Ultrathin bronchoscopic barium marking with virtual bronchoscopic navigation for fluoroscopy-assisted thoracoscopic surgery

Study objectives: To facilitate marking and to reduce its complications, we performed barium marking using an ultrathin bronchoscope with virtual bronchoscopic (VB) navigation before thoracoscopic surgery for small pulmonary peripheral lesions. We then evaluated the feasibility, safety, and efficacy of this technique. Design: A pilot study. Setting: A tertiary teaching hospital. Patients: The subjects were consecutive patients with small pulmonary peripheral lesions (ie, less than or equal to 10 mm) showing a CT scan-confirmed pure ground-glass opacity pattern between December 2001 and August 2003. Interventions: NIB images to the planned marking sites near each lesion were produced from helical CT scan data. Based on these images, an ultrathin bronchoscope was advanced to the target bronchus under direct vision. Under CT scan and radiographic fluoroscopy, a catheter was inserted to the planned site via the bronchoscope, and barium sulfate suspension was instilled for marking. Results: The subjects were 23 patients (8 men and 15 women) who had a total of 31 lesions. The bronchial branching patterns seen in VB images were highly consistent with those confirmed using the ultrathin bronchoscope. Therefore, the ultrathin bronchoscope could be guided under direct vision to a median of the sixth generation bronchi (range, fourth to ninth generation bronchi) toward the planned marking sites. Marking was achieved without causing complications in any of the patients. The median marking time was 23.5 min, and the median shortest distance between the barium inarker and the lesion was 4 mm (within 10 mm in 27 lesions). In patients undergoing thoracoscopic surgery, all barium-marked sites were identified by intraoperative radiographic flouroscopy, and all lesions were resected. A pathologic examination demonstrated primary lung cancer in 17 lesions (bronchioloalveolar carcinoma, 15; adenocarcinoma, 2), atypical adenomatous hyperplasia in 12 lesions, and pneumonia in 2 lesions. Conclusions: This method can be readily performed without complications and is a useful marking method before thoracoscopic surgery for small pulmonary peripheral lesions.