Localization Technique Using Mixture of Indigo Carmine and Lipiodol of Pulmonary Nodule via Bronchoscopic Navigation.

Background and Objectives: As the number of minimally invasive surgeries, including video-assisted thoracoscopic surgery, increases, small, deeply located lung nodules are difficult to visualize or palpate; therefore, localization is important. We studied the use of a mixture of indigo-carmine and lipiodol, coupled with a transbronchial approach-to achieve accurate localization and minimize patient discomfort and complications. Materials and Methods: A total of 60 patients were enrolled from May 2019 to April 2022, and surgery was performed after the bronchoscopy procedure. Wedge resection or segmentectomy was performed, depending on the location and size of the lesion. Results: In 58/60 (96.7%) patients, the localization of the nodules was successful after localization, and 2/60 required c-arm assistance. None of the patients complained of discomfort during the procedure; in all cases, margins were found to be free from carcinoma, as determined by the final pathology results. Conclusions: We recommend this localization technique using mixture of indigo carmine and lipiodol, in concert with the transbronchial approach, because the procedure time is short, patient's discomfort is low, and success rate is high.

Clinical significance of spread of lipiodol marking for pulmonary nodules and its influence on surgery.

OBJECTIVE: Computed tomography (CT)-guided lipiodol marking is one of the targeting methods for resecting small pulmonary nodules or ground-glass nodules in video-assisted thoracic surgery (VATS). However, lipiodol spreading during marking has not been assessed, practically. In this study, we examined the clinical significance and the influence of lipiodol spreading on surgery. METHODS: From April 2010 to March 2021, 176 pulmonary nodules in 167 patients were marked with lipiodol under CT guided before VATS. The marking images after lipiodol injection were classified into "Spread" and "non-Spread." Lung resection was sequentially performed on the same day. RESULTS: All target nodules were successfully resected in VATS. In the classification of marking images, Spread was 32 (18%), non-Spread was 144 (82%). There was a significant difference in duration of surgery (mean; 138.7 min vs. 118.3 min, p = 0.0496) and amount of bleeding (mean; 32.7 g vs. 11.2 g, p = 0.0173). Provided that limited to the data of wedge resections without intrathoracic pleural adhesion (n = 117), there was no significant difference in duration of surgery (mean; 104.8 min vs. 99.6 min, p = 0.48), amount of bleeding (mean; 4.9 g vs. 5.3 g, p = 0.58). In the multivariate logistic regression analysis, the risk factor of lipiodol spreading was intrathoracic pleural adhesion (odds ratio: 3.16, 95% confidence interval: 1.12-8.97, p = 0.03). There was no relationship between marking image and complication rate. CONCLUSIONS: Lipiodol spreading did not directly influence surgery and complication. However, it was a sign of intrathoracic pleural adhesion, which could lead to increased duration of surgery and amount of bleeding.

Expert consensus on thermal ablation therapy of pulmonary subsolid nodules (2021 Edition).

The Expert Consensus reviews current literatures and provides clinical practice guidelines for thermal ablation of pulmonary subsolid nodules or ground-glass nodule (GGN). The main contents include the following: (1) clinical evaluation of GGN; (2) procedures, indications, contraindications, outcomes evaluation, and related complications of thermal ablation for GGN; and (3) future development directions.

Cerebral arterial air embolism after computed tomography-guided hook-wire localization of a pulmonary nodule: A case report.

RATIONALE: Cranial arterial air embolism is a rare but potentially fatal complication after computed tomography (CT)-guided pulmonary interventions. PATIENT CONCERNS: A 64-year-old man was diagnosed with a pulmonary nodule (diameter: approximately 1 cm) in the right lower lobe. The patient developed convulsions after CT-guided hook-wire localization. DIAGNOSIS: Cranial CT revealed arborizing/linearly distributed gas in the territory of the right middle cerebral artery. INTERVENTIONS: The patient was administered hyperbaric oxygen, antiplatelet aggregation therapy, and dehydration treatment. OUTCOMES: Clinical death occurred 55 hours after air embolism. LESSONS: Systemic air embolism is a serious complication of lung puncture. Clinicians should improve their understanding of this complication and remain vigilant against air embolism.

The Utility of Indigo Carmine and Lipiodol Mixture for Preoperative Pulmonary Nodule Localization before Video-Assisted Thoracic Surgery.

PURPOSE: To evaluate the safety and efficacy of a mixture of indigo carmine and lipiodol (MIL) as a marker of pulmonary nodule before video-assisted thoracic surgery (VATS). MATERIALS AND METHODS: One hundred sixty-eight sessions of pulmonary marking were performed using MIL before VATS for 184 nodules (mean size, 1.2 ± 0.6 cm; range, 0.3-3.6 cm) on 157 patients (83 men and 74 women; median age, 66 years). The mean distance between the lung surface and the nodule was 0.8 ± 0.7 cm (range, 0-3.9 cm). MIL was injected near the nodule using a 23-gauge needle. Mean number of 1.2 ± 0.4 (range, 1-3) punctures were performed in a session for the target nodules, with mean number of 1.1 ± 0.3 (range, 1-3). Successful targeting, localization, and VATS were defined as achievement of lipiodol accumulation at the target site on computed tomography, detection of the nodule in the operative field by fluoroscopy or visualization of dye pigmentation, and complete resection of the target nodule with sufficient margin, respectively. RESULTS: The successful targeting rate was 100%, and the successful localization rate was 99.5%, with dye pigmentation for 160 nodules (87.0%) and intraoperative fluoroscopy for 23 nodules (12.5%). Successful VATS was achieved for 181 nodules (98.4%). Two nodules (1.1%) were not resectable, and surgical margin was positive in 1 nodule (0.5%). Complications requiring interventions occurred in 5 sessions (3.0%) and included pneumothorax with chest tube placement (n = 3) and aspiration (n = 2). No complication related to the injected MIL occurred. CONCLUSIONS: MIL was safe and useful for preoperative pulmonary nodule marking.

Marcación de nódulos pulmonares con lipiodol bajo tomografía computada: experiencia local y correlación anatomopatológica / Marking of pulmonary nodules with lipiodol by computerized tomography: local experience and anatomopathological correlation

El objetivo de este estudio es la descripción de la novedosa y poco invasiva técnica de marcación de pequeños nódulos pulmonares con lipiodol, guiado con TAC para su posterior resección por cirugía videotoracoscópica con apoyo radioscópico. Se trata de un estudio retrospectivo que incluye 51 pacientes consecutivos en un tiempo comprendido entre junio del 2012 a septiembre del 2017, obteniendo el diagnóstico final mediante la correlación anatomopatológica, representando los procesos malignos el 81% y los benignos el 19%. Mediante esta técnica se lograron identificar y extraer con éxito el 100% de los nódulos marcados, demostrándose la efectividad y seguridad del procedimiento por las mínimas complicaciones relacionadas.

The purpose of this study is describing a novel and minimally invasive technique of CT-guided marking of small pulmonary nodules with lipiodol prior to resection by videothoracoscopic surgery with radioscopic support. This is a retrospective study that includes 51 consecutive patients between June 2012 and September 2017, with the final diagnosis confirmed by pathology. Malignant nodules represented 81% of the cases with the remaining 19% being benign nodules. Through this technique, 100% of the marked nodules were successfully identified and extracted with few procedure related complications and no adverse clinical outcome, demonstrating the effectiveness and safety of the procedure.

[Management Strategies of Pulmonary Ground Galss Nodule].

Pulmonary ground glass nodule (GGN) is a term of radiological manifestation, which may be malignant or benign. The management for pulmonary GGN remains controversial. Both Fleischner society and National Comprehensive Cancer Network (NCCN) panel updated the guideline for the management of GGN in 2017. Compared with previous versions, the indication for surgery or biopsy is stricter, and the recommended follow-up interval is prolonged. In clinical practice, the size of GGN component, the size of consolidation component, dynamic change during follow-up and computed tomography (CT) value are the four factors that help surgeons to decide the timing of surgery. There are some misunderstandings for the management of GGN, such as the administration of antibiotics, the use of positron emission tomography-computed tomography (PET-CT), pure GGN adjacent to visceral pleura, and GGN with penetrating vessel. In conclusion, GGN is a kind of slowly growing lesion, which can be followed up safely.
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Comparative Effectiveness and Safety of Preoperative Lung Localization for Pulmonary Nodules: A Systematic Review and Meta-analysis.

BACKGROUND: An optimal method of preoperative localization for pulmonary nodules has yet to be established. This systematic review and meta-analysis aimed to compare the success and complication rates associated with three pulmonary nodule localization methods for video-assisted thoracoscopic surgery (VATS): hook-wire localization, microcoil localization, and lipiodol localization. METHODS: We searched the PubMed, MEDLINE, and EMBASE databases for prospective or retrospective English language studies of VATS localization in adult patients. A noncomparative, random effects model-based meta-analysis was performed to obtain pooled success and complication rates for the three localization methods. RESULTS: A total of 46 clinical studies were enrolled, including 30, 9, and 7 studies of hook-wire, microcoil, and lipiodol localization, respectively. The successful targeting rates for hook-wire, microcoil, and lipiodol localization were 0.98 (95% CI, 0.97-0.99), 0.98 (95% CI, 0.96-0.99), and 0.99 (95% CI, 0.98-1.00), respectively, with corresponding successful operative field targeting rates of 0.94 (95% CI, 0.91-0.96), 0.97 (95% CI, 0.95-0.98), and 0.99 (95% CI, 0.98-1.00), respectively. In addition, the successful VATS rates with hook-wire, microcoil, and lipiodol localization were 0.96 (95% CI, 0.94-0.97), 0.97 (95% CI, 0.94-0.99), and 0.99 (95% CI, 0.98-1.00), respectively. Regarding complications, hook-wire, microcoil, and lipiodol localization were associated with pneumothorax rates of 0.35 (95% CI, 0.28-0.43), 0.16 (95% CI, 0.07-0.34), and 0.31 (95% CI, 0.20-0.46), respectively and hemorrhage rates of 0.16 (95% CI, 0.11-0.23), 0.06 (95% CI, 0.03-0.11), and 0.12 (95% CI, 0.05-0.23), respectively. CONCLUSIONS: All three localization methods yielded similarly highly successful targeting rates. However, hook-wire localization had a relatively lower successful operative field targeting rate because of dislodgement or migration. Lipiodol localization had the highest overall success rate, and microcoil localization yielded the lowest complication rates.

Lipiodol lOcalization for Ground-glass opacity mInimal Surgery: Rationale and design of the LOGIS trial.

OBJECTIVES: The diagnosis and treatment of ground-glass opacity (GGO) lesions have become important issues because subsolid nodules including GGO are known to frequently represent the histologic spectrum of lung adenocarcinoma. Because small GGO lesions cannot usually be palpated or visualized during surgery, several marking techniques have been reported for localization during thoracoscopic surgery, such as lipiodol and hook-wire localization. This study is designed to demonstrate the usefulness and safety of the lipiodol localization technique for individuals undergoing GGO VATS resection compared to the hook-wire localization technique. METHODS: Two hundred fifty participants will be prospectively enrolled in a 1:1 manner to the lipiodol or hook-wire group according to the inclusion criteria. All study participants will undergo preoperative lung localization using either the lipiodol or hook-wire method. Thoracoscopic surgery will be performed by experienced thoracoscopic surgeons within several hours after marking under general anesthesia. The primary endpoint is the procedure success rate, and the secondary endpoints are the procedure complication rate, procedure time, surgery time and the margin from the lesion in the resected specimen. RESULTS: Patient enrollment will be completed within 2years. We will analyze the procedure success rate and the presence of complications with regard to the CT results. In addition, the procedure and surgery times, and the safety margin will be also compared between the 2 techniques. CONCLUSION: If the aims of this study are achieved, then the use of lipiodol localization technique will be widespread in the localization of non-palpable pulmonary lesions that are indicated for surgical resection. (ClinicalTrials.gov: NCT02180568).

Computed tomography guided percutaneous injection of a mixture of lipiodol and methylene blue in rabbit lungs: evaluation of localization ability for video-assisted thoracoscopic surgery.

Preoperative localization is necessary prior to video assisted thoracoscopic surgery for the detection of small or deeply located lung nodules. We compared the localization ability of a mixture of lipiodol and methylene blue (MLM) (0.6 mL, 1:5) to methylene blue (0.5 mL) in rabbit lungs. CT-guided percutaneous injections were performed in 21 subjects with MLM and methylene blue. We measured the extent of staining on freshly excised lung and evaluated the subjective localization ability with 4 point scales at 6 and 24 hr after injections. For MLM, radio-opacity was evaluated on the fluoroscopy. We considered score 2 (acceptable) or 3 (excellent) as appropriate for localization. The staining extent of MLM was significantly smaller than methylene blue (0.6 vs 1.0 cm, P<0.001). MLM showed superior staining ability over methylene blue (2.8 vs 2.2, P=0.010). Excellent staining was achieved in 17 subjects (81%) with MLM and 8 (38%) with methylene blue (P=0.011). An acceptable or excellent radio-opacity of MLM was found in 13 subjects (62%). An appropriate localization rate of MLM was 100% with the use of the directly visible ability and radio-opacity of MLM. MLM provides a superior pulmonary localization ability over methylene blue.

Computed Tomography Guided Percutaneous Injection of a Mixture of Lipiodol and Methylene Blue in Rabbit Lungs: Evaluation of Localization Ability for Video-Assisted Thoracoscopic Surgery

Preoperative localization is necessary prior to video assisted thoracoscopic surgery for the detection of small or deeply located lung nodules. We compared the localization ability of a mixture of lipiodol and methylene blue (MLM) (0.6 mL, 1:5) to methylene blue (0.5 mL) in rabbit lungs. CT-guided percutaneous injections were performed in 21 subjects with MLM and methylene blue. We measured the extent of staining on freshly excised lung and evaluated the subjective localization ability with 4 point scales at 6 and 24 hr after injections. For MLM, radio-opacity was evaluated on the fluoroscopy. We considered score 2 (acceptable) or 3 (excellent) as appropriate for localization. The staining extent of MLM was significantly smaller than methylene blue (0.6 vs 1.0 cm, P<0.001). MLM showed superior staining ability over methylene blue (2.8 vs 2.2, P=0.010). Excellent staining was achieved in 17 subjects (81%) with MLM and 8 (38%) with methylene blue (P=0.011). An acceptable or excellent radio-opacity of MLM was found in 13 subjects (62%). An appropriate localization rate of MLM was 100% with the use of the directly visible ability and radio-opacity of MLM. MLM provides a superior pulmonary localization ability over methylene blue.

Laser application enables awake thoracoscopic resection of pulmonary nodules with minimal access.

BACKGROUND: Thoracoscopic resection of indeterminate pulmonary nodules is most commonly performed through three trocars using an endoscopic stapler. We assessed the safety, feasibility, and results of laser resection via minimal access under only local anesthesia. METHODS: Between September 2009 and June 2010, excision of subpleural nodules using laser application under only local anesthesia was performed in 28 patients (Laser group). A 2-mm trocar (minigrasper) and an 11-mm trocar (operating scope) were used. Anesthesia time, surgery time, global operating room time, chest tube time, piritramid dose, and hospital stay were assessed and compared with data from a patient group (n = 28) that required nodule resection through three trocars using an endoscopic stapler under general anesthesia (Control group). RESULTS: There was no mortality or major morbidity. There was no difference in technical feasibility between the groups. Two patients in the Laser group and one patient in the Control group required conversion to thoracotomy due to severe adhesions. The mean nodule size was 0.9 ± 0.2 cm in the Laser group and 1.0 ± 0.3 cm in the Control group (P = 0.05). Comparisons of Laser group results with Control group results showed that in the Laser group, anesthesia time (3 ± 0.7 vs. 42 ± 6.3 min, P < 0.001), global operating room time (51 ± 4.8 vs. 88 ± 10.8 min, P < 0.001), piritramid dose (65.9 ± 30.5 vs. 109.1 ± 21.9 mg, P < 0.001), and hospital stay (2.3 ± 0.9 vs. 3.2 ± 0.6 days, P < 0.001) were significantly reduced. Patients' satisfaction was high. Ninety-eight percent of patients said they would undergo this surgery again. CONCLUSION: Awake thoracoscopic laser resection of subpleural pulmonary nodules proved safe and feasible. This technique may enable further reduction of invasiveness, length of hospital stay, and costs in selected patients.

Experience of fluoroscopy-aided thoracoscopic resection of pulmonary nodule localised with Lipiodol in a child.

We report the case of a 12-year-old boy with a huge liver tumour 20 cm in diameter with multiple lung metastases. Six months after systemic chemotherapy was initiated, all tumours had disappeared with the exception of the liver tumour and a tiny lung tumour 2.5 mm in diameter. Fluoroscopy-assisted thoracoscopic resection of the pulmonary nodule was performed to evaluate whether viable tumour tissue remained in the lung lesion. Before moving the patient to the operating room, the nodule was marked by Lipiodol under CT fluoroscopic guidance with the patient under local anaesthesia. This procedure allowed correct visualisation of the area that should be resected.

Localization of pulmonary nodules with lipiodol prior to thoracoscopic surgery.

BACKGROUND: Preoperative localization with lipiodol for identifying small or deeply seated pulmonary nodules is simple and useful for thoracoscopic surgery. Although several studies about performance and complication rates of lipiodol localization have been reported, there has been no report about the performance and complication rates of lipiodol localization with regard to the CT appearance of pulmonary nodules. PURPOSE: To evaluate the performance and complication rates of localization of pulmonary nodules with lipiodol prior to video-assisted thoracoscopic surgery with regard to the CT appearance of nodules. MATERIAL AND METHODS: After institutional review board approval and informed consent were obtained, lipiodol marking was performed in 67 patients (33 men and 34 women; mean age 58 years) with 68 nodules. All nodules were marked with 0.4-0.5 mL lipiodol under CT guidance on the day of surgery. The size of the targeted nodule and the shortest distance to the accessible pleural surface were measured. Lipiodol accumulation of a targeted nodule was scored by use of a four-point scale (0: none, 1: within 1 cm around a nodule, 2: partial accumulation within a nodule, 3: total accumulation within a nodule). Any complications after localization of nodules were noted. We analyzed the score of lipiodol accumulation and the presence of complications for the CT appearance of pulmonary nodules using the Mann Whitney U test, Fisher's exact test and the Kruskall Walis test. RESULTS: The average nodule size was 11.4 mm (range 3.0-28.3 mm) and the average distance to the pleural surface was 13.7 mm (range 0-51.4 mm). Lipiodol accumulation scores of nodules were as follows: score 3 (n=19, 28%), score 2 (n=37, 54%), score 1 (n=11, 16%), and score 0 (n=1, 2%). Lipiodol accumulation scores of nodules were different according to the size of nodules (Kruskal Wallis test, p=0.023). Pneumothorax after localization occurred in 20 (29%) patients and the incidence was higher in nodules located in the subpleural area (Mann Whitney U test, p=0.048). Pulmonary hemorrhage along the needle tract occurred in five (7%) patients and was more frequent in patients with deep nodules as compared to shallow nodules (Mann Whitney U test, p < 0.001). CONCLUSION: Lipiodol marking under CT guidance is a useful and safe procedure for the intraoperative localization of pulmonary nodules. Of variable CT findings, lesion size is important to determine the degree of lipiodol accumulation and the lesion depth is the most important feature for the development of postprocedural complications.

Needlescopy-assisted resection of pulmonary nodule after dual localisation.

The aim of this study was to evaluate the feasibility of dual localisation with hookwire and lipiodol before needlescopy-assisted resection for pulmonary nodule. Computed tomography-guided dual marking was performed on 36 pulmonary nodules of 32 patients and needlescopy-assisted resection was performed monitored by C-arm fluoroscopy. The mean age of the patients was 58 ± 12 (range 12-77) yrs. The mean size of the nodules was 7.5 ± 3.7 (3-17) mm. Their mean distance from the pleural surface was 7.3 ± 7.5 (0-35) mm. There were nine pure ground-glass opacity lesions, five semi-solid lesions and 22 solid lesions. The time of the dual localisation procedure was 13.1 ± 4.8 (7-23) min. Complications of the marking were pneumothorax in nine patients, and intrapulmonary bleeding in three. One hookwire dislodged during the operation. All nodules were successfully resected under needlescopy without conversion to a conventional thoracoscopy (5 mm or 10 mm thoracoscopy) or a minithoracotomy. There was no complication related to needlescopy-assisted resection. Dual marking with hookwire and lipiodol is a safe and none time consuming procedure, and needlescopy-assisted lung resection for small nodules is technically feasible and useful for histological diagnosis and treatment.

Marking of small pulmonary nodules before thoracoscopic resection: injection of lipiodol under CT-fluoroscopic guidance.

RATIONALE AND OBJECTIVES: The aim of the present study was to examine the usefulness and record the complications of preoperative lipiodol marking using computed tomographic (CT) fluoroscopy for the intraoperative localization of 107 pulmonary nodules. METHODS: Lipiodol marking was performed under CT fluoroscopic guidance in 65 patients with 107 nodules. Of these, 65 (60.7%) were nodules with ground-glass opacity, and 42 were solid nodules on CT images. All nodules were marked with 0.3 to 0.5 mL lipiodol under CT fluoroscopic guidance 1 or 3 days before or on the day of surgery. At surgery, marked nodules were grasped with ring-shaped forceps under a C-arm fluoroscope and resected. Postoperatively, all 55 patients with malignant tumors (n = 78) were followed by computed tomography at 3-month intervals to detect needle tract or pleural recurrence. RESULTS: All 107 nodules were marked with lipiodol; under the C-arm fluoroscope, they appeared as radiopaque spots. On postprocedural computed tomography, pneumothorax occurred in 20 patients (31%); its incidence was higher in patients with lung emphysema surrounding the nodules (P = .09), three of whom required tube drainage. Computed tomography detected pulmonary hemorrhage in 10 patients (15%); it was more frequent in patients with deep than shallow nodules (>or=6 cm from the pleural surface and <6 cm from the pleural surface, respectively; P = .04). No patients presented with recurrence in needle tracts or on the pleural surface during a median postoperative follow-up of 14 months. CONCLUSION: Lipiodol marking under CT fluoroscopic guidance is a useful and safe procedure for the intraoperative localization of ground-glass opaque and/or small, deep, solid nodules.

Impalpable pulmonary nodules with ground-glass opacity: Success for making pathologic sections with preoperative marking by lipiodol.

BACKGROUND: The developments in high-resolution CT scanning have increased the chance of detecting small bronchioloalveolar carcinoma (BAC) or atypical adenomatous hyperplasia (AAH) that appears as a ground-glass opacity (GGO). However, these lesions are not only difficult to localize during surgery, but they are also hard to make pathologic sections of because they are usually impalpable. Here, we report a method of making pathologic sections for impalpable GGO lesions. METHODS: Twenty-nine impalpable GGO lesions < 1 cm in size were marked by 0.4 to 0.5 mL of lipiodol under CT scan before surgery. The lesions were resected under C-arm fluoroscopy. The radiopaque areas marked by lipiodol within the formalin-fixed specimens were cut serially under conventional fluoroscopy for pathologic examinations. RESULTS: The mean (+/- SD) size of the lesions was 0.5 +/- 0.2 cm (range, 0.2 to 1 cm), and the mean depth from the pleural surface was 1.6 +/- 1.4 cm (range, 0.2 to 6 cm). The mean number of sections submitted for pathologic examinations was 2.3 +/- 1.7 per lesion (range, 1 to 7 per lesion). While 11 of the 29 lesions (38%) were invisible even on the cut surface of the specimens, all were demonstrated in hematoxylin-eosin sections. The pathologic diagnosis was BAC in 17 lesions, AAH in 10 lesions, and organized pneumonia in 2 lesions. The use of lipiodol did not affect the pathologic findings. CONCLUSIONS: The use of fluoroscopy to cut sections from resected specimens after preoperative marking with lipiodol was useful for making pathologic sections of impalpable GGOs < 1 cm in size.

Usefulness and complications of computed tomography-guided lipiodol marking for fluoroscopy-assisted thoracoscopic resection of small pulmonary nodules: experience with 174 nodules.

OBJECTIVE: Several techniques have been reported for the localization of small pulmonary nodules in thoracoscopic resection. In the present study we examined the usefulness and complications of computed tomography-guided lipiodol marking for thoracoscopic resection in our experience of 174 nodules. METHODS: Computed tomography-guided lipiodol marking was performed on 174 nodules less than 30 mm in size. Of these nodules, 45 showed ground-glass opacity images and 129 showed solid images on computed tomography. The mean size of the nodules was 10 +/- 6 mm (range, 2-30 mm), and their mean depth from the pleural surface was 10 +/- 7 mm (range, 0-30 mm). One to 7 days before thoracoscopy, all of the nodules were marked with 0.4 to 0.5 mL of lipiodol by using computed tomography. The marked nodules were grasped with a ring-shaped forceps during fluoroscopy and resected by means of thoracoscopy. RESULTS: All the nodules could be marked and localized by means of fluoroscopy as a clear spot during thoracoscopic surgery. Complications of the marking were chest pain requiring analgesia in 16 (11%) patients, hemosputum in 11 (6%) patients, pneumothorax in 30 (17%) patients, and hemopneumothorax in 1 (0.6%) patient. Eleven (6%) patients with pneumothorax required drainage, and the patient with hemopneumothorax required an emergency operation. No other complications were observed. CONCLUSION: Lipiodol marking is a useful, safe, and inexpensive procedure for localizing ground-glass opacity lesions, small pulmonary nodules, or both for thoracoscopic resection.

Fluoroscopy-assisted thoracoscopic resection of lung nodules marked with lipiodol.

BACKGROUND: To localize small and deeply situated pulmonary nodules under thoracoscopy with roentgenographic fluoroscopy, we developed a marking procedure that uses both lipiodol and colored collagen. METHODS: Pulmonary nodules were marked with 0.4 mL of lipiodol under computed tomography. The visceral pleura near each nodule was marked with 1 mL of colored collagen, ie, a mixture of atelocollagen and methylene blue. Nodules were marked more than 1 day before thoracoscopy. At thoracoscopy, C-arm-shaped roentgenographic fluoroscopy was used to detect the radiopaque nodules. Eighteen nodules in 16 patients were localized by this procedure. The nodules had an average diameter of 7 mm (range: 4 to 10 mm) and were located an average distance of 19 mm (range: 8 to 30 mm) from the pleural surface under computed tomographic measurement. RESULTS: There were no complications from the marking procedure except for pneumothorax in 1 patient who required chest tube drainage for additional marking. All 18 nodules could be easily localized at thoracoscopy. The colored collagen revealed the pleura near the nodules. The lipiodol showed the nodules on the fluoroscopic monitor, which was used to guide the forceps to grasp the nodules. All of the nodules could be resected completely under thoracoscopy without adding minithoracotomy. The pathologic diagnosis was malignant tumor in 9 patients, atypical adenomatous hyperplasia in 3, and benign lesion in 4. CONCLUSIONS: A marking procedure that uses both lipiodol and colored collagen can localize small and deeply situated pulmonary nodules under fluoroscopy and facilitate safe and successful thoracoscopic resection.