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F14. A novel technique for resection of subcentimeter pulmonary nodules combining radiotracer localization with 1318-nm Nd:YAG laser excision
Brendon M Stiles, Talissa A. Altes, Patrice K. Rehm, Brian M. Trotta, Anthony J. Herring, Juan Olazagasti, Bijoy Kundu, Mark B. Williams, Thomas M. Daniel; Charlottesville, VA
Objective: Subcentimeter pulmonary nodules are frequently detected during the radiographic evaluation of smokers. Although these lesions may represent early lung cancers, they often cannot be reliably biopsied percutaneously. Surgical localization and excision of subcentimeter pulmonary nodules using current techniques necessitates the removal of relatively large amounts of lung tissue in order to incorporate the lesion in the specimen. A technique to reliably localize and resect small nodules without removing significant normal lung tissue is needed. The purpose of this study was to test the feasibility of radiotracer localization combined with YAG laser dissection, for lung-sparing resection.
Methods: Technetium 99m radiotracer solution was injected into the lungs of pigs at depths up to 1cm following thoracotomy. Thoracoscopic localization of preexisting lung nodules by this technique has been previously described by our group. Lesions were identified with a gamma radioprobe at surgery. A novel Nd:YAG laser (1318-nm) was used to dissect the lesion from the surrounding lung parenchyma. This laser has a higher absorption coefficient and lower extinction coefficient than standard lasers (1064-nm) used in thoracic surgery. This allows for a distinct and broad coagulation zone with a small rim of residual lung necrosis. After removal, specimens were examined radiographically and grossly to determine accuracy of resection and size. Thoracotomies were closed after placement of pleural drainage tubes.
Results: Eight lung lesions were created in 4 pigs. All lesions were successfully localized with the gamma radioprobe and completed resected with 2-3mm margins. No stapling devices or bioadhesives were used. Average specimen size was 1.8 (±0.2)cm3. Average chest tube drainage was 14 (±1.7)cc. No air leaks were identified.
Conclusions: Outside of the USA, The 1318-nm Nd:YAG laser has been safely used for resection of metastatic lung lesions in human patients. In this study, we demonstrated the feasibility of localizing artificial pulmonary lesions with a gamma probe using radiotracer localization and in subsequently resecting them with the novel YAG laser. This combined method allowed for precise localization and dissection, with excellent hemostasis and pneumostasis. Clinically, this parenchyma-sparing technique could be used for resection of subcentimeter indeterminate pulmonary nodules or for metastatectomy. While the current trials using the 1318-nm Nd:YAG laser require open thoracotomy to localize lung lesions, we believe that by combining radiotracer localization with the laser resection, thoracoscopic resection will become feasible.
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