Hospital from June 2018-March 2022. Factors correlated with the BAL recovery rate were detected. Furthermore, the patients were divided into the failure group (recovery rate <30%; 36 patients) and the success group (recovery rate ≥30%; 302 patients), and data were compared between the two groups by analysing the target bronchus by using a 3D image analysis system. The patients in the failure group were older (median 74.5 years old [IQR 68.0-79.0] vs. median 70.0 years old [IQR 59.0-76.0], p = 0.016), more likely to be male (n = 27 [75.0%] vs. n = 172 [57.0%], p = 0.048), more likely to have COPD (n = 7 [19.4%] vs. n = 14 [4.6%], p = 0.003), and more likely to perform a target site of BAL other than the middle/lingual lobe (n = 11 [30.5%] vs. n = 35 [11.6%], p = 0.004) than those in the success group. The area of the bronchial wall was positively related to the recovery rate (r = 0.141, p = 0.009), and the area of the bronchial wall in the failure group was lower than that in the success group (median 10.5 mm2 [interquartile range (IQR) 8.1-14.6] vs. median 14.5 mm2 [11.4-19.0], p<0.001). The study shows that a thin bronchial wall, COPD, and a target site of BAL other than the middle/lingual lobe were identified as the predicted factors for BAL recovery failure. The weakness of the bronchial wall might cause bronchial collapse during the BAL procedure.

Thin bronchoscopic cryobiopsy using a nasobronchial tube

BackgroundTransbronchial lung cryobiopsy is useful when diagnosing lung lesions. However, prevention of associated bleeding complications is essential. This study aimed to evaluate the safety and efficacy of our novel bronchoscopic cryobiopsy technique, which uses a long nasobronchial tube to prevent blood flooding the central airway.MethodsPatients with localized or diffuse lung lesions were prospectively enrolled and underwent cryobiopsy using a 1.9 mm diameter cryoprobe and a 4.0 mm diameter thin bronchoscope under conscious sedation. For cryobiopsy, a long silicone tube (inner diameter, 5.0 mm) was advanced through the nose to the target bronchus, then wedged to drain blood under thin-tube bronchoscopic control. The primary endpoint was the frequency of bleeding complications.ResultsOf the 80 patients initially enrolled, 73 that underwent at least one cryobiopsy were ultimately included. Mild bleeding during cryobiopsy occurred in 58 patients (79.5%), but there was no moderate or severe bleeding. Other complications occurred in four patients (two pneumothorax, one pneumomediastinum, and one pneumonia). Tube dislocation was noted in eight patients (11%). Cryobiopsy specimens were significantly larger than forceps biopsy specimens (9.0 mm2 vs. 2.7 mm2, P < .001) and allowed specific diagnoses in 50 patients (68.5%).ConclusionsThin bronchoscopic cryobiopsy using a nasobronchial tube in consciously sedated patients is safe and effective.Trial registration Date of registration: 24/06/2019. UMIN-Clinical Trials Registry; Identifier: UMIN000037156 https://www.umin.ac.jp/ctr/index.htm

Application of Image Processing and 3D Printing Technique to Development of Computer Tomography System for Automatic Segmentation and Quantitative Analysis of Pulmonary Bronchus

This study deals with the development of a computer tomography (CT) system for automatic segmentation and quantitative analysis of the pulmonary bronchus. It includes three parts. Part I employed an adaptive median and four neighbors low pass filters to eliminate the noise of CT. Then, k-means clustering was used to segment the lung region in the CT data. In Part II, the pulmonary airway was segmented. The three-grade segmentation was employed to divide all pixels in the lung region into three uncertain grades, including air, blood vessels, and tissues, and uncertain portions. The airway wall was reformed using a border pixel weight mask. Afterwards, the seed was calculated automatically with the front-end image masking the aggregation position of the lung region as the input of the region growing to obtain the initial airway. Afterwards, the micro bronchi with different radii were detected using morphological grayscale reconstruction to modify the initial airway. Part III adopted skeletonization to simplify the pulmonary airway, keeping the length and extension direction information. The information was recorded in a linked list with the world coordinates based on the patients’ carina, defined by the directions of the carina to the top end of the trachea and right and left main bronchi. The whole set of bronchi was recognized by matching the target bronchus direction and world coordinates using hierarchical classification. The proposed system could detect the location of the pulmonary airway and detect 11 generations’ bronchi with a bronchus recognition capability of 98.33%. Meanwhile, 20 airway parameters’ measurement and 3D printing verification have been processed. The diameter, length, volume, angle, and cross-sectional area of the main trachea and the right and left bronchi, the cross-sectional area of the junction, the left bronchus length, and the right bronchus length have been calculated for clinical practice guidelines. The system proposed in this study simultaneously maintained the advantages of automation and high accuracy and contributed to clinical diagnosis.

One Lung Extraluminal Bronchial Blocker

Introduction: This video shows the various methods employed for one lung ventilation (OLV) for thoracoscopic surgery in infants and toddlers. Currently, there are no best practice guidelines on the best method to achieve OLV in this challenging patient population. The different methods include main stem intubation, double lumen tubes, and extraluminal bronchial blockers.1 Extraluminal bronchial blocker for OLV has unique advantages for infants and smaller children that balances the needs of both the surgical and anesthesia providers. We demonstrate a standard method for extraluminal bronchial blocker placement in an infant and a novel modification of the technique that facilitates more accurate blocker placement into the target bronchus.2 The rationale for a multicenter study of OLV techniques in infants is presented as next steps are discussed. Materials and Methods: A novel modification for the technique of extraluminal bronchial blocker for OLV using an uncuffed tube facilitates deployment of the bronchial blocker. To start, the endotracheal tube (ET) here is placed through video laryngoscopy. A flexible fiberoptic endoscope is then used to ensure correct placement into the left main stem. The bronchial blocker is then deployed directly into the left mainstem through the main stemmed endotracheal tube. While holding the blocker in place, The ET tube is then removed from the trachea over the external portion of the blocker shaft. Next, under direct or video laryngoscopy, a new ET tube is positioned in the trachea and anterior to the now extraluminal/endotracheal bronchial blocker. Flexible bronchoscopy through the ET tube is then used to observe the bronchial blocker in the left bronchus and the balloon is inflated once placement is confirmed. Results: Effective placement of extraluminal bronchial blockers into the left mainstem can be achieved with this novel modification to placement. Conclusions: The primary literature on this subject is limited and there are no best practice guidelines at this time. Small single-center studies have shown that extraluminal bronchial blockers are associated with less hypoxemia and hypercarbia.3 The novel modification to the placement of extraluminal bronchial blockers described in this video may help with ease of placement and encourage wider adoption of this technique. There is a need for multicenter study to adequately determine the most effective method for OLV that maximizes the safety profile for patients, ensures ease of placement for the anesthesia providers, and maintains quality lung isolation for the surgeon. No competing financial interests exist. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 5 mins

Usefulness of near-infrared fluorescence for identifying the segmental bronchus in minimally invasive segmentectomy

Minimally invasive anatomical sublobar resections have gained relevance in recent years mainly due to advances in imaging techniques, screening programs and the increase in second neoplasms. Accurate identification of the segmental or subsegmental bronchus is vital to guarantee optimal results in segmentectomies and subsegmentectomies. Given the complexity and the possibility of anatomical variations, several authors have published different methods to identify the target bronchus. However, these methods have certain limitations. This article describes a new rapid and effective technique, with a low risk of complications and without additional cost, for the identification of segmental bronchi in minimally invasive segmentectomies.

Utilidad de la fluorescencia cercana al infrarrojo para la identificación del bronquio segmentario en segmentectomías mínimamente invasivas

Minimally invasive anatomical sublobar resections have gained relevance in recent years mainly due to advances in imaging techniques, screening programs and the increase in second neoplasms. Accurate identification of the segmental or subsegmental bronchus is vital to guarantee optimal results in segmentectomies and subsegmentectomies. Given the complexity and the possibility of anatomical variations, several authors have published different methods to identify the target bronchus. However, these methods have certain limitations. This article describes a new rapid and effective technique, with a low risk of complications and without additional cost, for the identification of segmental bronchi in minimally invasive segmentectomies.

Progress in three‐dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy

The number of minimally invasive surgeries, such as video‐assisted thoracoscopic surgery and robot‐assisted thoracoscopic surgery, has increased enormously in recent years. More and more relevant studies report that anatomic pulmonary segmentectomy has the same effect as traditional lobectomy in the surgical treatment of early stage non‐small cell lung cancer (diameter less than 2.0 cm). Segmentectomy requires sufficient knowledge of the location of the pulmonary nodules, as well as the anatomy of the target segments, blood vessels, and bronchi. With the rapid development of imaging technology and three‐dimensional technology, three‐dimensional reconstruction has been widely used in the medical field. It can effectively assess the vascular branching patterns, discover the anatomic variations of the blood vessels and bronchi, determine the location of the lesion, and clarify the division of the segments. Therefore, it is helpful for preoperative positioning, surgical planning, preoperative simulation and intraoperative navigation, and provides a reference for formulating an individualized surgical plan. It therefore plays a positive role in anatomic pulmonary segmentectomy. This study reviews the progress made in three‐dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy.

Virtual Bronchoscopy-Guided Transbronchial Biopsy Simulation Using a Head-Mounted Display: A New Style of Flexible Bronchoscopy.

Background/need. The increases in reference images and information during bronchoscopy using virtual bronchoscopic navigation (VBN) and fluoroscopy has potentially created the need for support using a head-mounted display (HMD) because bronchoscopists feel difficulty to see displays that are at a distance from them and turn their head and body in various directions. Methodology and device description. The binocular see-through Moverio BT-35E Smart Glasses can be connected via a high-definition multimedia interface and have a 720p high-definition display. We developed a system that converts fluoroscopic (live and reference), VBN, and bronchoscopic image signals through a converter and references them using the Moverio BT-35E. Preliminary results. We performed a virtual bronchoscopy-guided transbronchial biopsy simulation using the system. Four experienced pulmonologists performed a simulated bronchoscopy of 5 cases each with the Moverio BT-35E glasses, using bronchoscopy training model. For all procedures, the bronchoscope was advanced successfully into the target bronchus according to the VBN image. None of the operators reported eye or body fatigue during or after the procedure. Current status. This small-scale simulation study suggests the feasibility of using a HMD during bronchoscopy. For clinical use, it is necessary to evaluate the safety and usefulness of the system in larger clinical trials in the future.

Consensus for Thoracoscopic Lower Lobectomy: Essential Components and Targets for Simulation

BackgroundDespite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training. MethodsAfter randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation. ResultsAfter 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein. ConclusionsUsing a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development.

P02.01 CT Integrated Bronchoscopy Manual Spraying Pigment Labeling to Localize of Small Pulmonary Nodules

Popularization of High Resolution Computed Tomography (HRCT) has greatly improved the detection rate of pulmonary nodules. Video Assistant Thoracic Surgery (VATS) lobectomy (sublobar lung resection in selected patients) has been the standard surgical treatment for these early stage non-small cell lung cancer. Uniportal VATS, a widely used innovative technique in minimally invasive thoracic surgery, makes less incision and also demands more precise intraoperative palpation/localization which is often challenging for small nodules. Various strategies such as the hookwire method, CT fluoroscopy-guided bronchoscopic dye marking, contrast median injection, radiotracer localization and a virtual assisted lung mapping technology (VAL-MAP). While they provide new options of nodule location for thoracic surgeons, all of these strategies require expensive hardware or software and additional two or three more doctors which are often not affordable for centers with limited resources. The purpose of this study is to develop a practically cheap method of pigment labeling for bronchoscope with no additional need of medical equipment and medical human resources. This is an ethic committee approved clinical trial. Medically operable patients with the HRCT detected small nodules were eligible. This nodule localization method involved a manual drawing the route by the surgeon/bronchoscopist, through a series of bronchial opening sketches and marking the leading bronchus at every bifurcation point based on the HRCT. Two to four appropriate bronchial pathways were selected for each lesion. A metal-tip catheter was inserted into a selected bronchus and advanced to the pleura. The location of the catheter tip was fluoroscopically confirmed, and 1 mL of diluted methylene blue was injected for each marking. All these procedures were completed by one doctor and one nurse. Then low dose CT scan was used to visualize the localization of the multiple markings, which were used as references in the subsequent operation. Success rate and procedure related complication are reported. From April 2019 to July 2020, 18 lesions in 17 patients were enrolled. All surgical procedures were performed using uniportal VATS. The lesions ranged in size from 3 to 23mm, 15 (83%) were nodules of Ground Glass Opacity (GGO). The depth ranged from 0 to 19 mm. A total of 57 lung markings were planned. 54 of them (95%) were completed. Of the 3 failed markings, the target bronchus could not be accessed under the bronchoscopy because of improper angle. Fifty-two (91%) were visible during the operations. The 3 unidentified markings were in the same patient, who had been a coal miner and had a severe carbon deposition on his lung and pleura. There was no adverse event associated with this manual marking procedures. All lesions were successfully resected. In 3 patients failed multiple markings, alternative localization was used successfully. This HRCT guided manual drawing method of lesion localization is safe and effective for small nodule localization for lung cancer surgery. Results of this study appears to be better than conventional percutaneous techniques in clinically evident complications. Because it does not need special equipment, it is more suitable for developing countries with limited equipment and human resources.

Transbronchial lung parenchyma cryoablation with a novel flexible cryoprobe in an in vivo porcine model

PurposeThe purpose of this study was to evaluate the feasibility and safety of transbronchial cryoablation with a novel flexible cryoprobe using nitrogen as the refrigerant in an in vivo porcine model of lung parenchyma. Materials and methodsA novel flexible cryoprobe using nitrogen as the refrigerant was used for transbronchial cryoablation of lung parenchyma in six normal female pigs. The cryoprobe was delivered to the distal bronchus in the bilateral porcine lungs via the bronchoscopic working channel under virtual bronchoscopy guidance. The position was confirmed with real-time computed tomography (CT). The whole procedure included two freeze-thaw cycles (15 min and 2 min, respectively). CT images were obtained during cryoablation and at 24 h, one week, two weeks and four weeks after the treatment to assess the effectiveness and safety of the procedure. Ablation zone tissue samples were obtained at 24 h and four weeks after the cryoablation for further histopathological analysis. ResultsAll ablation procedures (12/12; 100%) were performed successfully. No major complications occurred during the procedure or the observation period. The ablation zones were clearly depicted on CT with a maximal ablation zone volume at 24 h (21.88 ± 12.61 [SD] cm3) compared to 3.64 ± 2.06 (SD) cm3 and 10.73 ± 3.84 (SD) cm3 at the end of the 1st and 2nd freeze-thaw cycles, respectively (P < 0.001). Histopathological analysis revealed that a coagulative necrotic zone was formed along the target bronchus, with obvious vascular occlusion and hemorrhage 24 h after treatment. The lesions gradually formed fibrosis after four weeks. ConclusionThe novel flexible bronchoscopy-guided cryoablation is a feasible, safe and effective modality in an in vivo porcine model of peripheral normal lung parenchyma, suggesting potential capabilities for the treatment of peripheral lung cancer in humans.

Diversity of lymphatic flow in patients with lung cancer revealed by computed tomography lymphography

This study was conducted to verify the optimal extent of lymph node dissection or sampling during lung cancer surgery based on the sentinel node (SN) map created by computed tomography (CT) lymphography. From April 2010 to January 2015, patients with clinical stage I non-small-cell lung cancer, who were candidates for lobectomy or segmentectomy with standard hilar and mediastinal lymph node dissection, and in whom bronchus reached the tumour, were enrolled. An ultrathin bronchoscope was inserted to the target bronchus under the guidance of virtual bronchoscopic navigation images. CT images of the chest were obtained 30 s after 2.5 ml of iopamidol was injected. SNs were identified when the maximum CT attenuation value of the lymph nodes on postcontrast CT images increased by 30 Hounsfield units or more compared with the precontrast images. Patients underwent lobectomy with standard lymph node dissection. SNs were identified in 36 (87.8%) of the 41 patients. The average number of SNs was 1.6 (range, 1-4). There was 1 false negative case; therefore, the accuracy of SN identification was 97.2% (35/36). In 5 (13.9%) of 36 patients, SNs were outside the lobe-specific lymph node station range (#11i from right S1, #7 from right S1, #4R from right S8, #12u from right S8, #7 and #12l from left S1 + 2). CT lymphography demonstrated the diversity of lymphatic spreading patterns and there were cases in which lymph flows are found outside the lymph node dissection range.

Cone-beam computed tomography versus computed tomography-guided ultrathin bronchoscopic diagnosis for peripheral pulmonary lesions: A propensity score-matched analysis.

CBCT-guided TBB using a UTB under VBN is a useful method for the diagnosis of peripheral small pulmonary lesions. CBCT-guided TBB using UTB under VBN has been used as an alternative to CT-guided TBB. However, the advantage of CBCT-guided TBB using UTB under VBN over CT-guided TBB is still unknown. This study aimed to compare the diagnostic yield of CT-guided TBB and CBCT-guided TBB using a propensity score-matched analysis. Patients with peripheral pulmonary lesions ≤30 mm were included. Lesions whose bronchus could not be determined by CT were excluded. A UTB and biopsy forceps were advanced to the target bronchus under VBN, 2D-fluoroscopy and CT or CBCT. The CT-guided and CBCT-guided groups were matched for their propensity scores based on patient characteristics. We retrospectively reviewed 93 patients in the CT-guided group and 79 patients in the CBCT-guided group for this study. Furthermore, 48 distinct examination pairs were generated by propensity score matching. In the overall diagnostic yield, the CBCT-guided group showed better results (72.9%) than did the CT-guided group (47.9%) (P = 0.012). The median examination time lasted for 43 (IQR: 37-51) min in the CBCT-guided group and 50 (IQR: 43-62) min in the CT-guided group. The examination time in the CBCT-guided group was significantly shorter than that of the CT-guided group (P = 0.001). CBCT-guided TBB had a better diagnostic yield and shorter examination time than did CT-guided TBB.