Real-time image-guided indocyanine green fluorescence dual-visualization technique to measure the intraoperative resection margin during thoracoscopic segmentectomy.

AIMS: The primary goal of thoracoscopic segmentectomy is the complete resection of early pulmonary carcinoma while sparing as much of the normal pulmonary parenchyma as possible, but an obvious trade-off exists between the pulmonary parenchymal preservation and an adequate resection margin. In this clinical trial, we explored a real-time image-guided indocyanine green (ICG) fluorescence dual-visualization technique to confirm the resection margin by improving the intraoperative localization of the pulmonary nodule and identification of the intersegmental boundary line (IBL). METHODS: This study was utilized in 35 patients with a screening-detected lung nodule <2 cm to complete thoracoscopic segmentectomy from December 2020 to June 2021. Computed tomography-guided localization of the pulmonary nodule with ICG solution was performed on the day of surgery. During the surgery, after dissecting the targeted pulmonary segmental arteries, ICG at 5 mg/body was injected into the systemic vein. RESULTS: We observed no toxicity. The dual-visualization technique was successfully implemented in all 35 patients to achieve a negative resection margin, which was more than 2 (mean 2.71 ± 0.59) cm, or the size of the tumor based on the final pathological examinations. No intraoperative complications occurred and only one patient had postoperative prolonged air leaks, which was ceased 8 days later after conservative management without reoperation. CONCLUSIONS: This method is a safe and feasible alternative to ensure a negative resection margin without removing an unreasonable amount of pulmonary parenchyma during pulmonary segmentectomy. Future studies will be needed to compare this method to alternative techniques in a clinical trial.

[Feasibility Investigation of Fluorescence Method in Uniport Thoracoscopic Anatomical Segmentectomy for Identifying the Intersegmental Boundary Line].

BACKGROUND: Segmentectomy has gradually become one of the standard surgical methods for small pulmonary nodules with early lung cancer on imaging. This study aimed to investigate the perioperative outcomes of patients who underwent uniport video-assisted thoracoscopic surgery (VATS) segmentectomy for identifying the intersegmental boundary line (IBL) by the near-infrared fluorescence imaging with intravenous indocyanine green (ICG) method or the modified inflation-deflation (MID) method and assess the feasibility and effectiveness of the ICG fluorescence (ICGF)-based method. METHODS: We retrospectively analyzed the perioperative data in total 198 consecutive patients who underwent uniport VATS segmentectomy between February 2018 and August 2020. With the guidance of preoperative intelligent/interactive qualitative and quantitative analysis-three dimensional (IQQA-3D), the targeted segment structures could be precisely identified and dissected, and then the IBL was confirmed by ICGF-based method or MID method. Clinical effectiveness and postoperative complications of the two methods were evaluated. RESULTS: An IBL was visible in 98% of patients by the ICGF-based group, even with the low-doses of ICG. The ICGF-based group was significantly associated with the shorter IBL clear presentation time [(23.59±4.47) s vs (1,026.80±318.34) s] (P<0.01) and operative time [(89.3±31.6) min vs (112.9±33.3) min] (P<0.01), compared to the MID group. The incidence of postoperative prolonged air leaks was higher in the MID group than in the ICGF-based group (8.0% vs 26.5%, P=0.025). There were no significant differences in bleeding volume, chest tube duration, postoperative hospital stays, surgical margin width and other postoperative complications (P>0.05). CONCLUSIONS: The ICGF-based method could highly accurately identify the IBL and make anatomical segmentectomy easier and faster, and therefore has the potential to be a feasible and effective technique to facilitate the quality of uniport VATS segmentectomy.

Feasibility investigation of near-infrared fluorescence imaging with intravenous indocyanine green method in uniport video-assisted thoracoscopic anatomical segmentectomy for identifying the intersegmental boundary line.

OBJECTIVES: To investigate the perioperative outcomes of patients who underwent uniport video-assisted thoracoscopic (VATS) segmentectomy for identifying the intersegmental boundary line (IBL) by the near-infrared fluorescence imaging with the intravenous indocyanine green (ICG) method or the modified inflation-deflation (MID) method and assess the feasibility and effectiveness of the ICG fluorescence (ICGF)-based method. METHODS: We retrospectively analyzed the perioperative data in total 198 consecutive patients who underwent uniport VATS segmentectomy between February 2018 and August 2020. With the guidance of a preoperative imaging interpretation and analysis system (IQQA-3D), the targeted segment structures could be precisely identified and dissected, and then the IBL was confirmed by the ICGF-based method or the MID method. The clinical effectiveness and postoperative complications of the two methods were evaluated. RESULTS: An IBL was visible in 98% of patients in the ICGF-based group, even with low doses of ICG. The ICGF-based group was significantly associated with a shorter IBL clear presentation time (23.6 ± 4.4 vs. 23.6 ± 4.4 s) (p < 0.01) and operative time (89.3 ± 31.6 vs. 112.9 ± 33.3 min) (p < 0.01) compared to the MID group. The incidence of postoperative prolonged air leaks was higher in the MID group than in the ICGF-based group (8/100, 8% vs. 26/98, 26.5%, p = 0.025). There were no significant differences in bleeding volume, chest tube duration, postoperative hospital stays, surgical margin width, and other postoperative complications. CONCLUSION: The ICGF-based method could highly accurately identify the IBL and make anatomical segmentectomy easier and faster, and therefore has the potential to be a feasible and effective technique to facilitate the quality of uniport VATS segmentectomy.

Efficacy of Xenon Light With Indocyanine Green for Intersegmental Visibility in Thoracoscopic Segmentectomy.

BACKGROUND: We previously reported useful methods that can be implemented to identify intersegmental boundary lines (IBLs) by using an intravenous indocyanine green (ICG) fluorescence imaging system (ICG-FS) during a thoracoscopic anatomical segmentectomy (TAS). The aim of this study was to evaluate the recently released third-generation ICG-FS that features an emphasizing xenon-light source for IBL identification. METHODS: We prospectively studied cases involving 106 consecutive patients who underwent TAS. Intraoperatively, we used the third-generation ICG-FS, the conventional ICG methods (CIM) emphasizing xenon-light (CIM-X), and the spectra-A method (SAM) emphasizing xenon-light (SAM-X), for IBL identification. Furthermore, 16 of the 106 patients (15%) could be simultaneously evaluated using old-generation ICG-FSs, CIM, and SAM. All images were completely quantified for illuminance and for three colors, red, green, and blue. RESULTS: IBLs were successfully identified in all the patients (100%) with no adverse events. The SAM-X significantly increased the illuminance, especially in the resecting segments, compared to the CIM (39.0 versus 22.2, P < 0.01) and SAM (39.0 versus 29.3, P < 0.01), with enhanced red color compared to the CIM (33.1 versus 21.9, P < 0.01) and SAM (33.1 versus 14.0, P < 0.01). Furthermore, the SAM-X significantly increased the illuminance contrast compared to the CIM-X (34.1 versus 15.3, P < 0.01). CONCLUSIONS: The present study suggests that the SAM-X potentially provided images with the highest visibility and colorfulness compared to the older generation ICG-FSs or CIM-X. Secure IBL identification can be more easily and safely performed using the SAM-X.

Feasibility Investigation of Fluorescence Method in Uniport Thoracoscopic Anatomical Segmentectomy for Identifying the Intersegmental Boundary Line / 中国肺癌杂志

BACKGROUND@#Segmentectomy has gradually become one of the standard surgical methods for small pulmonary nodules with early lung cancer on imaging. This study aimed to investigate the perioperative outcomes of patients who underwent uniport video-assisted thoracoscopic surgery (VATS) segmentectomy for identifying the intersegmental boundary line (IBL) by the near-infrared fluorescence imaging with intravenous indocyanine green (ICG) method or the modified inflation-deflation (MID) method and assess the feasibility and effectiveness of the ICG fluorescence (ICGF)-based method.@*METHODS@#We retrospectively analyzed the perioperative data in total 198 consecutive patients who underwent uniport VATS segmentectomy between February 2018 and August 2020. With the guidance of preoperative intelligent/interactive qualitative and quantitative analysis-three dimensional (IQQA-3D), the targeted segment structures could be precisely identified and dissected, and then the IBL was confirmed by ICGF-based method or MID method. Clinical effectiveness and postoperative complications of the two methods were evaluated.@*RESULTS@#An IBL was visible in 98% of patients by the ICGF-based group, even with the low-doses of ICG. The ICGF-based group was significantly associated with the shorter IBL clear presentation time [(23.59±4.47) s vs (1,026.80±318.34) s] (P0.05).@*CONCLUSIONS@#The ICGF-based method could highly accurately identify the IBL and make anatomical segmentectomy easier and faster, and therefore has the potential to be a feasible and effective technique to facilitate the quality of uniport VATS segmentectomy.