Prediction of micropapillary and solid pattern in lung adenocarcinoma using radiomic values extracted from near-pure histopathological subtypes.

OBJECTIVES: Near-pure lung adenocarcinoma (ADC) subtypes demonstrate strong stratification of radiomic values, providing basic information for pathological subtyping. We sought to predict the presence of high-grade (micropapillary and solid) components in lung ADCs using quantitative image analysis with near-pure radiomic values. METHODS: Overall, 103 patients with lung ADCs of various histological subtypes were enrolled for 10-repetition, 3-fold cross-validation (cohort 1); 55 were enrolled for testing (cohort 2). Histogram and textural features on computed tomography (CT) images were assessed based on the "near-pure" pathological subtype data. Patch-wise high-grade likelihood prediction was performed for each voxel within the tumour region. The presence of high-grade components was then determined based on a volume percentage threshold of the high-grade likelihood area. To compare with quantitative approaches, consolidation/tumour (C/T) ratio was evaluated on CT images; we applied radiological invasiveness (C/T ratio > 0.5) for the prediction. RESULTS: In cohort 1, patch-wise prediction, combined model (C/T ratio and patch-wise prediction), whole-lesion-based prediction (using only the "near-pure"-based prediction model), and radiological invasiveness achieved a sensitivity and specificity of 88.00 ± 2.33% and 75.75 ± 2.82%, 90.00 ± 0.00%, and 77.12 ± 2.67%, 66.67% and 90.41%, and 90.00% and 45.21%, respectively. The sensitivity and specificity, respectively, for cohort 2 were 100.0% and 95.35% using patch-wise prediction, 100.0% and 95.35% using combined model, 75.00% and 95.35% using whole-lesion-based prediction, and 100.0% and 69.77% using radiological invasiveness. CONCLUSION: Using near-pure radiomic features and patch-wise image analysis demonstrated high levels of sensitivity and moderate levels of specificity for high-grade ADC subtype-detecting. KEY POINTS: • The radiomic values extracted from lung adenocarcinoma with "near-pure" histological subtypes provide useful information for high-grade (micropapillary and solid) components detection. • Using near-pure radiomic features and patch-wise image analysis, high-grade components of lung adenocarcinoma can be predicted with high sensitivity and moderate specificity. • Using near-pure radiomic features and patch-wise image analysis has potential role in facilitating the prediction of the presence of high-grade components in lung adenocarcinoma prior to surgical resection.

Efficacy and Safety of Cone-Beam Computed Tomography-Derived Augmented Fluoroscopy Combined with Endobronchial Ultrasound in Peripheral Pulmonary Lesions.

BACKGROUND: The diagnostic yield of peripheral pulmonary lesions (PPLs) using radial endobronchial ultrasound (EBUS) remains challenging without navigation systems. Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) represents a recently developed technique, and its clinical utility remains to be investigated. OBJECTIVES: The aim of this study was to investigate the diagnostic yield of transbronchial biopsy (TBB) using a combination of CBCT-AF and radial EBUS. METHODS: We recruited consecutive patients with PPLs who underwent radial EBUS-guided TBB, with or without AF, between October 2018 and July 2019. Following propensity score 1:1 matching, we recorded the procedure-related data and measured their efficacy and safety. RESULTS: While 72 patients received EBUS-plus-AF, 235 patients received EBUS only. We included 53 paired patients following propensity score matching. The median size of lesions was 2.8 and 2.9 cm in the EBUS-plus-AF group and EBUS-only group, respectively. Diagnostic yield was higher in the former group (75.5 vs. 52.8%; p = 0.015). The diagnostic yield for the EBUS-plus-AF group was significantly higher for lesions ≤30 mm (73.5 vs. 36.1%; p = 0.002). Moreover, there was no significant difference in the complication rates (3.8 vs. 5.7%; p = 1.000). Twenty-four nodules (45.3%) were invisible by fluoroscopy in the EBUS-plus-AF group. All of them were identifiable on CBCT images and successfully annotated for AF. The mean radiation dose of total procedure, CBCT, and fluoroscopy was 19.59, 16.4, and 3.17 Gy cm2, respectively. CONCLUSIONS: TBB using a combination of CBCT-AF and EBUS resulted in a satisfactory diagnostic yield and safety.

Complications of clavicle fracture surgery in patients with concomitant chest wall injury: a retrospective study.

BACKGROUND: The impact of associated chest wall injuries (CWI) on the complications of clavicle fracture repair is unclear to date. This study aimed to investigate the complications after surgical clavicle fracture fixation in patients with and without different degrees of associated CWI. METHODS: A retrospective review over a four-year period of patients who underwent clavicle fracture repair was conducted. A CWI and no-CWI group were distinguished, and the CWI group was subdivided into the minor-CWI (three or fewer rib fractures without flail chest) and complex-CWI (flail chest, four or more rib fractures) subgroup. Demographic data, classification of the clavicle fracture, number of rib fractures, and associated injuries were recorded. Overall complications included surgery-related complications and unplanned hospital readmissions. Univariate analysis and stepwise backward multivariate logistic regression were used to identify potential risk factors for complications. RESULTS: A total of 314 patients undergoing 316 clavicle fracture operations were studied; 28.7% of patients (90/314) occurred with associated CWI. Patients with associated CWI showed a significantly higher age, body mass index, and number of rib fractures. The overall and surgical-related complication rate were similar between groups. Unplanned 30-day hospital readmission rates were significantly higher in the complex-CWI group (p = 0.02). Complex CWI and number of rib fractures were both independent factor for 30-day unplanned hospital readmission (OR 1.59, 95% CI: 1.00-2.54 and OR 1.33, 95% CI: 1.06-1.68, respectively). CONCLUSION: CWI did not affect surgery-related complications after clavicle fracture repair. However, complex-CWI may increase 30-day unplanned hospital readmission rates.

Real-time augmented fluoroscopy-guided lung marking for thoracoscopic resection of small pulmonary nodules.

BACKGROUND: Small pulmonary nodule localization via an endobronchial route is safe and has fewer complications than that with the transthoracic needle approach, but accurate marking without a navigation system remains challenging. We aimed to evaluate the safety and efficacy of endobronchial dye marking using conventional bronchoscopy guided by cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) for small pulmonary nodules. METHODS: We retrospectively reviewed the clinical records of 61 nodules in 51 patients who underwent preoperative CBCT-AF-guided bronchoscopic dye marking, followed by thoracoscopic resection, between July 2018 and March 2019. RESULTS: The median nodule size was 8.6 mm [interquartile range (IQR) 7.0-11.8 mm], and the median distance from the pleural space was 15.4 mm (IQR 10.6-23.1 mm). All nodules were identifiable on CBCT images and annotated for AF. The median bronchoscopy duration was 8.0 min (IQR 6.0-11.0 min), and the median fluoroscopy duration was 2.2 min (IQR 1.2-4.0 min). The median radiation exposure (expressed as the dose area product) was 2337.2 µGym2 (IQR 1673.8-4468.8 µGym2). All nodules were successfully marked and resected, and the median duration from localization to surgery was 16.4 h (IQR 4.2-20.7 h). There were no localization-related complications or operative mortality, and the median length of the postoperative stay was 4 days (IQR 3-4 days). CONCLUSIONS: Bronchoscopic dye marking under CBCT-AF guidance before thoracoscopic surgery was safely conducted with satisfactory outcomes in our initial experience.

Augmented fluoroscopic bronchoscopy (AFB) versus percutaneous computed tomography-guided dye localization for thoracoscopic resection of small lung nodules: a propensity-matched study.

BACKGROUND: Dye localization is a useful method for the resection of unidentifiable small pulmonary lesions. This study compares the transbronchial route with augmented fluoroscopic bronchoscopy (AFB) and conventional transthoracic CT-guided methods for preoperative dye localization in thoracoscopic surgery. METHODS: Between April 2015 and March 2019, a total of 231 patients with small pulmonary lesions who received preoperative dye localization via AFB or percutaneous CT-guided technique were enrolled in the study. A propensity-matched analysis, incorporating preoperative variables, was used to compare localization and surgical outcomes between the two groups. RESULTS: After matching, a total of 90 patients in the AFB group (N = 30) and CT-guided group (N = 60) were selected for analysis. No significant difference was noted in the demographic data between both the groups. Dye localization was successfully performed in 29 patients (96.7%) and 57 patients (95%) with AFB and CT-guided method, respectively. The localization duration (24.1 ± 8.3 vs. 21.4 ± 12.5 min, p = 0.297) and equivalent dose of radiation exposure (3.1 ± 1.5 vs. 2.5 ± 2.0 mSv, p = 0.130) were comparable in both the groups. No major procedure-related complications occurred in either group; however, a higher rate of pneumothorax (0 vs. 16.7%, p = 0.029) and focal intrapulmonary hemorrhage (3.3 vs. 26.7%, p = 0.008) was noted in the CT-guided group. CONCLUSION: AFB dye marking is an effective alternative for the preoperative localization of small pulmonary lesions, with a lower risk of procedure-related complications than the conventional CT-guided method.

Localization of Small Pulmonary Nodules Using Augmented Fluoroscopic Bronchoscopy: Experience from 100 Consecutive Cases.

BACKGROUND: We developed augmented fluoroscopic bronchoscopy (AFB) for the localization of small pulmonary nodules. Here, we review the results of 100 consecutive cases of AFB localization performed in our institute in order to evaluate its efficacy, safety, and procedural details. METHODS: This study was a retrospective analysis of prospectively collected data. Between July 2018 and September 2019, a total of 100 patients with 124 small lung nodules underwent AFB localization with dye marking and/or microcoil placement. All localizations were performed in a cone-beam computed tomography examination room followed by thoracoscopic resection within 3 days. RESULTS: The mean nodule size was 9.7 mm, and the mean distance from the pleural space was 18.6 mm. Sixty-three patients received dye marking only, and 37 patients received microcoil placement with/without additional dye marking. The mean bronchoscopy duration was 10.4 min, and the mean fluoroscopy duration was 3.4 min. The mean radiation exposure (expressed as the dose-area product) was 3140.8 µGy × m2. The AFB procedures were successful in 94 patients [augmented fluoroscopy discrepancy (n = 2), incomplete C-arm confirmation (n = 3), microcoil unlooping (n = 1)]; of those, 91 received successful marker-guided resection [invisible dye (n = 2), failed nodule resection with first wedge (n = 1)]. The mean length of postoperative stay and chest drainage was 4.2 and 2.9 days, respectively. CONCLUSIONS: The AFB technique is a safe and reproducible alternative for localizing small pulmonary nodules, and various localization strategies can be implemented for different nodule locations and resection plans.

Needlescopic-assisted thoracoscopic pulmonary anatomical lobectomy and segmentectomy for lung cancer: a bridge between multiportal and uniportal thoracoscopic surgery.

PURPOSE: Needlescopic instruments allow us to perform complex laparoscopic procedures, which are almost painless and scarless postoperatively; however, their utilization in thoracoscopic surgery has been limited to minor procedures, including bullectomy and sympathectomy. We present our initial experience of performing thoracoscopic anatomical lung resection via a single utility incision with additional needlescopic working ports and compare the operative results with those of uniportal video-assisted thorascopic surgery (VATS). METHODS: We reviewed data on 75 consecutive patients with lung cancer, who underwent anatomical lung resections, including lobectomy and segmentectomy, between February 2015 and September 2017. Of the 75 patients, 39 underwent uniportal VATS (uniportal group), and 36 underwent needlescopic-assisted VATS (n-VATS group). We compared the peri- and postoperative outcomes of the two groups. RESULTS: The clinical characteristics did not differ significantly between the groups, except in the ages of the patients. The n-VATS group had a shorter operation time (mean 159.3 min vs. 198.8 min, P = 0.023) and lower intraoperative blood loss (mean 40.9 mL vs. 143.2 mL, P = 0.047). Two major pulmonary arterial bleeding events and one conversion to thoracotomy occurred in the uniportal group. CONCLUSION: Uniportal VATS can be performed more efficiently and safely with the assistance of additional needlescopic ports and instruments, without compromising the benefits of less postoperative pain and early recovery.

Diagnosis and management of a trapped lung or diaphragm by fractured ribs: analysis of patients undergoing rib fracture repair.

BACKGROUND: There are few reports regarding a lung or diaphragm trapped by a fractured rib. This study aimed to describe the clinical presentations, diagnosis, and management of these intrathoracic pathologies. METHODS: We retrospectively reviewed the database at our institute for patients with rib fractures who underwent thoracoscope-assisted surgical stabilization of rib fracture (SSRF). We analyzed the demographic data, mechanism of trauma, presentations, operative findings, and subsequent management strategies. RESULTS: A total of 38 consecutive patients who underwent SSRF were analyzed. Three patients had a trapped lung and one had a trapped diaphragm. Abnormal radiographic findings were observed in 50% of cases. The median waiting time for surgery was 25 days. Surgery was indicated for intractable dynamic pain following conservative treatment. A definitive diagnosis was made during thoracoscopic exploration. Thoracoscopic repair and resection were used for trapped lungs and thoracoscopic release for a trapped diaphragm. We subsequently performed SSRF for unhealed rib fractures. CONCLUSION: As per our analysis, the incidence of a trapped lung or diaphragm was 10.5%. If a patient presents with persistent intractable dynamic pain, thoracoscopic exploration with concurrent SSRF may be a feasible and effective treatment option.

Computed tomography-guided dual localization with microcoil and patent blue vital dye for deep-seated pulmonary nodules in thoracoscopic surgery.

BACKGROUND/PURPOSE: In video-assisted thoracic surgery (VATS) resection of small lung nodules, preoperative dye marking around the visceral pleura provides surface localization to help initiate resection, while implantation of a fiducial marker such as a microcoil can provide inner localization to aid nodule resection under fluoroscopic guidance. We aimed to determine whether dual localization with microcoil placement and dye marking is safe and useful for guiding the resection of small deep-seated lung nodules. METHODS: We retrospectively evaluated data pertaining to 39 consecutive patients (40 nodules) managed between January 2016 and December 2017 in our hospital. Dual localization with patent blue V dye and microcoil was performed preoperatively because the pulmonary nodules were expected to be difficult to visualize or palpate intraoperatively. The patients underwent computed tomography-guided dual localization in a single puncture and were then transferred to the operation room. Intraoperative fluoroscopy was used to ensure that the lung tissue resected included the microcoil. RESULTS: All 40 lesions were successfully resected using the dual localization technique followed by fluoroscopy-assisted thoracoscopic surgery. The median lesion diameter and depth were 0.9 and 1.7 cm, respectively, while the median margin/diameter ratio in the first resected specimen was 1.25. One patient had failure of localization due to partial release of the microcoil into the chest wall. Localization-related pneumothorax was detected in six of 39 patients (15.4%) and was always self-limited. CONCLUSION: Dual localization with microcoil placement and dye marking is safe and supports successful VATS resection of small deep-seated lung nodules.

Cumulative experience of preoperative real-time augmented fluoroscopy-guided endobronchial dye marking for small pulmonary nodules: An analysis of 30 initial patients.

BACKGROUND/PURPOSE: Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) for use in guiding endobronchial dye marking of small pulmonary nodules prior to thoracoscopic surgery is still under development. We sought to evaluate the effect of the cumulative experience on procedural parameters of CBCT-AF-guided endobronchial dye marking for preoperative localization of small pulmonary nodules. METHODS: Clinical variables and treatment outcomes of the 30 initial patients with small pulmonary nodules who were managed with CBCT-AF-guided endobronchial dye marking followed by thoracoscopic resection in our institution were analyzed. Two sequential groups of patients (group I and group II, n = 15 each) were compared with regard to localization time and radiation doses. The Mann-Whitney U test and chi-square test or Fisher exact test were used in the statistical analyses. RESULTS: In the entire cohort, the median size of solitary pulmonary nodules on preoperative computed tomography (CT) images was 9.3 mm (interquartile range, 7.4-13.6 mm), and their median distance from the pleural surface was 15.2 mm (interquartile range, 10.3-27.1 mm). The median tumor depth-to-size ratio was 1.6 (interquartile range, 1.1-2.3). A significant reduction in single DynaCT radiation (3690.4 versus [vs.] 1132.3 µGym2; P < 0.001) and total radiation exposure (median, 4878.8 vs. 1673.8 µGym2; P < 0.001) was noted in group II (late patients) compared with group I. CONCLUSION: Our initial results of CBCT-AF-guided lung marking demonstrate that the cumulative experience with several technical modifications can achieve the same purpose of endobronchial localization with less procedure-related radiation exposure.

Surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures following cardiopulmonary resuscitation: An international, retrospective matched case-control study.

BACKGROUND: The presence of six or more rib fractures or a displaced rib fracture due to cardiopulmonary resuscitation (CPR) has been associated with longer hospital and intensive care unit (ICU) length of stay (LOS). Evidence on the effect of surgical stabilization of rib fractures (SSRF) following CPR is limited. This study aimed to evaluate outcomes after SSRF versus nonoperative management in patients with multiple rib fractures after CPR. METHODS: An international, retrospective study was performed in patients who underwent SSRF or nonoperative management for multiple rib fractures following CPR between January 1, 2012, and July 31, 2020. Patients who underwent SSRF were matched to nonoperative controls by cardiac arrest location and cause, rib fracture pattern, and age. The primary outcome was ICU LOS. RESULTS: Thirty-nine operatively treated patient were matched to 66 nonoperatively managed controls with comparable CPR-related characteristics. Patients who underwent SSRF more often had displaced rib fractures (n = 28 [72%] vs. n = 31 [47%]; p = 0.015) and a higher median number of displaced ribs (2 [P 25 -P 75 , 0-3] vs. 0 [P 25 -P 75 , 0-3]; p = 0.014). Surgical stabilization of rib fractures was performed at a median of 5 days (P 25 -P 75 , 3-8 days) after CPR. In the nonoperative group, a rib fixation specialist was consulted in 14 patients (21%). The ICU LOS was longer in the SSRF group (13 days [P 25 -P 75 , 9-23 days] vs. 9 days [P 25 -P 75 , 5-15 days]; p = 0.004). Mechanical ventilator-free days, hospital LOS, thoracic complications, and mortality were similar. CONCLUSION: Despite matching, those who underwent SSRF over nonoperative management for multiple rib fractures following CPR had more severe consequential chest wall injury and a longer ICU LOS. A benefit of SSRF on in-hospital outcomes could not be demonstrated. A low consultation rate for rib fixation in the nonoperative group indicates that the consideration to perform SSRF in this population might be associated with other nonradiographic or injury-related variables. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury.

PURPOSE: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. METHODS: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. RESULTS: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034). CONCLUSION: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI).

BACKGROUND: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI. METHODS: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI. RESULTS: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034). CONCLUSION: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI. LEVEL OF EVIDENCE: Therapeutic, level IV.

Early versus late surgical stabilization of severe rib fractures in patients with respiratory failure: A retrospective study.

INTRODUCTION: The timing of surgical stabilization of rib fractures remains controversial. We hypothesized that early surgical stabilization (within 3 days of injury) can improve clinical outcome in patients with severe rib fractures and respiratory failure. The aim of this study was to analyze the impact of early surgical stabilization of rib fractures on the perioperative results, clinical outcomes, and medical costs of patients with severe rib fractures and respiratory failure. METHODS: This was a retrospective comparative study based on a prospectively collected database at a single institute. Patients with severe rib fractures and respiratory failure who underwent surgical stabilization were classified into early (within 3 days of injury) and late (more than 3 days after injury) groups. Outcome measures included operation time, duration of mechanical ventilation, intensive care unit stay, hospital stay, complication rate, mortality rate, and medical cost. RESULTS: A total of 33 patients were enrolled (16 and 17 in the early and late groups, respectively). The demographics, trauma mechanism, associated injuries, and severity of trauma were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (median 36 vs. 90 hours, p = 0.03), intensive care unit stay (median 123 vs. 230 hours, p = 0.004), and hospital stay (median 12 vs. 18 days, p = 0.005); and lower National Health Insurance costs (median 6,617 vs. 10,017 US dollars, p = 0.031). The early group tended to have lower rates of morbidity and mortality, but the difference was not statistically significant. CONCLUSION: Early surgical stabilization of rib fractures in selected patients may significantly shorten their duration of mechanical ventilation, and intensive care unit and hospital stays, while incurring less medical costs.

Quantitative feature analysis of CT images of transbronchial dye markings mimicking true pulmonary ground-glass opacity lesions.

BACKGROUND: Transbronchial dye marking is a preoperative localization technique aiding pulmonary resection. Post-marking computed tomography (CT) is performed to confirm the locations of the actual markings. This study aimed to evaluate the CT images of dye markings that present as ground-glass opacities (GGO), using quantitative feature analysis. METHODS: Thin-slice (1 mm) CT images of the dye markings and true ground glass nodule (GGN) lesions were obtained for quantitative analysis with gray-level co-occurrence matrix (GLCM) features. The quantification features including correlation, auto correlation, contrast, energy, entropy, and homogeneity were evaluated. Statistical analysis with boxplot was performed. RESULTS: GLCM features of multi-detector computed tomography (MDCT) images of the dye markings (n=13) and true GGN lesions (n=13) differed significantly in contrast, energy, entropy, auto correlation, and homogeneity. Cone beam computed tomographic (CBCT) image features of another group of dye markings (n=15) also showed a different distribution of feature values, than those of the MDCT images. CONCLUSIONS: Quantitative analysis of the dye marking images revealed a discriminative variance, compared with those of the true GGN lesions. Furthermore, the image textures of dye markings on MDCT and CBCT also presented with obvious discrepancies.

Single-stage hybrid localization: a combination of bronchoscopic lung mapping followed by post-mapping computed tomographic reconstruction and additional transthoracic needle localization in a cone beam computed tomography room.

BACKGROUND: Bronchoscopic lung mapping is a multispot dye-marking technique, which should be performed under real-time fluoroscopic guidance and post-mapping computed tomographic reconstruction. This study aimed to investigate the feasibility of lung mapping followed by post-mapping computed tomography (CT) and additional needle localization in a cone bean CT (CBCT) room. METHODS: Between February 1, 2018 and August 31, 2018, 11 consecutive patients presenting with 14 lung lesions underwent bronchoscopic lung mapping in a CBCT room followed by thoracoscopic surgery. The efficacy and safety of the procedure were assessed through a retrospective chart review. RESULTS: The median size of the pulmonary lesions was 8.1 mm [interquartile range (IQR), 7.2-10.8 mm] with a median depth-to-size ratio (D-S) ratio of 2.43 (IQR, 1.56-2.79). Additional needle localizations were performed in 4 patients, of which 3 and 1 patients underwent dual localization with dye and microcoil and localization with dye only, respectively. The median total localization time was 28 min (IQR, 18-69 min), and the median radiation exposure was 345.0 mGy (IQR, 161.8-486.6 mGy). A total of 8 wedge resections, 5 segmentectomies, and 1 lobectomy were performed. The final pathological diagnoses were as follows: primary lung cancer (n=6), lung metastases (n=4), and benign lung lesions (n=4). No adverse events were observed, and the median length of postoperative stay was 4 days (IQR, 3-5 days). CONCLUSIONS: Bronchoscopic lung mapping followed by post-mapping CT and additional needle localization can be performed together in a single examination room equipped with a C-arm CBCT, and the results of localization are contributory to the surgery.

Combined virtual-assisted lung mapping (VAL-MAP) with CT-guided localization in thoracoscopic pulmonary segmentectomy.

BACKGROUND/OBJECTIVE: Virtual assisted lung mapping (VAL-MAP) is a bronchoscopic lung marking technique developed to assist in navigational lung resection. It can be used for nodule localization and segmental identification. This article presents our initial experience of thoracoscopic pulmonary segmentectomy using combined VAL-MAP and computed tomography (CT)-guided localization. MATERIAL AND METHODS: Markings with India Ink were made bronchoscopically, before surgery, using a virtual bronchoscopy system (LungPoint® Planner) without fluoroscopy guidance. Post VAL-MAP CT scans localized the actual markings. All data on patients, markings, and outcomes were retrospectively collected, and the contribution of VAL-MAP to the operation was graded by the surgeon. RESULTS: From March 2017 to September 2017, 24 consecutive patients received the VAL-MAP marking procedure before thoracoscopic segmentectomy. Nineteen patients also received pre-operative CT-guided percutaneous localization after VAL-MAP; fifteen patients received CT-guided localization with dye (patent blue V) and microcoil, and four patients received with dye only. Of the 101 marking attempts made in all the patients, 71 (70.3%) were identified as contributing to the surgery. No clinically evident complications were associated with the procedure. A total of 24 segmentectomies were thoracoscopically conducted for 18 cases of lung cancer and six cases of benign diseases. CONCLUSION: The combination of VAL-MAP and CT-guided percutaneous localization contribute to precise thoracoscopic pulmonary segmentectomy.

Ultrasound-guided percutaneous dilatational tracheostomy using a saline-filled endotracheal tube cuff as an ultrasonographic puncture target: A feasibility study.

PURPOSE: The saline-filled endotracheal tube (ETT) cuff can be easily identified under cervical ultrasound and can serve as an ideal puncture target during percutaneous dilatational tracheostomy (PDT). The authors present their initial experience with this novel technique. MATERIALS AND METHODS: The records of 38 consecutive critically ill patients who underwent saline-filled cuff puncture PDT between October 2016 and December 2017 were retrospectively reviewed. The saline-filled ETT cuff was easily identified using ultrasound. Ultrasound-guided puncture into the cuff, followed by an inward-push of the ETT through the tube exchanger, facilitated accurate passage of the guidewire through the needle tip into the tracheal lumen. RESULTS: Of 38 consecutive procedures, 37 (97.4%) were performed successfully, with only one converted to surgical tracheostomy due to guidewire displacement. The median procedure time was 8 min. There were no complications, such as accidental extubation, major bleeding, or posterior tracheal wall laceration or pneumothorax, and no procedure-related mortalities. CONCLUSIONS: PDT performed using a saline-filled cuff as the ultrasound-guided puncture target and an endotracheal tube exchanger is feasible, and appeared to be easier to perform than standard PDT. Larger studies are required to confirm the safety and benefits of this technique.