2024 multidisciplinary consensus on image-guided lung tumor ablation from the Taiwan Academy of Tumor Ablation.

In this article, the multidisciplinary team of the Taiwan Academy of Tumor Ablation, who have expertise in treating lung cancer, present their perspectives on percutaneous image-guided thermal ablation (IGTA) of lung tumors. The modified Delphi technique was applied to reach a consensus on clinical practice guidelines concerning ablation procedures, including a comprehensive literature review, selection of panelists, creation of a rating form and survey, and arrangement of an in-person meeting where panelists agreed or disagreed on various points. The conclusion was a final rating and written summary of the agreement. The multidisciplinary expert team agreed on 10 recommendations for the use of IGTA in the lungs. These recommendations include terms and definitions, line of treatment planning, modality, facility rooms, patient anesthesia settings, indications, margin determination, post-ablation image surveillance, qualified centers, and complication ranges. In summary, IGTA is a safe and feasible approach for treating primary and metastatic lung tumors, with a relatively low complication rate. However, decisions regarding the ablation technique should consider each patient's specific tumor characteristics.

The impact of surgical learning curve on short-term outcomes after bilateral lung transplantation: results from a multidisciplinary surgical team.

OBJECTIVES: The aim of this study was to examine the impact of surgical learning curve on short-term clinical outcomes of patients after bilateral lung transplantation (LTx) performed by a surgical multidisciplinary team (MDT). METHODS: Forty-two patients underwent double LTx from December 2016 to October 2021. All procedures were performed by a surgical MDT in a newly established LTx program. The time required for bronchial, left atrial cuff and pulmonary artery anastomoses was the main end point to assess surgical proficiency. The associations between the surgeon's experience and procedural duration were examined by linear regression analysis. We employed the simple moving average technique to generate learning curves and evaluated short-term outcomes before and after achieving surgical proficiency. RESULTS: Both total operating time and total anastomosis time were inversely associated with the surgeon's experience. On analysing the learning curve for bronchial, left atrial cuff and pulmonary artery anastomoses using moving averages, the inflection points occurred at 20, 15 and 10 cases, respectively. To assess the learning curve effect, the study cohort was divided into early (cases 1-20) and late (cases 21-42) groups. Short-term outcomes-including intensive care unit stay, in-hospital stay and severe complications-were significantly more favourable in the late group. Furthermore, there was a notable tendency for patients in the late group to experience a decreased duration of mechanical ventilation along with reduced instances of grade 3 primary graft dysfunction. CONCLUSIONS: A surgical MDT can perform double LTx safely after 20 procedures.

Bronchoscopy Findings during Percutaneous Dilation Tracheostomy: A Single Tertiary Medical Center Experience.

Percutaneous dilation tracheostomy (PDT) is a common procedure in intensive care units. Bronchoscopy has been recommended to guide PDT to decrease complication rates, but no study has analyzed bronchoscopy outcomes during PDT. In this retrospective study, we analyzed bronchoscopy findings and clinical outcomes during PDT. We collected data on all patients who underwent PDT between May 2018 and February 2021. All PDT operations were guided by bronchoscopy, and we assessed the airway to the third order of the bronchi. Forty-one patients who underwent PDT were included in this study. The average duration of PDT was 102.8 ± 34.6 s, and the average duration of bronchoscopy was 49.8 ± 43.8 s. No complications related to bronchoscopy and no significant changes in gas exchange or ventilator parameters were noted after the procedure. Fifteen patients (36.6%) exhibited abnormal bronchoscopy findings, including two patients (13.3%) with intra-airway mass lesions and obvious airway obstruction. None of the patients with intra-airway masses could be liberated from mechanical ventilation. This study observed a non-negligibly high incidence of unexpected endotracheal or endobronchial masses in patients with chronic respiratory failure during PDT, and a high rate of weaning failure was noted in these patients. The completion of bronchoscopy during PDT may provide additional clinical benefits.

Esophageal stenting with minimally-invasive surgical intervention for delayed spontaneous esophageal perforation.

Background: Spontaneous esophageal perforation is a challenging surgical emergency with significant morbidity and mortality, and timely primary repair carries good outcomes. However, direct repair for a delayed spontaneous esophageal perforation is not always feasible and is associated with high mortality. Esophageal stenting can provide therapeutic benefits in the management of esophageal perforations. In this study, we review our experience with placing esophageal stents in combination with minimally-invasive surgical drainage to treat delayed spontaneous esophageal perforations. Methods: We retrospectively analyzed patients with delayed spontaneous esophageal perforations between September 2018 and March 2021. All patients were treated using a hybrid approach, including esophageal stenting across the gastroesophageal junction (GEJ) to reduce continued contamination, gastric decompression with extraluminal sutures to prevent stent migration, early enteral nutrition, and aggressive minimally-invasive thoracoscopic debridement and drainage of infected material. Results: There were 5 patients with delayed spontaneous esophageal perforation treated with this hybrid approach. The mean duration between symptoms and diagnosis was 5 days, and the interval between symptoms and esophageal stent insertion was 7 days. The median time to oral nutrition and to esophageal stent removal was 43 and 66 days. There was no stent migration or hospital mortality. Three patients (60%) had postoperative complications. All patients were successfully resumed on oral nutrition with esophageal preservation. Conclusions: A hybrid approach combining endoscopic esophageal stent placement with extraluminal sutures to prevent stent migration, thoracoscopic decortication with chest tube drainage, gastric decompression, and jejunostomy tube placement for early nutrition was feasible and effective in the treatment of delayed spontaneous esophageal perforations. This technique offers a less invasive treatment approach for a challenging clinical problem which has traditionally carried a high rate of morbidity and mortality.

Safety and Efficacy of Cone-Beam Computed Tomography-Guided Lung Tumor Localization with a Near-Infrared Marker: A Retrospective Study of 175 Patients.

Preoperative localization holds promise for overcoming the limitations of video-assisted thoracoscopic surgery (VATS) in the treatment of impalpable lung nodules. The purpose of this study was to assess the safety and efficacy of cone-beam computed tomography (CBCT)-guided localization using near-infrared (NIR) marking. Between 2017 and 2021, patients presenting with a solitary pulmonary nodule (SPN) who had undergone CBCT-guided lesion localization with indocyanine green (ICG) in a hybrid operating room were included. The primary outcomes were the efficacy of localization and the occurrence of complications. The study cohort consisted of 175 patients with the mean age of 58.76 years. The mean size and depth of the 175 SPNs were 8.34 mm and 5.3 mm, respectively. The mean time required for lesion marking was 14.71 min. Upon thoracoscopic inspection, the NIR tattoo was detected in the vast majority of the study participants (98.3%). An utility thoracotomy to allow digital palpation was required in two of the three patients in whom the tattoo was not identifiable. The perioperative survival rate was 100%, and the mean length of hospital stay was 3.09 days. We conclude that needle localization with ICG injection is a safe and feasible technique to localize SPNs prior to resection.

Ultrasound-Guided Pleural Effusion Drainage: Effect on Oxygenation, Respiratory Mechanics, and Liberation from Mechanical Ventilation in Surgical Intensive Care Unit Patients.

The question as to whether an aggressive management of post-operative pleural effusion may improve clinical outcomes after major surgery remains unanswered. The aim of this study was to investigate the effect of ultrasound-guided pleural effusion drainage on oxygenation, respiratory mechanics, and liberation from mechanical ventilation in surgical intensive care unit patients. Oxygenation and respiratory mechanics were measured before and after drainage. Over an 18-month period, a total of 62 patients were analyzed. The mean drainage volume during the first 24 h was 864 ± 493 mL, and there were no procedural complications. Both the mean PaO2/FiO2 ratio and lung compliance improved after drainage. Additionally, 41.9% (n = 26) of patients were ventilator-free within 72 h after drainage. Multivariable logistic regression analysis revealed that non-cardiovascular or thoracic surgery (odds ratio [OR] = 4.968, p = 0.046), a longer time interval from operation to the onset of pleural effusion (OR = 1.165, p = 0.005), and a higher peak airway pressure (OR = 1.303, p = 0.009) were independent adverse predictors for being free from mechanical ventilation within 72 h after drainage. Specifically, patients with a time from surgery to the onset of pleural effusion ≤6 days-but not those with an interval >6 days-showed a significant post-procedural improvement in terms of PaO2/FiO2 ratio, PaCO2, peak airway pressure, and dynamic lung compliance. In summary, ultrasound-guided pleural effusion drainage resulted in significant clinical benefits in mechanically ventilated ICU patients after major surgery-especially in those with early-onset effusion who received thoracic surgery.

Single-step localization and excision of small pulmonary nodules using a mobile 3D C-arm.

OBJECTIVES: The use of a hybrid operating room equipped with robotic C-arm cone-beam computed tomography for single-step localization and excision of small pulmonary nodules finds high cost barriers. The new generation of 3D C-arm system not only depicts soft tissues with high contrast but also offers a more affordable and sustainable solution. This approach has been chiefly applied in the field of orthopedic surgery. In this case series, we describe the use of a mobile 3D C-arm system for localizing and removing small pulmonary nodules. METHODS: Between July and September 2020, we identified 14 patients who underwent localization and removal of small pulmonary nodules with a 3D C-arm system. We retrospectively reviewed clinical records to document the feasibility and safety of the procedure. RESULTS: The median tumour size was 7.5 mm [interquartile range (IQR): 5 - 9.75 mm], with a median distance from the pleural surface of 4.2 mm (IQR: 0.5 - 6.45 mm). We successfully visualized all of the pulmonary lesions by intraoperative CT imaging. Localization was achieved in 13 patients, who subsequently underwent complete thoracoscopic resection. The median time required to localize lesions was 41.5 min (IQR: 33.75 - 53.25 min), with a median radiation exposure (expressed through the skin absorbed dose) of 143.45 mGy (IQR: 86.1 - 194.6 mGy). Failure to localize occurred in 1 patient because of pneumothorax caused by repeated needle puncture. All patients were successfully discharged and the median length of stay was 2.5 days (IQR: 2 - 3 days). CONCLUSIONS: This case series demonstrates the feasibility of single-step localization and excision of small pulmonary nodules using a mobile 3D C-arm.

Efficacy and Safety of Preoperative vs. Intraoperative Computed Tomography-Guided Lung Tumor Localization: A Randomized Controlled Trial.

Background: Thoracoscopic removal of small pulmonary nodules is traditionally accomplished through a two-step approach-with lesion localization in a CT suite as the first step followed by lesion removal in an operating room as the second step. While the advent of hybrid operating rooms (HORs) has fostered our ability to offer a more patient-tailored approach that allows simultaneous localization and removal of small pulmonary nodules within a single-step, randomized controlled trials (RCTs) that compared the two techniques (two- vs. single-step) are still lacking. Methods: This is a RCT conducted in an academic hospital in Taiwan between October 2018 and December 2019. To compare the outcomes of traditional two-step preoperative CT-guided small pulmonary nodule localization followed by lesion removal vs. single-step intraoperative CT-guided lesion localization with simultaneous removal performed by a dedicated team of thoracic surgeons. The analysis was conducted in an intention-to-treat fashion. The primary study endpoint was the time required for lesion localization. Secondary endpoints included radiation doses, other procedural time indices, and complication rates. Results: A total of 24 and 25 patients who received the single- and two-step approach, respectively, were included in the final analysis. The time required for lesion localization was significantly shorter for patients who underwent the single-step procedure (median: 13 min) compared with the two step-procedure (median: 32 min, p < 0.001). Similarly, the radiation dose was significantly lower for the former than the latter (median: 5.64 vs. 10.65 mSv, respectively, p = 0.001). Conclusions: The single-step procedure performed in a hybrid operating room resulted in a simultaneous reduction of both localization procedural time and radiation exposure.

Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique to localize deep pulmonary nodules in a hybrid operating room.

Herein, we describe a Dyna-computed tomography-guided electromagnetic navigation bronchoscopy technique aimed at localizing deep pulmonary nodules. The method was implemented in a hybrid operating room and required the use of 2 markers (a near-infrared dye as a surface marker and a microcoil as a deep marker).

Preoperative versus intraoperative image-guided localization of multiple ipsilateral lung nodules.

OBJECTIVES: Computed tomography (CT)-guided localization of multiple ipsilateral pulmonary nodules remains challenging. Hybrid operating rooms equipped with cone-beam CT and laser navigation systems have the potential for improving clinical workflows and patient outcomes. METHODS: Patients with multiple ipsilateral pulmonary nodules requiring localization were divided according to the localization method [preoperative CT-guided (POCT group) localization versus intraoperative CT-guided (IOCT group) localization]. The 2 groups were compared in terms of procedural efficacy, safety and radiation exposure. RESULTS: Patients in the IOCT (n = 12) and POCT (n = 42) groups did not differ in terms of demographic and tumour characteristics. Moreover, the success and complication rates were similar. Notably, the IOCT approach allowed multiple nodules to be almost simultaneously localized-resulting in a shorter procedural time [mean difference (MD) -15.83 min, 95% confidence interval (CI) -7.97 to -23.69 min] and lower radiation exposure (MD -15.59 mSv, 95% CI -7.76 to -23.42 mSv) compared with the POCT approach. However, the total time under general anaesthesia was significantly longer in the IOCT group (MD 34.96 min, 95% CI 1.48-68.42 min), despite a similar operating time. The excess time under anaesthesia in the IOCT group can be attributed not only to the procedure per se but also to a longer surgical preparation time (MD 21.63 min, 95% CI 10.07-33.19 min). CONCLUSIONS: Compared with the POCT approach, IOCT-guided localization performed in a hybrid operating room is associated with a shorter procedural time and less radiation exposure, albeit at the expense of an increased time under general anaesthesia.

Preoperative CT versus intraoperative hybrid DynaCT imaging for localization of small pulmonary nodules: a randomized controlled trial.

BACKGROUND: Localization of small and/or deep pulmonary nodules before thoracoscopic exploration is paramount to minimize the likelihood of unplanned conversion to thoracotomy. As far as the percutaneous approach is concerned, the most common workflow consists of preoperative computed tomography (POCT) imaging-guided tumor marking (performed in an interventional CT suite) followed by their removal in an operating room (OR). However, the advent of hybrid ORs has allowed intraoperative computed tomography (IOCT)-guided lesion localization. This single center, open-label, randomized, controlled clinical trial aims to compare the efficacy and safety of IOCT versus POCT. METHODS/DESIGN: The study sample will consist of patients presenting with small and/or deep pulmonary nodules who will be randomly allocated to either POCT or IOCT. The time required to complete lesion localization will be the primary efficacy outcome. The following parameters will serve as secondary endpoints: rate of successful targeting during localization and in the operating field, time at risk, operating time, length of time under anesthesia, global OR utilization time, complication (pneumothorax and hemorrhage) rates, and radiation exposure. DISCUSSION: Owing to the increased availability of HORs, our data will be crucial to clarify the feasibility and safety of IOCT versus the traditional POCT approach. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03395964 . Registered on October 8, 2018.

Image-guided thoracoscopic lung resection using a dual-marker localization technique in a hybrid operating room.

BACKGROUND: We sought to describe the feasibility and safety of a dual-marker technique-based on a combination of near-infrared (NIR) marking and microcoil localization-before image-guided video-assisted thoracoscopic surgery (iVATS) of small and/or deep pulmonary lesions in a hybrid operating room (HOR). METHODS: We retrospectively reviewed the clinical records of consecutive patients who underwent iVATS resection in a HOR using the proposed dual-marker localization technique. Patients were initially imaged with cone-beam CT, and the needle trajectory was subsequently planned with the Syngo iGuide Needle Guidance software. Using a coaxial needle technique, a microcoil was initially deployed either in the immediate proximity or within the lesion of interest followed by injection of diluted indocyanine green (ICG; quantity: 0.3-0.5 mL; dye concentration: 0.125 mg/mL) at the pleural surface. A NIR thoracoscopic camera and a C-arm portable fluoroscopic system were used to guide the subsequent resection. RESULTS: A total of 11 patients were examined. The median lesion size was 6 mm, with a median distance from the pleural surface of 4 mm. Three nodules were solid, whereas the remaining eight were GGOs. All lesions were identifiable on intraoperative cone-beam CT images. The median time required for localization was 19 min. No conversion to thoracotomy or a multi-port approach was required, and there were no clinically significant adverse events after ICG injection or microcoil placement. CONCLUSIONS: Our study indicates that iVATS with a dual-marking approach (NIR marking and microcoil localization) is safe and useful to localize difficult-to-identify pulmonary nodules.

Hybrid operating room for the intraoperative CT-guided localization of pulmonary nodules.

Video-assisted thoracic surgery (VATS) requires preoperative computed tomography (CT)-guided localization of small pulmonary nodules or ground glass opacities (GGOs). However, this traditional two-stage approach is not devoid of potential complications, including wire dislodgement, pneumothorax, and/or hemothorax. With the advent of hybrid operating rooms (HORs), simultaneous single-stage localization and removal of such lesions has become possible. Here, we review the technical developments and the state-of-the-art in the field of intraoperative CT-guided localization and resection of small pulmonary nodules performed within a HOR.

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 surgeon's experience (Pearson's 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.

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 surgeon's specific facility.

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 institution's 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 surgeon's experience (Pearson's 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.

Image-guided video-assisted thoracoscopic small lung tumor resection using near-infrared marking.

BACKGROUND: Localization of non-visible, non-palpable small pulmonary nodules during video-assisted thoracoscopic surgery (VATS) remains challenging. We sought to investigate the feasibility and safety of image-guided video-assisted thoracoscopic surgery (iVATS) with near-infrared (NIR) marking in a hybrid operating room (OR). METHODS: Both localization and surgery were performed by a single team of thoracic surgeons. Diluted indocyanine green (ICG; quantity: 0.3-0.5 mL; dye concentration: 0.125 mg/mL) was injected percutaneously to pinpoint the tumor's location under cone beam computed tomography (CBCT) guidance using a laser-guided navigation system. Real-time fluorescence images were intraoperatively obtained using a NIR thoracoscopic camera to guide subsequent resection. RESULTS: Between March and December 2017, 26 patients underwent NIR marking of small pulmonary nodules for iVATS. The median tumor size was 7 mm (interquartile range [IQR] 5.3-10.8 mm), whereas their median distance from the pleural surface was 5 mm (IQR 0.3-10.5 mm). Seven nodules (35%) were solid, whereas 17 (65%) were ground-glass opacities. All lesions were identifiable on intraoperative CBCT. The median time required for NIR localization was 13 min. An NIR(+) "tattoo" was identified in all cases, and no intraoperative conversion to thoracotomy occurred. The final pathological diagnoses were primary lung cancer (n = 11), metastatic cancer (n = 6), and benign lung tumor (n = 9). Adverse events were not observed, and the median length of post-operative stay was 4 days (IQR 3-4 days). CONCLUSIONS: Our data show that iVATS with NIR marking is useful, has no adverse effects, and can successfully localize difficult-to-identify small pulmonary nodules.

Serial evaluation of the SOFA score is reliable for predicting mortality in acute severe pancreatitis.

Acute severe pancreatitis caused high mortality, and several scoring systems for predicting mortality are available. We evaluated the effectiveness of serial measurement of several scoring systems in patients with acute severe pancreatitis.We retrospectively obtained serial measurements of Ranson, Acute Physiology and Chronic Health Assessment (APACHE) II, and Sequential Organ Failure Assessment (SOFA) scores of 159 patients with acute severe pancreatitis.The overall mortality rate was 20%, and early mortality (in the first 2 weeks) occurred in 10 (7.4%) patients, while late mortality occurred in 17 (12.6%).All scoring systems were reliable for predicting overall and intensive care unit mortality, while the SOFA score on day 7 presented the largest area under the receiver operator characteristic (ROC) curve (0.858, SE 0.055). Changes in scores over time were evaluated for predicting the progression of organ failure, and the change in SOFA score on hospital day 7 or no interval change in SOFA score was associated with higher mortality rates.APACHE II and SOFA scores are both sensitive for predicting mortality in acute pancreatitis. The serial SOFA scores showed reliable for predicting mortality. Hospital day 7 is a reasonable time for SOFA score reassessment to predict late mortality in acute severe pancreatitis.

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 Pearson's 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 (Pearson's 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.