The accuracy of cone-beam computed tomography and augmented fluoroscopy-guided bronchoscopic marking of multiple small-sized pulmonary nodules in a hybrid operating room: a retrospective cohort study

Background: For the minimally invasive excision of small-sized pulmonary nodules, bronchoscopic markings are increasingly being performed owing to advancements in video-assisted thoracic surgery (VATS). Hybrid operating room equipment is utilized for bronchoscopic VATS markings. We aimed to compare the marking accuracy between bronchoscopic VATS and other marking techniques such as computed tomography-guided percutaneous marking and conventional X-ray fluoroscopy-guided bronchoscopic marking. Methods: Patients with small-sized pulmonary nodules scheduled to undergo VATS were enrolled in the study. A mixture of 50 to 100 mu L of diluted indocyanine green and iopamidol was injected adjacent to the pulmonary nodules as a VATS marker. Patients receiving each of the three image-guided techniques were categorized into group A (computed tomography-guided percutaneous injection), group B (X-ray fluoroscopy-guided virtual bronchoscopy-assisted bronchoscope injection), and group C (cone-beam computed tomography and augmented fluoroscopy-guided virtual bronchoscope-assisted bronchoscopic injection in the hybrid operating room). VATS marking accuracy and procedural complications were compared among the three groups. Results: In total, 61 patients with 73 pulmonary nodules were eligible for analysis. VATS marking was successful for 15/16 nodules in group A, 28/30 nodules in group B, and 25/27 nodules in group C. Marking accuracy was 5.75 +/- 4.59, 15.00 +/- 14.02, and 6.05 +/- 6.11 (mm), respectively. Multiple markings were successful in 0/1 (0%), 5/6 (83.3%), and 5/5 (100.0%) nodules in groups A, B, and C, respectively. A small pneumothorax occurred in 3/15 (20.0%) patients in group A. Conclusions: The cone-beam computed tomography and augmented fluoroscopy-guided bronchoscopic approach performed in a hybrid operating room is accurate and equivalent to the computed tomographyguided percutaneous approach, and it enables the VATS marking of multiple pulmonary nodules without causing a secondary pneumothorax.