Real-time Augmented Fluoroscopy-Guided Lung Marking for Thoracoscopic Resection of Small Pulmonary Nodules

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. 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. 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). Bronchoscopic dye marking under CBCT-AF guidance before thoracoscopic surgery was safely conducted with satisfactory outcomes in our initial experience.