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A7301 - Developing and Troubleshooting a Protocol for Peri-Operative Localization of Difficult to Visualize/Palpate Nodules During Minimally Invasive Thoracic Surgery
Author Block: D. Chambers1, C. Colosimo2, A. R. Belanger1, A. C. Burks1, J. Long3, B. Haithcock3, R. Petrov4, L. Dunham2, J. Akulian1; 1Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, United States, 2Kaiser Permanente Skyridge Colorado, Skyridge, CO, United States, 3Thoracic Surgery, University of North Carolina, Chapel Hill, NC, United States, 4Fox Chase Cancer Center, Philadelphia, PA, United States.
RATIONALE: Minimally invasive thoracic surgery (MITS) has become the standard of care in lung resection. Lack of tactile feedback during MITS can prove to be a challenge for the thoracic surgeon when attempting to resect ground glass, deep and/or small pulmonary nodules. This challenge has led to reported rates of failure to visualize or palpate nodules as high as 54%. Due to this, nodule localization for MITS has become increasingly commonplace. Previous techniques have included radiology-guided hookwire insertion, dye marking and fiducial placement, which lead to delays in surgery and complications including parenchymal laceration and fiducial embolization. Here we present the development of a multidisciplinary peri-operative electromagnetic transthoracic nodule localization protocol (EMTTNL).
METHODS: From September 2016 to August 2017, patients at the University of North Carolina Chapel Hill evaluated by thoracic surgery and anticipated to have lesions difficult to locate by visual evaluation during MITS were referred to the interventional pulmonary service for peri-operative lung nodule marking. Preoperative CT scans were obtained per standardized protocol. After induction of anesthesia and positioning, bronchoscopic landmark registration was performed. EMTTNL was then used to dye localize the target lesion. Dye was injected into the lesion and tracked to the visceral pleural surface.
RESULTS: Forty patients underwent peri-operative lesion marking. Initially, the technique was limited by the time associated with transition from the supine position used for the CT scan to the lateral decubitus position used for MITS. In addition, posterior lesions were not readily approachable in the supine position. Performing the CT scan in lateral decubitus position used in surgery resolved this issue. Patient-image registration through a double-lumen endotracheal tube created significant registration error when data points were collected through both lumens. Using only the right-sided lumen for registration of the trachea and right lung then the left-sided lumen for registration of only the left lung resulted in more accurate registration. The next challenge encountered was diffusion of methylene blue between localization and MITS, which limited the efficacy of the EMTTNL procedure. Using a 1:1 mixture of methylene blue and the patient’s blood prevented diffusion and greatly improved nodule localization.
CONCLUSION: EMTTNL for peri-operative nodule localization successfully facilitates MITS in patients with difficult to locate lung nodules. Results may be improved by performing the registration CT scan in the same position used for surgery, using a 1:1 mixture of blood and methylene blue and using only one endotracheal lumen for tracheal registration.