LOCALIZATION OF PULMONARY NODULES BEFORE THORACOSCOPIC SURGERY - VALUE OF PERCUTANEOUS STAINING WITH METHYLENE-BLUE

OBJECTIVE. Video-assisted thoracic surgery (VATS) is a new procedure t hat makes it possible to see the intrathoracic organs and to resect pu lmonary nodules without thoracotomy, Preoperative localization of smal l nodules that may not be visible or palpable during VATS is desirable , Percutaneous placement of spring hook wires is widely used to locali ze pulmonary nodules before VATS; infrequently, the adjacent lung pare nchyma is also stained with methylene blue. The purpose of this study was to evaluate the effectiveness of methylene blue staining of pulmon ary nodules without placement of a hookwire. SUBJECTS AND METHODS. Fif teen pulmonary nodules in 15 patients were localized preoperatively un der CT guidance by using techniques identical to those for CT-guided f ine-needle aspiration of pulmonary nodules. Approximately 0.3 mi of me thylene blue dye was injected into the nodule with a 22-gauge Chiba ne edle to stain the nodule, the needle pathway, and the visceral pleura. In two patients, a hookwire also was placed. All patients had solitar y nodules in which transbronchial or transthoracic biopsy had been uns uccessful. The mean nodule diameter was 16 mm (range, 8-33 mm), and th e mean distance to the nearest pleural surface was 10 mm (range, 0-21 mm). The localization procedure required a mean of 32 min (range, 18-4 7 min). RESULTS. All 15 nodules were stained successfully either in th e center or within the margins; the two hookwires were found to be dis placed, In three cases, pulmonary hemorrhage occurred as a complicatio n of the percutaneous staining procedure: in one case, subsequent conv ersion to thoracotomy was necessary owing to pulmonary hemorrhage and additional pleural bleeding during VATS, which resulted from puncture with a trocar directly into the pleural adhesions. Anticipated complic ations, such as pneumothorax, occurred in five patients; one patient h ad pleuritic pain, but none required treatment, In one patient, conver sion to thoracotomy was done so that an adenocarcinoma could be treate d by means of a lobectomy. In two others, thoracotomy was done because of problems with technical devices. CONCLUSION. Percutaneous staining of pulmonary nodules is an accurate technique for localizing nodules before VATS. The procedure is easily and safely performed, and it obvi ates wire-related complications, such as severe pleuritic pain.