Editorial
Hybrid Procedures for Pulmonary Nodule Resection: The Beginning of a New Era
Procedimientos híbridos para la resección de nódulos pulmonares: el comienzo de una nueva era
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array:1 [ 0 => array:4 [ "autoresLista" => "Andrés Obeso, Hicham Abada, Redha Souilamas" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Andrés" "apellidos" => "Obeso" "email" => array:1 [ 0 => "andresobca@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Hicham" "apellidos" => "Abada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Redha" "apellidos" => "Souilamas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Imaging Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Procedimientos híbridos para la resección de nódulos pulmonares: el comienzo de una nueva era" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although hybrid procedures have been used for some time in surgical specialties such as vascular surgery or neurosurgery, they have been introduced only relatively recently in thoracic surgery, primarily for the simultaneous localization and resection of pulmonary nodules in a single diagnostic-therapeutic procedure. The use of these techniques has increased steadily over the past few years. This is due in part to the increasingly frequent detection of small pulmonary nodules with part-solid or pure ground glass features, which can be a challenge to locate during surgery, especially in minimally invasive procedures using either Video Assisted Thoracic Surgery (VATS) or robotic procedures.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A series of image-guided techniques are now available to help locate pulmonary nodules as part of the hybrid process.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Transthoracic Insertion of Metal Needles (Hook Wires, Microcoils)</span><p id="par0015" class="elsevierStylePara elsevierViewall">Since the 1990s,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> pulmonary nodules have been located with the transthoracic insertion of a hook wire, generally in the radiology room a few hours before surgery. A hybrid approach offers a series of advantages over the conventional sequential 2-step procedure: it avoids patient discomfort and stress during transfer between the radiology room and the operating room, reduces the chance of displacement of the hook wire, obviates the need for chest tubes in the case of pneumothorax, and reduces the anesthetic risk, as the procedure is performed with a single induction. In 2015, Gill et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> published a phase I-II clinical trial in which they analyzed the safety and perioperative outcomes of this new hybrid workflow. They studied a series of 23 adults with solid or part-solid pulmonary nodules and ground glass opacities measuring less than 30<span class="elsevierStyleHsp" style=""></span>mm, who were candidates for atypical segmentectomy using VATS. T-bar fiducials were successfully placed in 87% of the patients, allowing the pulmonary nodule to be localized. Dislodgement occurred in only 3 cases. Nevertheless, all patients underwent complete resection with no surgical conversion. Only 2 patients (8.6%) developed iatrogenic pneumothorax during the implantation of the fiducial. Three patients (13%) had postoperative complications, and all patients survived. These results led the authors to conclude that this transthoracic hybrid approach is feasible, safe, and effective.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Another alternative is the percutaneous insertion of microcoils. These are radiopaque titanium coils that are inserted into the lung parenchyma, near the nodule, leaving one of the ends in the visceral pleura. These characteristics allow the visualization, palpation, and even the localization of the microcoil by fluoroscopy, and confirm the correct position of the endostapler. The success rate for marking and resection is very high, approaching 100%.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Finley et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> concluded in a prospective randomized study that this technique reduces the need for thoracotomies or anatomical lung resection in the surgical treatment of small and peripheral pulmonary nodules.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Electromagnetic Navigational Bronchoscopy-Guided Dye Marking</span><p id="par0025" class="elsevierStylePara elsevierViewall">This technique can be used to mark peripheral pulmonary nodules by injecting dye, usually methylene blue, once the locatable electromagnetic guide reaches its target during the navigational procedure. One of the advantages of the hybrid operating room is that we can use the Cone-Beam Computed Tomography (CBCT) scan to check the correct position of the catheter, correct any electromagnetic navigational error, especially in subcentimeter nodules, and, thus, increase the accuracy of the marking.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Most studies of this technique are purely descriptive, and they all report optimal outcomes.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6–12</span></a> The percentage of success in marking nodules ranges from 79% to 100%, with a mean electromagnetic navigational time of 18<span class="elsevierStyleHsp" style=""></span>minutes<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> or 28<span class="elsevierStyleHsp" style=""></span>minutes,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> depending on the series. The main cause of failure to mark the lesion is extravasation of the dye into the pleural cavity, preventing correct localization. Only 1 study has analyzed the variables that might influence the efficacy of the technique.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> The authors conclude that the larger the lesion and the nearer it is to the visceral pleura, the greater the chance of success, although their results were not statistically significant. The percentage of postoperative complications is low (0%-6.8%), and no postoperative deaths within 30 days have been reported.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6–10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Transthoracic Dye Marking</span><p id="par0035" class="elsevierStylePara elsevierViewall">This hybrid procedure was described by Yan et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> in 2016. After interoperative CT, syngo needle guidance software (Siemens Healthcare GmbH, Forchheim, Germany) with skin laser projection can be used to calculate the direction of the needle and its point of entry into the skin. When the needle is introduced and its correct position has been confirmed by a second CT, 0.2<span class="elsevierStyleHsp" style=""></span>ml of dye is then instilled into the lesion. When the camera is introduced, the pleural surface with the blue-dyed nodule is visualized, and the lung resection is then performed. According to data from Yan et al., the pulmonary lesions could be correctly localized in 23 of 25 patients (92%). The mean time for localization was 46<span class="elsevierStyleHsp" style=""></span>minutes, and the mean surgical time was 109<span class="elsevierStyleHsp" style=""></span>minutes. Two patients (8%) had complications during the localization phase (transdiaphragmatic hepatic puncture, complete pneumothorax). Although outcomes are good, more prospective, randomized studies are needed to analyze the efficacy and safety of the technique.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Combined Hybrid Procedures</span><p id="par0040" class="elsevierStylePara elsevierViewall">Two publications in the literature<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">14,15</span></a> describe the hybrid approach using a combination of several of the techniques mentioned above, but the current evidence is insufficient to assess these combined procedures.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary, resection of pulmonary nodules using hybrid techniques is increasingly common, due to improved detection of subcentimeter, subsolid or ground glass lesions. However, there are still very few hospitals which perform these multidisciplinary procedures, due to limited resources and the lack of hybrid operating rooms. To further the development of these procedures, more studies are needed to establish the efficacy and perioperative outcomes of these techniques, along with a precise analysis of the economic aspects to examine their use and cost-effectiveness. The best approach may be to start a hybrid thoracic surgery program, using already familiar procedures, such as the transthoracic implantation of metal needles. Other more complex techniques, such as the use of the electromagnetic navigation in the marking of pulmonary nodules, could then follow.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Transthoracic Insertion of Metal Needles (Hook Wires, Microcoils)" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Electromagnetic Navigational Bronchoscopy-Guided Dye Marking" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Transthoracic Dye Marking" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Combined Hybrid Procedures" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Obeso A, Abada H, Souilamas R. Procedimientos híbridos para la resección de nódulos pulmonares: el comienzo de una nueva era. Arch Bronconeumol. 2018;54:183–184.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous localization of pulmonary nodules for thoracoscopic lung resection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.J. Mack" 1 => "M.J. Gordon" 2 => "T.W. Postma" 3 => "M.S. Berger" 4 => "R.J. Aronoff" 5 => "T.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 1 | 3 |
| 2024 October | 46 | 27 | 73 |
| 2024 September | 49 | 31 | 80 |
| 2024 August | 71 | 47 | 118 |
| 2024 July | 47 | 30 | 77 |
| 2024 June | 73 | 41 | 114 |
| 2024 May | 82 | 32 | 114 |
| 2024 April | 53 | 30 | 83 |
| 2024 March | 60 | 24 | 84 |
| 2024 February | 35 | 24 | 59 |
| 2024 January | 1 | 0 | 1 |
| 2023 March | 18 | 4 | 22 |
| 2023 February | 79 | 28 | 107 |
| 2023 January | 42 | 36 | 78 |
| 2022 December | 62 | 44 | 106 |
| 2022 November | 82 | 36 | 118 |
| 2022 October | 105 | 41 | 146 |
| 2022 September | 56 | 27 | 83 |
| 2022 August | 33 | 51 | 84 |
| 2022 July | 42 | 52 | 94 |
| 2022 June | 32 | 36 | 68 |
| 2022 May | 29 | 31 | 60 |
| 2022 April | 35 | 31 | 66 |
| 2022 March | 37 | 40 | 77 |
| 2022 February | 38 | 21 | 59 |
| 2022 January | 33 | 46 | 79 |
| 2021 December | 26 | 36 | 62 |
| 2021 November | 39 | 50 | 89 |
| 2021 October | 42 | 48 | 90 |
| 2021 September | 30 | 46 | 76 |
| 2021 August | 31 | 43 | 74 |
| 2021 July | 16 | 24 | 40 |
| 2021 June | 28 | 46 | 74 |
| 2021 May | 38 | 44 | 82 |
| 2021 April | 79 | 55 | 134 |
| 2021 March | 39 | 19 | 58 |
| 2021 February | 24 | 20 | 44 |
| 2021 January | 32 | 11 | 43 |
| 2020 December | 30 | 19 | 49 |
| 2020 November | 27 | 16 | 43 |
| 2020 October | 31 | 23 | 54 |
| 2020 September | 50 | 11 | 61 |
| 2020 August | 86 | 11 | 97 |
| 2020 July | 44 | 26 | 70 |
| 2020 June | 19 | 9 | 28 |
| 2020 May | 21 | 14 | 35 |
| 2020 April | 32 | 14 | 46 |
| 2020 March | 13 | 15 | 28 |
| 2020 February | 34 | 33 | 67 |
| 2020 January | 26 | 8 | 34 |
| 2019 December | 32 | 13 | 45 |
| 2019 November | 33 | 17 | 50 |
| 2019 October | 28 | 17 | 45 |
| 2019 September | 46 | 18 | 64 |
| 2019 August | 31 | 23 | 54 |
| 2019 July | 18 | 25 | 43 |
| 2019 June | 25 | 26 | 51 |
| 2019 May | 41 | 17 | 58 |
| 2019 April | 39 | 15 | 54 |
| 2019 March | 35 | 17 | 52 |
| 2019 February | 38 | 21 | 59 |
| 2019 January | 62 | 22 | 84 |
| 2018 December | 38 | 17 | 55 |
| 2018 November | 46 | 28 | 74 |
| 2018 October | 73 | 19 | 92 |
| 2018 September | 0 | 2 | 2 |
| 2018 April | 0 | 1 | 1 |
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