Ann Thorac Surg 2001;72:296-297
© 2001 The Society of Thoracic Surgeons
How to do it
Bronchoscopic dye injection for localization of small pulmonary nodules in thoracoscopic surgery
Toshihiko Sakamoto, MDa,
Yoshiki Takada, MDa,
Masahiro Endoh, MDa,
Hidehito Matsuoka, MDa,
Noriaki Tsubota, MDa
a Department of General Thoracic Surgery and Radiology, Hyogo Medical Center for Adults, Akashi, Japan
Accepted for publication February 22, 2001.
Address reprint requests to Dr Tsubota, Department of General Thoracic Surgery, Hyogo Medical Center for Adults, 13-70 Kitaoujicho, Akashi, Hyogo, 673-0022 Japan
e-mail: ntsubo{at}sanynet.ne.jp
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Abstract
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A new method of marking small pulmonary nodules situated deep within the visceral pleura using a transbronchial approach has been developed. Once the tip of the sheath catheter has passed the tumor and reached the visceral pleura, as confirmed by computed tomography fluoroscopy, indigo carmine is injected through a bronchoscope into the lung parenchyma just beneath the visceral pleura. No complications related to the procedure were experienced. The dye-marking procedure enabled the nodules to be precisely located. This technique can provide appropriate guidance when used in conjunction with video-assisted thoracic operations.
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Introduction
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It is often difficult to find or feel small, soft tumors, such as those appearing as regions of ground-glass attenuation on computed tomography (CT) during video-assisted thoracic surgery (VATS). Percutaneous localization techniques have been commonly used to locate these lesions [1–3]. However, these techniques are limited in their available puncture sites and require both a CT scan and an operation room to be simultaneously available because of anticipated complications. We herein describe a new marking technique using a transbronchial approach that is less harmful and more reliable, and can be easily performed.
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Technique
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In patients in whom a lesion may be difficult to identify by visual inspection and manual palpation, preoperative marking is scheduled. After the subsegment containing the nodule is located using high-resolution CT (HRCT), a bronchoscope is introduced into the related subsegmental bronchus. A Teflon sheath catheter is then advanced through the bronchiole beyond the tumor to the visceral pleura using CT fluoroscopy guidance (Asteion Multi Slice, Toshiba Corporation, Tokyo, Japan). The metal tip of the catheter twinkles during CT fluoroscopy, enabling the tip of the catheter to be detected on the CT monitor. When the catheter approaches the visceral pleura, which can be clearly seen on the monitor, 0.5 mL of indigo carmine is injected. A subsequent CT image is obtained after the procedure to confirm the location of the injected site relative to the nodule (Fig 1). The injected site appears as an obscure mass.
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Fig 1. Computed tomographic fluoroscopic monitor showing the metal tip of the sheath catheter in the vicinity of the visceral pleura (arrowhead). Arrow indicates a bronchofiber.
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Bronchoscopic dye injections were performed in 6 patients. All patients had a lesion that appeared as an area of ground-glass attenuation on CT. The lesions were independent of the visceral pleura with no pleural indentations. The maximum diameter of the tumor ranged from 5 to 15 mm (mean 11 mm). All but 1 patient with a tumor of 5 mm in diameter had a preoperative diagnosis of bronchiolo-alveolar carcinoma by transbronchial brush cytology. Five patients were marked the day before the operation and 1 patient was marked 3 days before the operation. The average time needed to complete the procedure was 30 minutes. The dyed area of the visceral pleura was clearly identified in all patients (Fig 2). The average diameter of the dyed area was 20 mm. Five nodules located just under the markings were palpable as a slight change on solidity when examined through an access thoracotomy incision (6 to 10 cm in length).
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Fig 2. (A) Computed tomographic scan of the chest showing a nodule (arrow) with a diameter of 5 mm. (B) The dyed area of the visceral pleura is clearly visible through an access thoracotomy.
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All patents underwent lung resection using VATS. None of the procedures was converted to an open thoracotomy. Two patients underwent a wedge resection. Three patients underwent an extended segmentectomy [4]. The markings provided sufficient guidance for a safe tumor margin to be obtained. In 1 patient, a limited operation was converted to a lobectomy because the tumor was not palpable. Postoperatively, the tumor was found 2 cm centrally from the marking. The pathologic diagnosis in these 6 patients was bronchiolo-alveolar carcinoma without active fibrotic proliferation.
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Comment
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Small pulmonary nodules have been resected for therapeutic or diagnostic purposes using VATS. Computed tomography-guided percutaneous marking is most commonly used for potentially invisible and nonpalpable nodules located deep within the visceral pleura. However, this method is associated with a high incidence of pneumothorax and the dislodgement of the wire [3]. Therefore, patients must be transported to the operation room immediately after or on the same day of the procedure [1–3]. In addition, some sites are difficult to punctuate, especially at the back of the scapula and near the vertebra. In the method described here, pneumothorax is not a problem, and fewer restrictions with regard to location are encountered than with the percutaneous methods. Dye injections of methylene blue have been reported to diffuse rapidly [2]. Although a different dye was used in our series, no blurred spots were observed even 3 days after the injection. The dye was probably injected very close to the visceral pleura because transbronchial injections are less vulnerable to respiratory movement. Because the nodules are usually small, proper identification of the closest subsegmental bronchus to the nodule using HRCT and accurate localization of the dyed site relative to the nodule by subsequent HRCT are essential to the success of this technique.
In conclusion, we believe that this method of marking small pulmonary nodules using a transbronchial approach is safer, more reliable, and more convenient than other marking methods.
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References
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Wicky S., Mayor B., Cuttat J.F., Schnyder P. CT-guided localizations of pulmonary nodules with methylene blue injections for thoracoscopic resections. Chest 1994;106:1326-1328.[Abstract/Free Full Text]
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Tsubota N., Ayabe K., Doi O., et al. Ongoing prospective study of segmentectomy for small lung tumors. Ann Thorac Surg 1998;66:1787-1790.[Abstract/Free Full Text]
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Abstract
Introduction
