Hsin-Yueh Fang

A Comparison of Efficacy and Safety of Preoperative versus Intraoperative Computed Tomography-Guided Thoracoscopic Lung Resection

Background The efficacy and safety of intraoperative computed tomography (IOCT)‐guided lung tumor localization and resection performed in a hybrid operating room (OR) compared with the conventional 2‐stage preoperative CT (POCT)‐guided approach for the treatment of small and deep solitary pulmonary nodules (SPNs) remains unknown. Methods We compared IOCT‐guided (IOCT group) and POCT‐guided (POCT group) thoracoscopic resections in 64 consecutive patients with SPNs. The main outcome measures included efficacy, safety, and radiation exposure. Results The IOCT (n = 34) and POCT (n = 30) groups had a similar SPN depth‐to‐size ratio. All SPNs were successfully localized and removed using a minimally invasive approach. There were no significant intergroup differences in localization procedural time (mean, 17.68 [IOCT] vs 19.63 minutes [POCT]; P = .257) and radiation exposure (median, 3.65 [IOCT] vs 6.88 mSv [POCT]; P = .506). The use of a hybrid operating room (OR) for tumor localization significantly reduced the patient time at risk (ie, the interval from completion of localization to skin incision; mean, 215.83 [POCT] vs 13.06 minutes [IOCT]; P < .001). However, the IOCT‐guided approach significantly increased the time under general anesthesia (mean, 120.61 [POCT] vs 163.1 minutes [IOCT]; P < .001) and the total OR utilization time (mean, 168.68 [POCT] vs 227.41 minutes [IOCT]; P < .001). Conclusions Compared with the POCT‐guided approach, the IOCT‐guided approach decreased the time at risk, despite a significant increase in the global OR utilization time. Because no significant outcome differences were evident, the choice between the 2 approaches should be based on the most readily available approach at a surgeons specific facility.

Learning curve of image-guided video-assisted thoracoscopic surgery for small pulmonary nodules: A prospective analysis of 30 initial patients

Objectives: The use of image‐guided video‐assisted thoracoscopic surgery for simultaneous localization and removal of small solitary pulmonary nodules in a hybrid operation room using C‐arm cone‐beam computed tomography is gaining momentum. We sought to assess the effect of the learning curve on procedural parameters and clinical outcomes of image‐guided video‐assisted thoracoscopic surgery for treating patients with small solitary pulmonary nodules. Methods: Clinical variables and treatment outcomes of the 30 initial patients with solitary pulmonary nodules who were treated with image‐guided video‐assisted thoracoscopic surgery at Chang Gung Memorial Hospital (Taiwan) were prospectively analyzed. Two sequential groups (groups I and II, n = 15 each) were compared with regard to localization time, radiation doses, and success rates. We used the Pearsons correlation coefficient to investigate the association between the surgical experience and the procedural time. Results: In the entire cohort, the median size of solitary pulmonary nodules on preoperative computed tomography images was 6 mm (interquartile range, 4.5‐9 mm), and their median distance from the pleural surface was 10 mm (interquartile range, 5‐15 mm). The median tumor depth‐to‐size ratio was 1.4 (interquartile range, 0.7‐2.5). The clinical parameters were similar between the 2 groups. There was an inverse association between the surgical experience and the procedural time (Pearsons r = −0.6873; P < .001). A significant reduction in localization time (median, 24 vs 49 minutes, respectively; P < .001) and radiation exposure (median, 70.7 vs 224 mGy, respectively; P < .001) was noted in group II (late patients) compared with group I (early patients). Notably, the success rates in groups II and I were similar (93.3% vs 86.7%, respectively; P =. 876). Conclusions: Our data demonstrate a significant learning curve for image‐guided video‐assisted thoracoscopic surgery in the treatment of solitary pulmonary nodules as evidenced by decreased localization time and radiation exposure occurring with increased surgical experience.

Image-guided video-assisted thoracoscopic surgery for small ground glass opacities: a case series

Background This case series demonstrated the feasibility of the image-guided video-assisted thoracoscopic surgery (iVATS) for localization and removal of ground glass opacities (GGOs). The procedure was performed in a hybrid operating room (OR) using C-arm cone-beam computed tomography (CBCT) equipped with a laser-guided navigation system. Methods Between October 1st 2016 to July 31st 2017, 14 consecutive patients presenting with GGOs underwent iVATS procedure. The efficacy and safety of the procedure were assessed through a retrospective chart review. Results The median GGOs size was 7 mm [interquartile range (IQR): 4-10 mm] with a median depth-to-size (D-S) ratio of 1.16 (IQR: 0-2.3). All of the lesions were visible on intraoperative CBCT images and localizations were successful in all patients with a median localization time of 22 min (IQR: 16-44 min). No patient required a conversion to thoracotomy. There was no operative mortality and the median length of postoperative stay was 4 days (IQR: 3-6 days). The final pathological diagnoses were as follows: primary lung cancer (n=6), lung metastases (n=2), and benign lung lesions (n=6). Conclusions Our study suggests the iVATS could be a helpful tool for single-stage detection and removal of GGOs.

Imaging-guided thoracoscopic resection of a ground-glass opacity lesion in a hybrid operating room equipped with a robotic C-arm CT system

The intraoperative identification of small pulmonary nodules through video-assisted thoracoscopic surgery remains challenging. Although preoperative CT-guided nodule localization is commonly used to detect tumors during video-assisted thoracoscopic surgery (VATS), this approach carries inherent risks. We report the case of a patient with stage I lung cancer presenting as an area of ground-glass opacity (GGO) in the right upper pulmonary lobe. He successfully underwent a single-stage, CT-guided localization and removal of the pulmonary nodule within a hybrid operating room (OR) equipped with a robotic C-arm.

A single-center experience of 100 image-guided video-assisted thoracoscopic surgery procedures

Background The advent of image-guided video-assisted thoracoscopic surgery (iVATS) has allowed the simultaneous localization and removal of small lung nodules. The aim of this study is to detail, in a retrospective review, one institutions experience using iVATS in this clinical setting, with a special attention to efficacy, safety, and procedural details. Methods This study was a retrospective analysis of prospectively collected data. Between October 2016 and January 2018, a total of 95 patients with 100 small lung nodules underwent iVATS. All procedures were performed in a hybrid operating room (HOR) in which a cone-beam computed tomography (CT) apparatus and a laser navigation system were present. Results The mean size of the 100 lung nodules was 7.94 mm, with their mean depth from the visceral pleura being 10 mm. A total of 98 nodules were successfully localized; of them, 94 were resected through a marker-guided procedure. There were four resection failures [wire dislodgement (n=2) or dye spillage (n=2)]). A significant inverse association was found between localization time (mean: 21.19 min) and the surgeons experience (Pearsons r=-0.632; P<0.001). The mean length of hospital stay was 4.87 days and there were no perioperative deaths. Conclusions In the current context of an increase in early diagnosis of lung cancer by screening programs, iVATS performed in a HOR offers a safe and efficient option for simultaneous localization and removal of small pulmonary nodules.

Intraoperative computed tomography-guided pulmonary tumour localization: a thoracic surgeon’s learning curve

OBJECTIVES With the increasing availability of hybrid operating rooms, single-stage tumour localization and removal under intraoperative computed tomography (CT) guidance is gaining popularity. The objective of this study was to describe the learning curve for this procedure. METHODS Over a 15-month period, a single team of thoracic surgeons without experience in intraoperative CT-guided lung tumour localization performed a total of 91 procedures in 89 patients. All these procedures were conducted in a hybrid operating room equipped with cone-beam CT and a laser navigation system. The learning curve was analysed using the cumulative sum method (target success rate 90%), whereas the moving average was used as an indicator of localization time. RESULTS The mean lung tumour size on preoperative CT images was 7.81 mm, whereas their mean distance from the pleural surface was 10.16 mm. The localization time (mean 21.19 min) was inversely associated with the surgeons experience (Pearsons r = -0.6601; P < 0.001). The moving average analysis revealed that localization time stabilized after 32 procedures. There were 6 failures; of these, 2 occurred during lesion localization (as a result of needle puncture-related pneumothorax) and 4 during surgery (caused either by wire dislodgement or dye spillage). The cumulative sum analysis revealed that proficiency was achieved after 38 procedures. The mean localization time and success rates before and after procedure 38 were 32.13 min vs 13.34 min (P < 0.001) and 86.8% vs 98.1% (P = 0.078), respectively. CONCLUSIONS The procedural time and success rates of intraoperative CT-guided lung tumour localization were optimized after 38 consecutive procedures.