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Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique to localize deep pulmonary nodules in a hybrid operating room

Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique to localize... Abstract Herein, we describe a Dyna-computed tomography-guided electromagnetic navigation bronchoscopy technique aimed at localizing deep pulmonary nodules. The method was implemented in a hybrid operating room and required the use of 2 markers (a near-infrared dye as a surface marker and a microcoil as a deep marker). Pulmonary nodules, Localization, Hybrid operating room, Navigation bronchoscopy INTRODUCTION Video-assisted thoracoscopic surgery (VATS) wedge resection of small and/or deep pulmonary nodules is a common challenge faced by thoracic surgeons. Failure to localize these nodules hampers a successful thoracoscopic resection and may eventually require conversion to open thoracotomy. Dye marking is commonly achieved either through a percutaneous computed tomography (CT)-guided approach or an electromagnetic navigation bronchoscopy (ENB) technique and is currently the most common localization technique for superficial lesions (distance to the pleural surface <10 mm) [1, 2]. With regard to deep lesions, a CT-guided hookwire localization remains the most commonly used approach despite the inherent risk of wire dislodgement [3]. Herein, we describe the feasibility and safety of a dual-marker technique aimed at localizing deep pulmonary nodules through the combined use of ENB and CT in a hybrid operating room. TECHNIQUE Patients with deep pulmonary nodules (distance from the visceral pleural surface >10 mm) were deemed eligible for the dual-marker approach. Video 1 illustrates the procedural workflow. All the steps were implemented within a hybrid operating room equipped with a cone-beam CT apparatus (ARTIS zeego; Siemens Healthcare GmbH, Erlangen, Germany). ENB was performed with a SuperDimension™ (Medtronic, Minneapolis, MN, USA) navigation system (version 7.0). Upon induction of general anaesthesia and a routine surveillance bronchoscopy, a locatable guide (LG) that allows position and orientation tracking within an extended working channel was inserted into the bronchoscope. Bronchoscopy images were registered and correlated with CT data, after which the planned virtual path was followed down until LG reached the nodule of interest. An intraoperative DynaCT scan was acquired to inspect LG positioning in relation to the target lesion. In the event of discordant findings between virtual and real images, the position of the LG tip was finely adjusted under fluoroscopic guidance with the aid of the syngo iGuide Toolbox software package. DynaCT imaging was performed to confirm successful positioning. The syngo iGuide Toolbox software was used to mark the tumour and an ideal deep margin location on DynaCT and then projected onto fluoroscopy. Upon removal of the LG, a 23-G Interject needle (Boston Scientific, Marlborough, MA, USA) was inserted into the extended working channel. Subsequently, an indocyanine green (Diagnogreen®; Daiichi Sankyo, Tokyo, Japan) dye solution (0.3 ml) was injected through the Interject needle onto the pleural surface surmounting the lesion. A 5-F TEMPO™ angiographic catheter (Cordis Corporation, Miami Lakes, FL, USA) was introduced through the extended working channel and used to deliver a Tornado® microcoil (Cook Inc., Bloomington, IN, USA) to the pre-selected location under X-ray fluoroscopy guidance followed by a postprocedural confirmatory DynaCT scan. Figure 1 provides representative images obtained at different time points. Video 1: Open in new tabDownload slide Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique. Video 1: Open in new tabDownload slide Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique. Figure 1: Open in new tabDownload slide (A) Preprocedural computed tomography image showing a subsolid pulmonary nodule (red circle). (B) Image obtained after electromagnetic navigation bronchoscopy navigation showing the locatable guide tip (blue arrow) within the tumour. (C) Postprocedural image showing a microcoil (yellow circle) at the lesion site. Figure 1: Open in new tabDownload slide (A) Preprocedural computed tomography image showing a subsolid pulmonary nodule (red circle). (B) Image obtained after electromagnetic navigation bronchoscopy navigation showing the locatable guide tip (blue arrow) within the tumour. (C) Postprocedural image showing a microcoil (yellow circle) at the lesion site. Upon VATS initiation, intraoperative near-infrared fluorescence images were acquired using a minimally invasive indocyanine green fluorescence system (PINPOINT®; Novadaq, Mississauga, ON, Canada) for the identification of the near-infrared tattoo. Thoracoscopic instruments were used to clamp the lung and set an intended resection line. Microcoil positioning in relation to the instrument and the mechanical staple was assessed on fluoroscopy to ensure an adequate resection margin (Figure 2). Figure 2: Open in new tabDownload slide Thoracoscopic view of near-infrared marking and fluoroscopic confirmation of microcoil placement. Figure 2: Open in new tabDownload slide Thoracoscopic view of near-infrared marking and fluoroscopic confirmation of microcoil placement. The technique was implemented in 15 patients (median tumour size: 10 mm, median distance from the pleura: 18 mm). The first post-ENB DynaCT scan confirmed a proper LG tip localization in two-thirds of patients. The remaining 6 cases required additional adjustments. The dual-marker placement was successful in all participants, the only exception being 1 patient in whom the coil was found to migrate to a segmental bronchus (ultimately requiring bronchoscopic removal). All lesions were successfully removed through VATS. DISCUSSION We describe a dual-marker technique that allowed a reliable localization of deep pulmonary nodules. Our method was based on the use of an indocyanine green dye (as a surface marker) followed by the insertion of a microcoil (as a deep marker). Compared with CT-guided hookwire localization, the proposed procedure requires neither a skin puncture nor the use of wires. Moreover, DynaCT and fluoroscopy provide real-time image guidance during ENB—ultimately minimizing possible discrepancies induced by respiratory movements [4]. Subject to future confirmation, the proposed methodology may have the potential for use in the presence of deep lesions which are technically difficult and/or relatively risky to approach through a percutaneous puncture (e.g. lesions located in the lung apex, in the proximity of the diaphragm or major mediastinal organs, or behind the scapula). Presented at the 7th Asian single port VATS symposium, Nagoya, Japan, 24-25 May 2019. Funding This study was financially supported by a grant [CMRPG3F1813] from the Chang Gung Memorial Hospital, Taiwan. Conflict of interest: none declared. REFERENCES 1 Lin M-W , Tseng Y-H , Lee Y-F , Hsieh M-S , Ko W-C , Chen J-Y et al. . Computed tomography-guided patent blue vital dye localization of pulmonary nodules in uniportal thoracoscopy . J Thorac Cardiovasc Surg 2016 ; 152 : 535 – 44.e2 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Abbas A , Kadakia S , Ambur V , Muro K , Kaiser L. Intraoperative electromagnetic navigational bronchoscopic localization of small, deep, or subsolid pulmonary nodules . J Thorac Cardiovasc Surg 2017 ; 153 : 1581 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Thistlethwaite PA , Gower JR , Hernandez M , Zhang Y , Picel AC , Roberts AC. Needle localization of small pulmonary nodules: lessons learned . J Thorac Cardiovasc Surg 2018 ; 155 : 2140 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Chen A , Pastis N , Furukawa B , Silvestri GA. The effect of respiratory motion on pulmonary nodule location during electromagnetic navigation bronchoscopy . Chest 2015 ; 147 : 1275 – 81 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique to localize deep pulmonary nodules in a hybrid operating room

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Oxford University Press
Copyright
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1010-7940
eISSN
1873-734X
DOI
10.1093/ejcts/ezz360
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Abstract

Abstract Herein, we describe a Dyna-computed tomography-guided electromagnetic navigation bronchoscopy technique aimed at localizing deep pulmonary nodules. The method was implemented in a hybrid operating room and required the use of 2 markers (a near-infrared dye as a surface marker and a microcoil as a deep marker). Pulmonary nodules, Localization, Hybrid operating room, Navigation bronchoscopy INTRODUCTION Video-assisted thoracoscopic surgery (VATS) wedge resection of small and/or deep pulmonary nodules is a common challenge faced by thoracic surgeons. Failure to localize these nodules hampers a successful thoracoscopic resection and may eventually require conversion to open thoracotomy. Dye marking is commonly achieved either through a percutaneous computed tomography (CT)-guided approach or an electromagnetic navigation bronchoscopy (ENB) technique and is currently the most common localization technique for superficial lesions (distance to the pleural surface <10 mm) [1, 2]. With regard to deep lesions, a CT-guided hookwire localization remains the most commonly used approach despite the inherent risk of wire dislodgement [3]. Herein, we describe the feasibility and safety of a dual-marker technique aimed at localizing deep pulmonary nodules through the combined use of ENB and CT in a hybrid operating room. TECHNIQUE Patients with deep pulmonary nodules (distance from the visceral pleural surface >10 mm) were deemed eligible for the dual-marker approach. Video 1 illustrates the procedural workflow. All the steps were implemented within a hybrid operating room equipped with a cone-beam CT apparatus (ARTIS zeego; Siemens Healthcare GmbH, Erlangen, Germany). ENB was performed with a SuperDimension™ (Medtronic, Minneapolis, MN, USA) navigation system (version 7.0). Upon induction of general anaesthesia and a routine surveillance bronchoscopy, a locatable guide (LG) that allows position and orientation tracking within an extended working channel was inserted into the bronchoscope. Bronchoscopy images were registered and correlated with CT data, after which the planned virtual path was followed down until LG reached the nodule of interest. An intraoperative DynaCT scan was acquired to inspect LG positioning in relation to the target lesion. In the event of discordant findings between virtual and real images, the position of the LG tip was finely adjusted under fluoroscopic guidance with the aid of the syngo iGuide Toolbox software package. DynaCT imaging was performed to confirm successful positioning. The syngo iGuide Toolbox software was used to mark the tumour and an ideal deep margin location on DynaCT and then projected onto fluoroscopy. Upon removal of the LG, a 23-G Interject needle (Boston Scientific, Marlborough, MA, USA) was inserted into the extended working channel. Subsequently, an indocyanine green (Diagnogreen®; Daiichi Sankyo, Tokyo, Japan) dye solution (0.3 ml) was injected through the Interject needle onto the pleural surface surmounting the lesion. A 5-F TEMPO™ angiographic catheter (Cordis Corporation, Miami Lakes, FL, USA) was introduced through the extended working channel and used to deliver a Tornado® microcoil (Cook Inc., Bloomington, IN, USA) to the pre-selected location under X-ray fluoroscopy guidance followed by a postprocedural confirmatory DynaCT scan. Figure 1 provides representative images obtained at different time points. Video 1: Open in new tabDownload slide Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique. Video 1: Open in new tabDownload slide Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique. Figure 1: Open in new tabDownload slide (A) Preprocedural computed tomography image showing a subsolid pulmonary nodule (red circle). (B) Image obtained after electromagnetic navigation bronchoscopy navigation showing the locatable guide tip (blue arrow) within the tumour. (C) Postprocedural image showing a microcoil (yellow circle) at the lesion site. Figure 1: Open in new tabDownload slide (A) Preprocedural computed tomography image showing a subsolid pulmonary nodule (red circle). (B) Image obtained after electromagnetic navigation bronchoscopy navigation showing the locatable guide tip (blue arrow) within the tumour. (C) Postprocedural image showing a microcoil (yellow circle) at the lesion site. Upon VATS initiation, intraoperative near-infrared fluorescence images were acquired using a minimally invasive indocyanine green fluorescence system (PINPOINT®; Novadaq, Mississauga, ON, Canada) for the identification of the near-infrared tattoo. Thoracoscopic instruments were used to clamp the lung and set an intended resection line. Microcoil positioning in relation to the instrument and the mechanical staple was assessed on fluoroscopy to ensure an adequate resection margin (Figure 2). Figure 2: Open in new tabDownload slide Thoracoscopic view of near-infrared marking and fluoroscopic confirmation of microcoil placement. Figure 2: Open in new tabDownload slide Thoracoscopic view of near-infrared marking and fluoroscopic confirmation of microcoil placement. The technique was implemented in 15 patients (median tumour size: 10 mm, median distance from the pleura: 18 mm). The first post-ENB DynaCT scan confirmed a proper LG tip localization in two-thirds of patients. The remaining 6 cases required additional adjustments. The dual-marker placement was successful in all participants, the only exception being 1 patient in whom the coil was found to migrate to a segmental bronchus (ultimately requiring bronchoscopic removal). All lesions were successfully removed through VATS. DISCUSSION We describe a dual-marker technique that allowed a reliable localization of deep pulmonary nodules. Our method was based on the use of an indocyanine green dye (as a surface marker) followed by the insertion of a microcoil (as a deep marker). Compared with CT-guided hookwire localization, the proposed procedure requires neither a skin puncture nor the use of wires. Moreover, DynaCT and fluoroscopy provide real-time image guidance during ENB—ultimately minimizing possible discrepancies induced by respiratory movements [4]. Subject to future confirmation, the proposed methodology may have the potential for use in the presence of deep lesions which are technically difficult and/or relatively risky to approach through a percutaneous puncture (e.g. lesions located in the lung apex, in the proximity of the diaphragm or major mediastinal organs, or behind the scapula). Presented at the 7th Asian single port VATS symposium, Nagoya, Japan, 24-25 May 2019. Funding This study was financially supported by a grant [CMRPG3F1813] from the Chang Gung Memorial Hospital, Taiwan. Conflict of interest: none declared. REFERENCES 1 Lin M-W , Tseng Y-H , Lee Y-F , Hsieh M-S , Ko W-C , Chen J-Y et al. . Computed tomography-guided patent blue vital dye localization of pulmonary nodules in uniportal thoracoscopy . J Thorac Cardiovasc Surg 2016 ; 152 : 535 – 44.e2 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Abbas A , Kadakia S , Ambur V , Muro K , Kaiser L. Intraoperative electromagnetic navigational bronchoscopic localization of small, deep, or subsolid pulmonary nodules . J Thorac Cardiovasc Surg 2017 ; 153 : 1581 – 90 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Thistlethwaite PA , Gower JR , Hernandez M , Zhang Y , Picel AC , Roberts AC. Needle localization of small pulmonary nodules: lessons learned . J Thorac Cardiovasc Surg 2018 ; 155 : 2140 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Chen A , Pastis N , Furukawa B , Silvestri GA. The effect of respiratory motion on pulmonary nodule location during electromagnetic navigation bronchoscopy . Chest 2015 ; 147 : 1275 – 81 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

European Journal of Cardio-Thoracic Surgery – Oxford University Press

Published: Jun 20, 2007

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