ABSTRACT
Objectives: Transbronchial microwave ablation of lung nodules using electromagnetic navigation bronchoscopy is an emerging local therapy for lung oligometastases and multifocal lung cancers as part of a lung-preserving strategy. Concomitant ablation of multiple lung nodules in a single operating session may provide a one-stop solution. Methods: Between April 2019 and April 2023, 25 patients had 2 or more lung nodules ablated concomitantly in our hybrid operating room. Nodules were proven or highly suspicious of malignancies or metastases. Feasibility and safety were retrospectively reviewed. Results: A total of 56 nodules in 25 patients received concomitant multi-nodular ablation. The mean age of patients was 60 years, and the reasons for the lung-preserving strategy were multifocal lung cancers (80%) and lung oligometastases (20%). Among those with multifocal disease, 65% had previous major lung resection for lung cancer. Two to 4 nodules were ablated in each session. The mean nodule size was 9.9 mm (range, 5-20 mm), and the mean minimal margin was 5.9 mm. When comparing concomitant nodule ablation with the 103 single-nodule ablations performed in our institute, a mean of 86 minutes of operative time and 131 minutes of anesthetic time were saved. There were no increased complications despite overlapping ablation zones, and the mean hospital stay was 1.23 days. The rate of pneumothorax was 8%, and that of pleural effusion, pain, and fever was 4% respectively. Conclusions: Concomitant transbronchial microwave ablation of multiple lung nodules is feasible, safe, and associated with reduction in overall anesthetic and operative time. It is an important armamentarium in the contemporary lung-preserving strategy for battling multifocal lung cancers or lung oligometastases.
ABSTRACT
Background: Transbronchial ablation of lung nodules is gaining popularity as part of lung-preserving strategy for patients with multifocal lung cancers or multiple lung oligometastases. Accuracy in placement of ablation catheter is of utmost importance in order to achieve adequate ablation margin. However, older systems are not precise enough for confident placement of ablation catheter and often require multiple cone-beam CT (CBCT) to confirm and readjust its position. The following case is the first microwave lung ablation utilizing the novel IllumisiteTM platform (Medtronic, Minneapolis, MN, USA) in the hybrid operating room (HOR), with enhanced accuracy and workflow. Case Description: A 66-year-old lady had multiple resected adenocarcinomas in bilateral lungs. Upon CT monitoring a right middle lobe (RML) ground glass opacity with solid centre was found to be suspicious due to increasing size and density. Transbronchial electromagnetic navigation bronchoscopy (ENB) microwave ablation of the lesion was performed as part of lung-conserving strategy. After initial navigation, the adjusted nodule position provided by the IllumisiteTM platform after correcting the CT-to-body divergence prompted operators to renavigate and readjust the position of the locatable guide (LG) swiftly to gain accurate access to the nodule, which was confirmed by CBCT. Positional data at the tip of extended working channel (EWC) also allowed precise placement of needle for subsequent ablation. Conclusions: IllumisiteTM is a novel electromagnetic navigational platform that corrects for CT-to-body divergence and ensures continuous locational information by an additional positional coil in the tip of EWC. This precision is especially important for the placement of ablation catheter, as slight deviation would lead to insufficient ablation margin and future recurrence. Workflow is improved by reducing the number of CBCT required for instrument position adjustment.
ABSTRACT
The demand for parenchyma-sparing local therapies for lung cancer is rising owing to an increasing incidence of multifocal lung cancers and patients who are unfit for surgery. With the latest evidence of the efficacy of lung cancer screening, more premalignant or early-stage lung cancers are being discovered and the paradigm has shifted from treatment to prevention. Transbronchial therapy is an important armamentarium in the local treatment of lung cancers, with microwave ablation being the most promising based on early to midterm results. Adjuncts to improve transbronchial ablation efficiency and accuracy include mobile C-arm platforms, software to correct for the CT-to-body divergence, metal-containing nanoparticles, and robotic bronchoscopy. Other forms of energy including steam vapor therapy and pulse electric field are under intensive investigation.
ABSTRACT
In the era of modernized medicine, thoracic surgery has been focusing on achieving minimally invasive surgery and providing a one-stop solution in treating thoracic diseases. Particularly in the Asia population, where patients are keen to have smaller wound and shorter hospital stay, thoracic surgery in Hong Kong has evolved from the traditional open thoracotomy approach to video-assisted thoracoscopic surgery (VATS). In our institution, uniportal VATS for major lung resection was developed in 2012. While uniportal VATS has brought advantages into managing thoracic pathologies, it also brought challenges like instrument fencing during manipulation and suboptimal visualization angle. To improve the procedure and its outcomes, novel techniques and equipment have been developed, for example, double-hinged instruments, robotic assisted technology and magnetic anchored and guided endoscopes (MAGS). With advanced medical imaging nowadays, management of small lung nodules or ground glass opacity (GGO) is in higher demand than ever before. Our hybrid operating room (HOR) can incorporate instant and real-time imaging in lesion localization, and provide treatment via VATS or electromagnetic navigated bronchoscopic (ENB) ablation in a one-stop manner. This paper will review the literature related to the historical development and clinical outcomes of thoracic surgery in Hong Kong and discuss the future perspective of ongoing development.
ABSTRACT
Electromagnetic navigation bronchoscopy (ENB)-guided indocyanine green (ICG) fluorescence dye marking of subsolid, small and deep lung lesions facilitates subsequent minimally invasive lung resection surgeries. The novel robotic-assisted bronchoscopy (RAB) platform can improve the accuracy and yield of ENB biopsy, and the use of RAB has been extended to ICG dye marking. However, performing this procedure in the hybrid operating room guided by cone-beam CT (CBCT) with immediate proceed to lung surgery has not been well reported. We studied the safety, feasibility and clinical outcomes of 5 consecutive cases performed between December 2021 and March 2022. Navigation success was 100% while localization success using ICG was 80%. The benefits and pitfalls of robotic bronchoscopy procedures, and challenges of combining with hybrid operating room CBCT were discussed in detail. In conclusion, robotic-assisted bronchoscopy is a promising and useful tool for ICG fluorescence dye-marking, providing accurate navigation, superior maneuverability and improved ergonomics compared to conventional bronchoscopy-guided ENB procedures. Learning curve is reasonable, but meticulous system set up to incorporate the robotic system into existing CBCT platform may be required to ensure a smooth procedure.
ABSTRACT
The Djumbodis™ dissection system was introduced as an alternative to aortic arch replacement in acute type A aortic dissection involving the arch. In our own experience, some patients with Djumbodis implantation developed distal aortic arch and descending aortic aneurysm during subsequent follow-up and required additional interventions. However, as there is a high incidence of fracture associated with the Djumbodis system, further endovascular interventions are not feasible. We report a case of successful open descending aortic replacement in a patient with a fractured Djumbodis stent system.
