Ann Thorac Surg 2005;79:316-317
© 2005 The Society of Thoracic Surgeons
New technology
INVITED COMMENTARY
Jeffrey M. Piehler, MD
Division of Cardiothoracic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
jpiehler{at}kumc.edu
This manuscript by Eichfeld and colleagues describes a relatively small and generally positive experience with preoperative localization of pulmonary nodules prior to attempted video thoracoscopic (VAT) removal. The premise behind the method is well established, namely that nodules that are small or deeply situated in the lung can be difficult to localize at VAT, and that localization can be facilitated by some method of preoperative marking.
As mentioned by the authors, a wide variety of techniques, usually involving CT scanning and some form of identifiable lung puncture at the site of the nodule, has been advocated by others including the use of methylene blue, radiolabeling, microcoil injection, and wire implantation. Perhaps not surprisingly, there does appear to be wide surgeon variability in the perceived need for these localization procedures, no doubt reflecting differing aggressiveness both in the use of VAT and in the selection of nodules for resection. Nevertheless, this experience is distinguished by the use of a laser marking system integrated with the CT scanner which, in the authors' hands, facilitates the localization procedure and the use of a spiral wire, as opposed to the more commonly used hook wire, for identification.
The described laser marking system appears to permit expeditious successful marking of the nodules, but only to a degree comparable to other widely utilized systems and techniques. On the other hand, the spiral wire does appear to have both theoretical and demonstrated benefits over the hook configuration with a lower incidence of dislodgement and offering the ability to elevate the nodule from the collapsed lung for facilitated excision with the linear stapler. Of course, the well-described complications of any lung puncture remain, including pneumothorax, hemorrhage, gas embolization, and potential tumor spread.
Although not addressed by the authors, the availability of facilitated removal of small lung nodules should not open the thoracoscopic procedural floodgates and obviate the unique role of the thoracic surgeon in deciding which lung nodules can be dismissed from concern, which require careful radiographic surveillance, which are best managed with percutaneous biopsy, which should be excised but with an open technique, and, yes, which are appropriately resected by VAT, perhaps with localization if needed. Not all lung nodules require initial excision, particularly in this era of screening CT scans that identify micronodules with distressing frequency, many of which are clearly benign with carefully planned ongoing evaluation. The authors describe a technique that appears to have some merit, but the need for our critical evaluation of each individual patient remains.
