Indocyanine green imaging for pulmonary segmentectomy

Morphologic Features of Invasion in Lung Adenocarcinoma: Diagnostic Pitfalls

Reproducibility of pulmonary invasive adenocarcinoma diagnosis is poor when applying the World Health Organization (WHO) classification. In this article, we aimed first to explain by 3-dimensional morphology why simple pattern recognition induces pitfalls for the assessment of invasion as applied in the current WHO classification of pulmonary adenocarcinomas. The underlying iatrogenic-induced morphologic alterations in collapsed adenocarcinoma in situ overlap with criteria for invasive adenocarcinoma. Pitfalls in seemingly acinar and papillary carcinoma are addressed with additional cytokeratin 7 and elastin stains. In addition, we provide more stringent criteria for a better reproducible and likely generalizable classification.

Simultaneous Visualization of Lung Tumor and Intersegmental Plane during Pulmonary Segmentectomy by Intravenous Injection of Indocyanine Green

Segmentectomy is a targeted surgical approach tailored for patients with compromised health and early-stage lung cancer. The key to successful segmentectomy lies in precisely identifying the tumor and intersegmental planes to ensure adequate resection margins. In this study, we aimed to enhance this process by simultaneously visualizing the tumor and intersegmental planes through the intravenous injection of indocyanine green (ICG) at different time points and doses. Lung tumors were detected by intravenous injection of ICG at a dose of 2 mg/kg 12 h before surgery in a rabbit model. Following the dissection of the pulmonary artery, vein, and bronchi of the target segment, 0.6 mg/kg of ICG was injected intravenously to detect the intersegmental plan. Fluorescent images of the lung tumors and segments were acquired, and the fluorescent signal was quantified using the signal-to-background ratio (SBR). Finally, a pilot study of this method was conducted in three patients with lung cancer. In a preclinical study, the SBR of the tumor (4.4 ± 0.1) and nontargeted segments (10.5 ± 0.8) were significantly higher than that of the targeted segment (1.6 ± 0.2) (targeted segment vs. nontarget segment, p < 0.0001; target segment vs. tumor, p < 0.01). Consistent with preclinical results, lung tumors and the intersegmental plane were successfully detected in patients with lung cancer. Consequently, adequate resection margins were identified during the surgery, and segmentectomy was successfully performed in patients with lung cancer. This study is the first to use intravenous ICG injections at different time points and doses to simultaneously detect lung cancer and intersegmental planes, thereby achieving segmentectomy for lung cancer.

Application of microwave surgical instrument to lung segmentectomy for small-sized lung cancer

Objectives

For lung segmentectomy of small lung cancers, we used a microwave surgical instrument for lung parenchymal dissection mainly at the pulmonary hilum, which is difficult to handle with surgical staplers. This technique facilitated the insertion of staples.

Methods

In total, 116 patients with cStage 0-1A3 non-small cell lung cancer who underwent lung segmentectomy were included in this study. We compared the perioperative factors of the group in which a microwave surgical instrument was used for dissection procedures, including lung parenchymal dissection at the pulmonary hilum, and peripheral intersegmental dissection was performed with surgical staplers (group M+S: N = 69), with those of the group in which parenchymal dissection was performed mainly with surgical staplers without using the microwave surgical instrument (group S: N = 47).

Results

Although more complex segmentectomies were performed in the M+S group (P = .001), the number of staple cartridges (7 staple cartridges vs 8 staple cartridges, P = .005), the surgical times (179 vs 221 minutes, P < .0001), and the blood loss (5 mL vs 30 mL, P = .012) were significantly lower in the M+S group. The duration of chest tube placement was significantly shorter in the M+S group (P = .019), and postoperative complications of grade 2 or greater were significantly lower in the M+S group (P = .049).

Conclusions

The effective use of the microwave surgical instrument combined with surgical staplers can simplify pulmonary hilar and intersegmental plane dissections not only for simple segmentectomy but also for complex segmentectomy, leading to favorable intraoperative and postoperative outcomes.

Impact of indocyanine green on prolonged air leak in minimally invasive segmentectomy

BACKGROUND

Video-assisted thoracoscopic segmentectomies have become the gold standard for the treatment of early-stage non-small cell lung cancer less than two centimeters. The main difficulty is the identification of intersegmental boundary lines which dictate postoperative morbidities.

METHODS

We conducted a retrospective study to compare the perioperative outcomes of patients who underwent minimally invasive segmentectomy using the traditional deflation-inflation method or the novel indocyanine green (ICG) technique. Using a prospectively maintained database, we performed a retrospective analysis of 197 consecutive anatomical segmentectomies, from 2020 to 2023. Clinical effectiveness, postoperative complications, and histological data were compared.

RESULTS

A total of 73 (37%) patients had the inflation-deflation method and 124 (63%) had the intravenous ICG method. There were no significant differences in chest tube duration, prolonged air leak, postoperative complications, and postoperative hospital stays. Surgical margin width was also similar between the two groups. The multivariable analysis confirmed these results. Lastly, intravenous ICG brought no additional value in complex segmentectomies.

CONCLUSION

This monocentric and retrospective analysis found no added value of the intravenous ICG on the perioperative results of minimally invasive segmentectomies. The place of this novel technique in the surgical armamentarium remains to be defined. Specific indications such as complex segmentectomy or patients with chronic pulmonary disease require further study.

The use of intravenous indocyanine green in minimally invasive segmental lung resections: a systematic review

Background

To identify intersegmental planes (ISPs) in video/robot-assisted thoracoscopic segmentectomies, indocyanine green (ICG) is commonly used. The aim of this systematic review is to evaluate the efficacy of intravenous ICG in the identification of ISP.

Methods

A systematic search was performed. Studies evaluating patients who underwent a video/robot-assisted thoracoscopic segmentectomy using intravenous ICG were included. The primary outcome measure was the frequency and percentage of patients in whom the ISP was adequately visualized. Secondary outcomes encompassed the ICG dose, time to visualization, time to maximum ICG visualization, time to disappearance of ICG effect and adverse reactions to ICG.

Results

Eighteen studies were included for systematic review, enrolling a total of 1,090 patients. Irrespective of the injected dose, intravenous ICG identified the ISP in 94% of the cases (range, 30-100%). Overall, there was a considerable amount of heterogeneity regarding the injected dose of ICG (range, 5-25 mg or 0.05-0.5 mg/kg). The mean time before first effect of ICG was visible ranged from 10 to 40 seconds. The mean total time of ICG visibility ranged from 90 to 140 seconds after a bolus injection and was 170 seconds after continuous infusion. No adverse reactions were reported.

Conclusions

After administration of intravenous ICG, visualization of the ISP is successful in up to 94% of cases, even after administration of a low dose (0.05 mg/kg) of ICG. The use of intravenous ICG is safe with no reported adverse effects in the immediate peri-operative period.

A novel technique proposition for determining the resection margins in lung resection by using a thermal camera

OBJECTIVES

Determination of resection margins is very important in anatomical lung resections for both oncologic outcomes and postoperative complications. Absence of intersegmental plans naturally in segmentectomy surgeries and presence of incomplete fissure variationally in pulmonary lobectomy procedures constitute a challenge for surgeons in determining resection margins. Thoracic surgeons can prefer various techniques such as inflation deflation method, indocyanine green imaging, and three-dimensional segment modeling to cope with this problem. These techniques have some disadvantages such as high cost, the necessity of intravenous drug administration, need for an additional imaging system and ineffectiveness due to emphysema, anthracotic lung surface or interalveolar pores. Here we studied an alternative method for the solution of these disadvantages and aimed to demonstrate the correctness of a hypothesis based on detecting the cooling of the ischemic lung portion by a thermal camera after dividing the related pulmonary artery.

METHODS

We planned determining margins of resection with a thermal camera in patients scheduled for pulmonary lobectomy or segmentectomy. We made some measurements and mapping with a thermal camera before and after the dividing of pulmonary artery of related lobe or segment then processed the images taken with a software on the computer.

RESULTS

We detected a significant decrease in temperature in the ischemic lung area and demonstrated mapping the demarcation line between ischemic and perfused areas effectively by thermography in a total of 32 patients underwent lung resection.

CONCLUSION

Pulmonary resection margins can be detected effectively by thermography in patients.

Arterial Embolization and Cone-Beam Computed Tomography-Guided Lung Resection for Anomalous Systemic Arterial Blood Supply to Normal Lung: Two Case Reports

Systemic arterial blood supply to a normal lung is a rare anatomical abnormality. Surgery is usually indicated because this abnormality leads to pulmonary hypertension. Herein, we report our experience and ideas for safe vessel dissection. Case 1 was a woman in her 50s. We performed a left lower lobectomy following percutaneous coil embolization. The aberrant artery with emboli was confirmed intraoperatively by cone-beam computed tomography (CBCT) to safely dissect under thoracoscopic surgery (TS). Case 2 was a man in his 40s. Following percutaneous endovascular plug occlusion, we performed a left partial resection using indocyanine green fluorescence navigation. Intraoperatively, CBCT imaging demonstrated the aberrant artery and exact position of the emboli. This combination technique of interventional radiology and TS with CBCT imaging was considered safe and more secure for the treatment of anomalous systemic arterial blood supply to a normal lung.

[Indocyanine green fluorescence in thoracoscopic segmentectomy: indications and benefits]

OBJECTIVE

To determine the role of ICG fluorescence in segmentectomies.

MATERIAL AND METHODS

One surgical team performed 178 thoracoscopic anatomical segmentectomies in two hospitals between 2017 and 2023. Of these, 93 (52.2%) patients underwent ICG fluorescence perfusion tests. This study was retrospective and consecutive. Intraoperative and early postoperative results were analyzed. Patients were divided into 3 equal periods. Ventilation and perfusion methods were used to navigate the intersegmental planes in the first period. In the second one, only ventilation methods were used due to the absence of ICG. In the third period, the choice of navigation method was determined by «surgical complexity of segment».

RESULTS

In 74% of patients, surgeries were performed for primary or metastatic lung tumors. The scheduled procedure was performed in all patients. However, 2 ones required lobectomy for total resection. Uneventful postoperative period was observed in 69.7% of patients. Other ones had complications grade I-IIIA. No reoperations or mortality were recorded.

CONCLUSION

ICG perfusion is not inferior to ventilation methods in identification of intersegmental planes. This method is also more convenient for thoracoscopy. ICG fluorescence thoracoscopy is the only method in patients with COPD scheduled for thoracoscopic segmentectomy with two or more intersegmental planes.

Influencing Factors on Intersegmental Identification Adequacy in Segmentectomy with Intraoperative Indocyanine Green (ICG) Intravenous Administration

Accurate identification of the intersegmental plane is essential in segmentectomy, and Indocyanine Green (ICG) assists in visualizing lung segments. Various factors, including patient-related, intraoperative, and technical issues, can influence boundary delineation. This study aims to assess the rate of unsuccessful intersegmental identification and identify the contributing factors. We analyzed cases of lung segmentectomy from April 2020 to March 2023, where intraoperative ICG was intravenously administered during robot-assisted or video-assisted thoracoscopic surgery. Cases where fluorescence extended beyond expected boundaries within 30 s were classified as the "unclear boundary group". This group was then compared to the "clear boundary group". The study encompassed 111 cases, 104 (94%) of which were classified under the "clear boundary group" and 7 (6%) under the "unclear boundary group". The "unclear boundary group" had a significantly lower DLCO (15.7 vs. 11.8, p = 0.03) and DLCO/VA (4.3 vs. 3.0, p = 0.01) compared to the "clear boundary group". All cases in the "unclear boundary group" underwent lower lobe segmentectomy. ICG administration effectively outlines pulmonary segments. Challenges in segment demarcation may occur in cases with low DLCO and DLCO/VA values, particularly during lower lobe segmentectomy.

Three-Dimensional Imaging-Guided Lung Anatomic Segmentectomy: A Single-Center Preliminary Experiment

Background and objectives: VATS segmentectomy has been proven to be effective in the treatment of stage I NSCLC, but its technical complexity remains one of the most challenging aspects for thoracic surgeons. Furthermore, 3D-CT reconstruction images can help in planning and performing surgical procedures. In this paper, we present our personal experience of 11 VATS anatomical resections performed after accurate pre-operative planning with 3D reconstructions. Materials and methods: A 3D virtual model of the lungs, airways, and vasculature was obtained, starting from a 1.25 mm 3-phase contrast CT scan, and the original images were used for the semi-automatic segmentation of the lung parenchyma, airways, and tumor. Results: Six males and five females were included in this study. The median diameter of the pulmonary lesion at the pre-operative chest CT scan was 20 mm. The surgical indication was confirmed in seven patients: in three cases, a lobectomy, instead of a segmentectomy, was needed due to intraoperative findings of nodal metastasis. Meanwhile, only in one case, we performed a lobectomy because of inadequate surgical resection margins. Skin-to-skin operative average time was 142 (IQR 1-3 105-182.5) min. The median post-operative stay was 6 (IQR 1-3 3.5-7) days. The mean value of the closest surgical margin was 13.7 mm. Conclusion: Image-guided reconstructions are a useful tool for surgeons to perform complex resections in order to spare healthy parenchyma and to ensure disease-free margins. Nevertheless, human skill and surgeon experience still remain fundamental for the final decisions regarding the proper resection to perform.

A novel, simple near-infrared thoracoscopic technique by a particular route for locating lung nodules

Background

The localization of pulmonary nodules prior to thoracoscopic surgery remains challenging for thoracic surgeons, especially for those nodules that are not visible or palpable on the lung surface. Our study is a simple and effective minimally invasive method using indocyanine green through a special pathway to locate pulmonary nodules and fluorescence thoracoscopic surgery.

Methods

Thoracoscopic surgery was performed for 18 undiagnosed peripheral non-solid nodules no larger than 2 cm after location. After 0.3 mg/kg indocyanine green was injected through the peripheral vein, the puncture needle was pulled out after it reached approximately 1 cm of the pulmonary parenchyma near the nodules. This was followed by transfer to the operating room. The nodule was initially localized by using a near-infrared thoracoscope to visualize indocyanine green fluorescence. Then, thoracoscopic resection was performed.

Results

Eighteen patients received this special and simple localization method, and underwent near-infrared, image-guided, video-assisted thoracoscopic surgery resection. Median computed tomography (CT) tumor size was 1.2 cm. Median depth from the pleural surface is 1.6 cm (range, 0.1-4.6 cm). The median time of CT-guided intervention was 12 min. The duration of thoracoscopic surgery was 67 min. Indocyanine green fluorescence was clearly identified in 17 of 18 patients (94.4%). The surgical margins were all negative on final pathology. The final diagnoses included 17 primary lung cancers, and 1 benign lung tumor.

Conclusions

CT-guided single puncture of indocyanine green after peripheral intravenous injection is a simple, effective, and safe method to locate the nodule. This offers surgeons the ease of localization through direct indocyanine green fluorescence imaging, and it can be used as an effective alternative to other placement methods of locating pulmonary nodules.

Robot-assisted segmentectomy with improved modified inflation-deflation combined with the intravenous indocyanine green method

To investigate the perioperative outcomes of patients who underwent robot-assisted thoracoscopic (RATS) segmentectomy for identifying the intersegmental plane (ISP) by improved modified inflation-deflation (MID) combined with near-infrared fluorescence imaging with the intravenous indocyanine green (ICG) method and to assess the feasibility of this method in a large-scale cohort according to the type of segmentectomy performed. We retrospectively analysed the perioperative data of a total of 155 consecutive patients who underwent RATS segmentectomy between April 2020 and December 2021. Data from the operation, including the demarcation status of the intersegmental plane, were analysed retrospectively. The mean operative time and estimated blood loss were 125.56 ± 36.32 min and 41.81 ± 49.18 mL, respectively. Good demarcation of the intersegmental plane was observed in 150 (96.77%) patients, with no correlation with the type of resected segments or the surgical method. Postoperative complications of Clavien-Dindo classification grade 3 or more were observed in 4 patients (2.58%), and no ICG-related adverse events were noted. Demarcation of the intersegmental plane by improved MID combined with ICG is feasible regardless of the type of segmentectomy and can be commonly applied in robot-assisted segmentectomy.

Feasibility and safety of computed tomography-guided intrapulmonary injection of indocyanine green for localization of peripheral pulmonary ground-glass nodules

Background

The early surgical intervention for pulmonary ground-glass nodules (GGNs) has become increasingly important, but accurate identification of these nodules during thoracoscopic surgery poses challenges due to the need for sublobar resections and reliance on visual and tactile perception alone. The prognosis of the procedure is closely tied to the use of precise positioning technology. Thus, it is crucial to develop an accurate positioning technology that can improve patient prognosis.

Methods

Clinical data from the cardiothoracic department of a tertiary hospital in Shanghai were collected and analyzed between January 2020 and December 2021. The patients were categorized into 2 groups: an indocyanine green (ICG) group and a hook-wire group. Outcome measures including success rate, complications, procedure time, localization-related pain, and interval time were assessed. Adverse events and reactions were reported and compared between the 2 groups.

Results

A total of 62 patients (17 males and 45 females, aged 50.5±13.2 years) were in the ICG group, while 66 patients (23 males and 43 females, aged 48.4±12.9 years) were localized in the hook-wire group. The success rate was comparable between the 2 groups. However, the ICG group showed significant advantages over the hook-wire group in terms of procedure time (22.6±4.4 vs. 24.1±4.9 min; P=0.012), localization-related pain (P<0.001), and interval time [median and interquartile range (IQR): 3 (0.7, 104.9) vs. 1.2 (0.5, 3.3) h; P<0.001]. In the ICG group, there were 11 cases of pneumothorax, 4 cases of hemothorax, and 2 cases of ICG diffusion. In the hook-wire group, there were 24 cases of pneumothorax, 25 cases of hemothorax, and 2 cases of dislodgement. The ICG group had fewer complications, including pneumothorax (P=0.018) and hemothorax (P=0.007), compared to the hook-wire group.

Conclusions

Computed tomography (CT)-guided intrapulmonary injection of ICG for preoperative localization of peripheral pulmonary GGNs is a practical and safe technique. It offers advantages in terms of reduced procedure time, localization-related pain, and interval time compared to the hook-wire method. Moreover, the ICG technique results in fewer complications, making it a valuable preoperative localization technique worthy of popularization.

Segmentectomy versus lobectomy. Which factors are decisive for an optimal oncological outcome?

Low-dose computed tomography is being used for lung cancer screening in high-risk groups. Detecting lung cancer at an early stage improves the chance of optimal treatment and increases overall survival. This article compares segmentectomy vs. lobectomy as surgical options, in the case of stage I non-small cell lung carcinoma, ideally IA. To compare the 2 previously referred strategies, data were collected from articles (40 studies were reviewed), reviews, and systematic analyses in PubMed Central, as well as reviewing recent literature. Segmentectomy could be an equal alternative to lobectomy in early-stage NSCLC (tumour < 2 cm). It could be preferred for patients with a low cardiopulmonary reserve, who struggle to survive a lobectomy. As far as early-stage NSCLC is concerned, anatomic segmentectomy is an acceptable procedure in a selective group of patients. For better tumour and stage classification, a systematic lymph node dissection should be performed.

Asia expert consensus on segmentectomy in non-small cell lung cancer: A modified Delphi study

Objective

Segmentectomy as a parenchymal-sparing surgical approach has been recommended over lobectomy in select patients with early-stage non-small cell lung cancer. This study aimed to address 3 aspects of segmentectomy ("patient indication"; "segmentectomy approaches"; "lymph node assessment") where there is limited clinical guidance.

Methods

A modified Delphi approach comprising 3 anonymous surveys and 2 expert discussions was used to establish consensus on the aforementioned topics among 15 thoracic surgeons (2 Steering Committee; 2 Task Force; 11 Voting Experts) from Asia who have extensive segmentectomy experience. Statements were developed by the Steering Committee and Task Force based on their clinical experience, published literature (rounds 1-3), and comments received from Voting Experts through surveys (rounds 2-3). Voting Experts indicated their agreement with each statement on a 5-point Likert scale. Consensus was defined as ≥70% of Voting Experts selecting either "Agree"/"Strongly Agree" or "Disagree"/"Strongly Disagree."

Results

Consensus from the 11 Voting Experts was reached on 36 statements (11 "patient indication" statements; 19 "segmentation approaches" statements; 6 "lymph node assessment" statements). In rounds 1, 2, and 3, consensus was reached on 48%, 81%, and 100% of drafted statements, respectively.

Conclusions

A recent phase 3 trial reported significantly improved 5-year overall survival rates for segmentectomy compared with lobectomy, proposing thoracic surgeons to consider segmentectomy as a surgical option in suitable patients. This consensus serves as a guidance to thoracic surgeons considering segmentectomy in patients with early non-small cell lung cancer, outlining key principles that surgeons should consider in surgical decision-making.

Identification of the Separation Range of an Incomplete Interlobar Fissure in Segmentectomy Using Near Infrared

In segmentectomy for patients with incomplete interlobar fissures, insufficient dissection of the interlobar parenchyma may result in incomplete segmentectomy, while excessive dissection may lead to excessive bleeding and air leaks. Here, we report a case of left apicoposterior (S¹⁺²) segmentectomy with incomplete interlobar fissure in which near-infrared thoracoscopy with indocyanine green was used to identify the separation range of interlobar fissure by dissecting the relevant vessels beforehand.

Utility of indocyanine green in assessing blood perfusion in anomalous systemic arterial supply to the lung

The chosen treatment for anomalous systemic arterial supply to the basal segment of the lung (ABLL) is typically the division of the anomalous artery and resection of the abnormal area, dependent on the anomalous artery. Although only division or interventional embolization of the anomalous artery may be selected. However, leaving the area dependent on the anomalous artery can lead to complications, such as necrosis and pulmonary infarction. We report the case of a 39-year-old female with ABLL. Intraoperatively, the anomalous artery was first divided. Indocyanine green (ICG) was subsequently injected intravenously to evaluate blood perfusion within the abnormal lung area. Since the abnormal area was still poorly perfused after a few minutes, a left basal segmentectomy was performed because of the possibility of complications. Thus, evaluation of perfusion via ICG can be used in the decision to resect abnormal area.

Hyperspectral imaging enables the differentiation of differentially inflated and perfused pulmonary tissue: a proof-of-concept study in pulmonary lobectomies for intersegmental plane mapping

OBJECTIVES

The identification of the intersegmental plane is a major interoperative challenges during pulmonary segmentectomies. The objective of this pilot study is to test the feasibility of lung perfusion assessment by Hyperspectral Imaging for identification of the intersegmental plane.

METHODS

A pilot study (clinicaltrials.org: NCT04784884) was conducted in patients with lung cancer. Measuring tissue oxygenation (StO₂; upper tissue perfusion), organ hemoglobin index (OHI), near-infrared index (NIR; deeper tissue perfusion) and tissue water index (TWI), the Hyperspectral Imaging measurements were carried out in inflated (P_vent) and deflated pulmonary lobes (P_nV) as well as in deflated pulmonary lobes with divided circulation (P_nVC) before dissection of the lobar bronchus.

RESULTS

A total of 341 measuring points were evaluated during pulmonary lobectomies. Pulmonary lobes showed a reduced StO2 (P_vent: 84.56% ± 3.92 vs. P_nV: 63.62% ± 11.62 vs. P_nVC: 39.20% ± 23.57; p<0.05) and NIR-perfusion (P_vent: 50.55 ± 5.62 vs. P_nV: 47.55 ± 3.38 vs. P_nVC: 27.60 ± 9.33; p<0.05). There were no differences of OHI and TWI between the three groups.

CONCLUSIONS

This pilot study demonstrates that HSI enables differentiation between different ventilated and perfused pulmonary tissue as a precondition for HSI segment mapping.

Use of a radiofrequency identification system for precise sublobar resection of small lung cancers

BACKGROUND

The incidence of sublobar resection is increasing because of the rise in the detection of small lung cancers. However, local recurrence needs to be addressed, and several methods are needed for the resection with secure margins of non-visible and non-palpable tumors.

METHODS

We retrospectively reviewed the use of a radiofrequency identification (RFID) system in sublobar resection of adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) at our institute.

RESULTS

From June 2020 to June 2022, 39 patients underwent sublobar resection for AIS or MIA. The median age was 69 years (interquartile range, 64-76). Among the 39 patients, 24 were diagnosed with AIS and 15 with MIA. Segmentectomy, subsegmentectomy, and wedge resection were performed in nine, six, and 24 patients, respectively. The median size of the target tumor was 9.0 mm (8.1-12.9) and the median distance between the tag and the tumor was 2.9 mm (0-7.5). The median pathological surgical margin was 15.0 mm (10-17.5). Complete resection of all lesions was performed with a secure surgical margin. The median follow-up duration was 6 months, during which no local recurrence was detected in any of the patients.

CONCLUSIONS

The RFID marking system accurately informed the surgeons of the tumor location and helped them to perform precise sublobar resection.

Conservative treatment for residual lung congestion after left upper trisegmentectomy: a case report

Background

Currently, segmentectomy is the procedure of choice in approximately 10% of lung cancer surgeries in Japan. However, complications are often observed in that procedure. In particular, residual pulmonary congestion after segmentectomy often leads to surgical intervention.

Case Description

We report a case of improved congestion in the residual lung after left upper trisegmentectomy (LUTS) with conservative treatment under careful observation. A 65-year-old man was diagnosed with bilateral lung cancer and initially underwent LUTS. On the next day after surgery, blood sputum was observed. Computed tomography (CT) showed consolidation in the lingual region of the left lung and stenosis of V4+5 in the left lung. The cause of the congestion was thought to be an isolated segment with part of the remaining S3 and a thin V4+5 with poor flow. Because pulmonary torsion or necrosis of the residual lung was not observed, conservative treatment with antibiotics under careful follow-up by CT was chosen. The pulmonary congestion and inflammatory reaction gradually improved, and the patient was discharged home on the 26th day after surgery.

Conclusions

We experienced a case of residual pulmonary congestion after LUTS that resolved with conservative treatment. Careful follow-up of the patient's general condition and imaging studies are considered to be important.

Comparison of various lung intersegmental plane identification methods

Keeping a sufficient surgical margin free of tumor is important to prevent local recurrence in lung segmentectomy. Accurate identification of the intersegmental plane is essential to achieve adequate surgical margins. Traditionally, the inflation-deflation method was used to identify the intersegmental plane. However, in recent years, various intersegmental plane identification methods, including systemic indocyanine green injection, have been reported and shown to be useful. The purpose of this review was to evaluate the identification rates, advantages, and disadvantages of various intersegmental identification methods in lung segmentectomy. There are primarily six methods: inflation-deflation method, selective segmental inflation, endobronchial dye injection, virtual-assisted lung mapping, systemic indocyanine green injection, and pure oxygen method. These are broadly classified into those that use bronchi and pulmonary arteries anatomically and those that use air and dye technically. In this review, all methods showed relatively high identification rates. Moreover, high identification rates were expected, especially with systemic indocyanine green injection and the pure oxygen method. Each method has its advantages and disadvantages as varying situations entail different methods. It is necessary to select and apply them effectively; therefore, further improvement for each method will be required in the future.

Robot-assisted segmentectomy for small lung cancer using a radiofrequency identification marker

Owing to the prevalence of robot-assisted thoracoscopic surgery and the increase in the number of small lung cancer cases, robot-assisted thoracoscopic segmentectomy cases have also been increasing. For small lung cancers, such as ground-glass opacity lesions, identifying the location and securing a sufficient free margin from the main tumor can be difficult. We have already developed and reported the clinical application of a new marking system, a radiofrequency identification marker. In the current study, we applied this technique to robot-assisted thoracoscopic segmentectomies. Concomitant with other devices, we believe that robot-assisted thoracoscopic surgery has a great advantage in segmentectomy.

[Application of Three-dimensional Computed Tomography Bronchography and Angiography Combined with Perfusion Area Identification Technique in Uniport Thoracoscopic Complex Segmentectomy]

BACKGROUND

With the extensive application of segmental lung resection in the treatment of early-stage lung cancer, how to complete segmentectomy more accurately and minimally invasively has become a research hotspot. The aim of this study is to explore the application of three-dimensional computed tomography bronchography and angiography (3D-CTBA) combined with perfusion area recognition technique in single-hole thoracoscopic complex segmentectomy.

METHODS

From January 2021 to January 2022, the clinical data of 112 consecutive patients undergoing single-port thoracoscopic complex segmentectomy in the Department of Thoracic Surgery, Xuanwu Hospital, Capital Medical University were retrospectively analyzed. The three-dimensional reconstruction combined with perfusion area identification technique was used to perform the operation and the clinical data were analyzed.

RESULTS

The average operation time was (141.1±35.4) min; the initial time of intersegmental plane display was (12.5±1.7) s; the maintenance time of intersegmental plane was (114.3±10.9) s; the intersegmental plane was clearly displayed (100%); the amount of bleeding was [10 (10, 20)] mL; the total postoperative drainage volume was (380.5±139.7) mL; the postoperative extubation time was (3.9±1.2) d; and the postoperative hospitalization time was (5.2±1.6) d. Postoperative complications occurred in 8 cases.

CONCLUSIONS

The advantages of 3D-CTBA combined with perfusion area recognition technique are fast, accurate and safe in identifying intersegmental boundary in single-port thoracoscopic complex segmentectomy, which could provide guidances for accuratding resection of tumors, shortening operation time and reducing surgical complications.

Robotic segmentectomy for early-stage lung cancer

Lobectomies have long been the gold standard for surgical treatment of early-stage non-small cell lung cancer (NSCLC), with segmentectomies limited to instances of benign disease or as an alternative in patients where lung preservation is indicated. However, a recently published randomized control trial has demonstrated the superiority of segmentectomy over lobectomy in terms of overall survival for early-stage lung cancer. Segmentectomy could thus be considered a standard procedure for small-sized peripheral NSCLC. While segmentectomy via video-assisted thoracic surgery (VATS) is the most widespread approach, development in video instrumentation and thoracic robotic surgery is rapidly gaining interest. Indeed, robotic surgery pioneers boast the advantages in three-dimensional view, improved magnification, ergonomics, dexterity, safety, and ease of surgery with this technology. This review aims to outline robotic-assisted segmentectomy indications, preoperative evaluation, and the operative conduct for the different lung segments from a single surgeon console. There are many ways to perform segmentectomies and therefore this review describes generalized approaches that can be tailored based on experience.

Expert consensus on indocyanine green fluorescence imaging for thoracoscopic lung resection (The Version 2022)

The use of the white-light thoracoscopy is hampered by the low contrast between oncologic margins and surrounding normal parenchyma. As a result, many patients with in situ or micro-infiltrating adenocarcinoma have to undergo lobectomy due to a lack of tactile and visual feedback in the resection of solitary pulmonary nodules. Near-infrared (NIR) guided indocyanine green (ICG) fluorescence imaging technique has been widely investigated due to its unique capability in addressing the current challenges; however, there is no special consensus on the evidence and recommendations for its preoperative and intraoperative applications. This manuscript will describe the development process of a consensus on ICG fluorescence-guided thoracoscopic resection of pulmonary lesions and make recommendations that can be applied in a greater number of centers. Specifically, an expert panel of thoracic surgeons and radiographers was formed. Based on the quality of evidence and strength of recommendations, the consensus was developed in conjunction with the Chinese Guidelines on Video-assisted Thoracoscopy, and the National Comprehensive Cancer Network (NCCN) guidelines on the management of pulmonary lesions. Each of the statements was discussed and agreed upon with a unanimous consensus amongst the panel. A total of 6 consensus statements were developed. Fluorescence-guided thoracoscopy has unique advantages in the visualization of pulmonary nodules, and recognition and resection of the anterior plane of the pulmonary segment. The expert panel agrees that fluorescence-guided thoracoscopic surgery has the potential to become a routine operation for the treatment of pulmonary lesions.

Application of three-dimensional computed tomography bronchography and angiography in thoracoscopic anatomical segmentectomy of the right upper lobe: A cohort study

Objective

Three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide detailed imaging information for pulmonary segmentectomy. This study aimed to investigate the safety and effectiveness of 3D-CTBA guidance of anatomical segmentectomy of the right upper lobe (RUL).

Methods

This was a retrospective analysis of anatomical segmentectomy of the RUL at the Thoracic Surgery Department of the Fourth Hospital of Hebei Medical University from December 9, 2013, to June 2, 2021. Preoperatively, all patients underwent contrast-enhanced CT of the chest (to determine the size of the pulmonary nodule) and a lung function test. 3D-CTBA has been performed since 2018; patients with vs. without 3D-CTBA were compared. Segmentectomy was performed according to nodule location.

Results

Of 139 patients (46 males and 93 females, aged 21–81 years), 93 (66.9%) completed single segmentectomy, 3 (2.2%) completed single subsegmentectomy, 29 had combined subsegmentectomy, 7 had segmentectomy combined with subsegmentectomy, and 6 had combined resection of two segments. Eighty-five (61.2%) patients underwent 3D-CTBA. 3D-CTBA cases had decreased intraoperative blood loss (67.4 ± 17.6 vs. 73.1 ± 11.0, P = 0.021) and shorter operation time (143.0 ± 10.8 vs. 133.4 ± 20.9, P = 0.001). 3D-CTBA (Beta = −7.594, 95% CI: −12.877 to −2.311, P = 0.005) and surgical procedure (Beta = 9.352, 95% CI: 3.551–15.153, P = 0.002) were independently associated with intraoperative blood loss. 3D-CTBA (Beta = −13.027, 95% CI: −18.632 to 17.422, P < 0.001) and surgical procedure (Beta = 7.072, 95% CI: 0.864–13.280, P = 0.026) were also independent factors affecting the operation time.

Conclusion

Preoperative use of 3D-CTBA to evaluate the pulmonary vessels and bronchial branch patterns of the RUL decreased blood loss and procedure time and so would be expected to improve the safety and effectiveness of thoracoscopic segmentectomy.

Near-infrared fluorescence guided surgery: State of the evidence from a health technology assessment perspective

Different applications of near-infrared fluorescence-guided surgery are very promising, and techniques that help surgeons in intraoperative guidance have been developed, thereby bridging the gap between preoperative imaging and intraoperative visualization and palpation. Thus, these techniques are advantageous in terms of being faster, safer, less invasive, and cheaper. There are a few fluorescent dyes available, but the most commonly used dye is indocyanine green. It can be used in its natural form, but different nanocapsulated and targeted modifications are possible, making this dye more stable and specific. A new active tumor-targeting strategy is the conjugation of indocyanine green nanoparticles with antibodies, making this dye targeted and highly selective to various tumor proteins. In this mini-review, we discuss the application of near-infrared fluorescence-guided techniques in thoracic surgery. During lung surgery, it can help find small, non-palpable, or additional tumor nodules, it is also useful for finding the sentinel lymph node and identifying the proper intersegmental plane for segmentectomies. Furthermore, it can help visualize the thoracic duct, smaller bullae of the lung, phrenic nerve, or pleural nodules. We summarize current applications and provide a framework for future applications and development.

Intraoperative Identification of the Intersegmental Plane: From the Beginning to the Future

Segmentectomy has played a crucial role in the treatment of early-stage lung cancer after the publication of JCOG0802, which indicated that patients with small-sized peripheral non-small-cell lung cancer could receive better survival from segmentectomy than lobectomy despite a higher local recurrence. The intraoperative identification of the intersegmental plane ensures complete resection of the lesion with sufficient margin so that it is deemed as the critical part of segmentectomy. Diverse methods have been developed to acquire distinguishable and lasting borderline between segments, but none of them is proved perfect. In this review, we searched and classified these techniques that emerged from the beginning when segmentectomy was used for bronchiectasis until now. Comparisons between different ways in mechanisms, facility, and safety were made to depict a comprehensive landscape for surgeons to select fit one. Furthermore, we presented our vision for the future of intersegmental plane identification.

Fluorescence-Guided Identification of the Thoracic Duct by VATS for Treatment of Postoperative Chylothorax: A Short Case Series

Background

Chylothorax is a relatively rare complication after surgery of the mediastinum. The occurrence and the results of surgical treatment of this condition are difficult to foresee due to the wide heterogeneity in thoracic duct anatomy.

Case summary

We report two cases of postoperative chylothorax treated with ligation by video-assisted thoracoscopic surgery (VATS). The first patient developed a massive left chylothorax shortly after discharge, following radical excision of a seminoma-involved left para-aortic lymphadenopathy. The second patient developed a high-output right chylothorax following VATS upper bilobectomy. In both cases, a surgical revision by VATS was performed. Inguinal injection of indocyanine green allowed an easy visualization of the lymphatic leakage point. In both cases, oral feeding was rapidly restarted after surgery. No recurrence of chylothorax was observed.

Conclusion

The use of indocyanine green may greatly improve the identification of the thoracic duct during surgical ligation by VATS, with a favorable impact on the postoperative course and overall admission costs.

Near-Infrared Fluorescence Tumor-Targeted Imaging in Lung Cancer: A Systematic Review

Lung cancer is the most common cancer type worldwide, with non-small cell lung cancer (NSCLC) being the most common subtype. Non-disseminated NSCLC is mainly treated with surgical resection. The intraoperative detection of lung cancer can be challenging, since small and deeply located pulmonary nodules can be invisible under white light. Due to the increasing use of minimally invasive surgical techniques, tactile information is often reduced. Therefore, several intraoperative imaging techniques have been tested to localize pulmonary nodules, of which near-infrared (NIR) fluorescence is an emerging modality. In this systematic review, the available literature on fluorescence imaging of lung cancers is presented, which shows that NIR fluorescence-guided lung surgery has the potential to identify the tumor during surgery, detect additional lesions and prevent tumor-positive resection margins.

Intraoperative margin assessment by wireless signals in thoracoscopic anterior (S3) segmentectomy using a radiofrequency identification marker

Despite the use of near-infrared thoracoscopy with intravenous indocyanine green, intraoperative assessment of the surgical margin for the resection of non-palpable tumors located near the intersegmental plane requires highly advanced surgical skill for the prevention of local recurrence. Because the demarcation line is limited to the pleural surface, to overcome uncertainty in tumor palpation for deeply located small-sized lesions, other supplemental localization techniques have been proposed. Here, we present a novel surgical technique using radiofrequency identification markers for intraoperative assessment of the lateral surgical margin in segmentectomy.