Clinical application of mobile CT combined with basic anesthesia in the preoperative localization of multiple pulmonary nodules

doi:10.21203/rs.3.rs-4877520/v1

Objective

To evaluate the safety and efficacy of mobile CT combined with basic anesthesia for the preoperative localization of multiple nodules.

Methods

The clinical data of 200 patients who underwent CT-guided localization before single-port thoracoscopic pulmonary lobe surgery at our hospital from July 2023 to September 2023 were retrospectively analyzed. The patients were divided into two groups according to the localization method: Group A consisted of 100 patients who were localized under local anesthesia, and Group B consisted of 100 patients who were localized under basic anesthesia combined with local anesthesia. The general clinical data and localization data of the two groups were compared and analyzed.

Results

The incidence of localization complications in Group B was significantly lower than that in Group A (4% vs. 13%). The localization success rate in Group B was significantly greater than that in Group A (98% vs. 92%). The localization time in Group B was significantly shorter than that in Group A (15.23 ± 5.96 min vs. 19.90 ± 8.66 min), and the pain score in Group B was significantly lower than that in Group A (2.01 ± 2.09 min vs. 3.29 ± 2.54 min).

Conclusion

Compared with traditional local anesthesia, mobile CT combined with basic anesthesia for preoperative puncture localization of multiple pulmonary nodules results in a shorter localization time, fewer complications, greater safety, a greater success rate, and greater patient comfort, indicating that this method is safe and effective and has significant clinical value.

With the improvement of residents' health awareness and the popularization of high-resolution low-dose spiral CT, an increasing number of small pulmonary nodules have been detected[1]. The detection rate of multiple primary lung cancers is also increasing annually. Multiple primary lung cancers (MPLC) refer to the occurrence of two or more primary malignant tumors successively or simultaneously in the lungs of the same patient (one or both lung lobes). In the 1990s, it was reported in the relevant literature that the detection rate of MPLC was 0.2-2.0%, and after 2000, its detection rate continued to increase, reaching 8%[2]. Although the American Association of Thoracic Surgeons has repeatedly updated the information related to MPLC, there are currently no clinical guidelines or expert consensuses for the diagnosis and treatment of multiple small nodules in both lungs.

At present, the commonly used clinical management methods include the following: 1. Regular follow-up to evaluate changes in nodules; 2. Surgical intervention; 3. Ablation therapy; 4. Stereotactic radiotherapy[3]. However, long-term follow-up is likely to cause anxiety and increase the number of CT scans, leading to varying degrees of physical and mental damage to patients. For patients with a high suspicion of malignancy, extreme anxiety, and a significant impact on quality of life, surgical removal of lung nodules is necessary for a definitive diagnosis. Most surgical methods involve local resection of pulmonary nodules, aiming to preserve as much normal lung tissue as possible. Most multiple pulmonary nodules in both lungs are small, with few solid components, and some are located deep in the lung parenchyma, making them difficult to identify macroscopically during surgery. Therefore, the accurate localization of multiple nodules before surgery has become a key factor in successful surgery.

Currently, CT-guided percutaneous localization under local anesthesia is commonly used in clinical practice. However, as the number of nodules increases, it becomes more challenging for patients to maintain fixed positions, leading to lower success rates and a greater incidence of localization complications. The Department of Thoracic Surgery and Anesthesiology in our hospital has implemented basic anesthesia combined with local anesthesia for the localization of multiple pulmonary nodules using mobile CT, achieving good results. This study retrospectively analyzed recent cases of localization under basic anesthesia compared with traditional local anesthesia to evaluate and compare the safety and effectiveness of the two methods and to assess whether mobile CT combined with basic anesthesia has clinical value in the preoperative localization of multiple pulmonary nodules.

1.1 Clinical data

We retrospectively analyzed the clinical data of 200 patients who underwent CT-guided localization before thoracoscopic lung surgery at the Affiliated Brain Hospital of Nanjing Medical University from July 2023 to September 2023. The patients were divided into two groups based on the localization method: Group A consisted of 100 patients (49 males and 51 females) who were localized under local anesthesia (average age: 50.94±14.29 years); Group B consisted of 100 patients (45 males and 55 females) who were localized under basic anesthesia combined with local anesthesia (average age: 48.25±14.04 years).

Inclusion criteria:

(1) Preoperative imaging revealed two or more nodules in the patient's ipsilateral lung, with a maximum nodule diameter of less than 2 cm.

(2) The proportion of solid components in the nodules was less than 50%.

Exclusion criteria:

(1) Patients with pneumothorax, pleural effusion, or giant pulmonary bulla.

(2) Patients who underwent direct pulmonary lobectomy.

(3) Patients with coagulation dysfunction.

(4) Patients with severe emphysema or pulmonary fibrosis.

(5) Patients with serious cardiopulmonary disease who cannot tolerate surgery.

All patients were discussed by the departments before surgery, had indications for surgery, and met the requirements for preoperative localization. All patients were informed of the relevant risks in detail and signed informed consent before the localization procedure. This study was approved by the Ethics Committee of Nanjing Chest Hospital, Jiangsu Province (approval number: 2022-KY146-01).

1.2 Research Methods

Preoperative localization

Group A: A radiologist and a surgeon performed CT-guided localization of pulmonary nodules 0.5 to 1 hour before surgery. The localization position, needle insertion path, and injection angle were determined collaboratively by the radiologist and surgeon. Before injection, 5 ml of 2% lidocaine was used for local infiltration anesthesia along the insertion path. Finally, the tip of the localization needle was placed within 5 mm of the lung tissue around the lesion, and then 1 ml of methylene blue was injected into the localization area through the localization cannula for staining. The remaining nodules were sequentially located by the above method, and the patient could be transferred to the operating room for surgery by multiple medical personnel within 5 minutes after localization. During the operation, the localization needle was observed to be fixed on the lung tissue under thoracoscopy, and the localization was judged to be successful.

Group B: One radiologist, one anesthesiologist, and one operating physician were employed to locate pulmonary nodules under the guidance of mobile CT 0.5 to 1 hour before the operation. After the patient entered the localization and operation room, the anesthesiologist set up a loop with an intravenous indwelling needle and connected the ECG monitoring device to monitor pulse oxygen, heart rate, blood pressure, and respiratory rate.

Preparation of the basic anesthetic solution: One dexmedetomidine injection (2 ml: 200 µg) mixed with 0.9% sodium chloride (48 ml) was used to prepare a solution with a concentration of 4 µg/ml. Five milliliters of atropine was prepared to prevent bradycardia, blood pressure drop, and other adverse reactions during localization.

Basic anesthesia was applied prior to local anesthesia. The loading dose of dexmedetomidine injected was 0.5 µg/kg, which was administered 5 minutes before localization began, and then changed to 0.2 µg/kg for maintenance, along with an intravenous injection of 3-5 mg of oxycodone. The localization needle placement method was the same as that used in Group A. Patient sensation was intermittently assessed during the process, and the dose was adjusted as necessary. Administration was stopped 5 minutes before the end of the operation, as shown in Figure 1. The criteria for determining successful localization were the same as those for Group A.

Figure 1

Note: a is the anesthesiologist performing basic anesthesia for the patient; b is a mobile CT scan under basic anesthesia. c is for the surgical physician to perform puncture localization of pulmonary nodules with the assistance of radiologists; d is the insertion of multiple heel localization needles into the lung tissue near the target nodule.

1.2.2 Surgical methods

In uniportal thoracoscopic surgery, the fourth intercostal area of the anterior axillary line is usually used as the observation and operation hole for upper lobe nodules, while the fifth intercostal area is used for middle or lower lobe nodules. After intrathoracic exploration, the endoscope dragged the steel wire located on the body surface into the thoracic cavity, and the location of the nodule was determined according to the preoperative localization image and the position of the hookwire needle used during the operation. The lesion was then removed with a linear cutting and closing device, ensuring an incision margin > 2 cm, and sent for rapid pathology. The next surgical procedure was determined based on the pathological results and the patient's tolerance.

1.2.3 Observing indicators

Sex, age, medical history, history of COPD, smoking history, nodule location, nodule number, localization time, localization success rate, number of needle adjustments, and localization-related complications (pneumothorax, pleural reaction, and intrathoracic hemorrhage) were collected and compared between the two groups. Anesthesia adverse reactions (respiratory depression, nausea and vomiting, bradycardia, etc.) and patients' pain scores (rated by the Number Rating Scale (NRS) from 0 to 10, representing no pain to the most pain) were evaluated. Pain levels were classified as mild (1-3), moderate (4-6), or severe (7-10). The operation time, postoperative extubation time, and postoperative hospitalization time were also recorded. The localization time refers to the time from the first CT scan to the last CT scan.

2. Statistical analysis

SPSS 24.0 statistical software was used for data analysis. The measurement data are presented as the means±s.D.s. T tests were used for group comparisons consistent with the overall distribution, and nonparametric tests were used for group comparisons inconsistent with a normal distribution. Count data are expressed as frequencies and percentages, and chi-square tests were used for intergroup comparisons. A P value < 0.05 indicated statistical significance.

3.1 General clinical data of patients in the two groups

There were no significant differences between Group A and Group B in terms of sex, age, medical history, history of COPD, smoking history, nodule location, or nodule number (P > 0.05), as shown in Table 1.

Tab. 1 Comparison of basic data between the two groups (n=200, patients)

Group	male/female	Age	Number of Nodules
A	49/51	50.94±14.29	2.68±0.76
B	45/55	48.25±14.04	2.69±0.77
t/X²	0.181	0.269	0.092
P	0.671	0.789	0.837

3.2 Localization data of the two groups

The localization time of Group A was significantly longer than that of Group B [(19.9±8.66) min vs. (15.23±5.98) min, P < 0.05]. There were 11 cases of pneumothorax, 2 cases of intrapulmonary hemorrhage, and 8 cases of needle dislodgement in Group A, which were properly treated during the operation, allowing successful completion of the procedure. Two patients had pleural reactions, and the localization was temporarily suspended. After oxygen inhalation, the localization was successfully completed. In Group B, there were 3 cases of pneumothorax, 1 case of pulmonary hemorrhage, and 2 cases of needle dislodgement. The incidence of localization complications in Group B was significantly lower than that in Group A (4% vs. 13%, P < 0.05). The number of needle adjustments in Group A was significantly greater than that in Group B [(0.51±0.86) vs. (0.20±0.51), P < 0.05]. The localization success rate in Group B was significantly greater than that in Group A (98% vs. 92%, P < 0.05). The pain score in Group B was significantly lower than that in Group A [(2.01±2.09) vs. (3.29±2.54), P < 0.05], and this difference was statistically significant. One patient in Group B had a local allergic reaction to lidocaine, while no other patients had allergic reactions to anesthetic drugs, as shown in Table 2.

Tab. 2 Comparison of patient positioning data between the two groups (n=200)

Group	A（n=100）	B（n=100）	t/X²	P
Time required for localization	19.90±8.66	15.23±5.96	4.43	＜0.01
Number of needle adjustments	0.51±±0.86	0.20±0.51	3.10	＜0.01
Complications of localization	13	4	2.63	0.04
pneumothorax	11	3
Pleural reaction	2	0
Intrapulmonary hemorrhage	2	1
Success rate of localization（%）	92	98	2.63	0.04
Pain score	3.29±2.54	2.01±2.09	3.89	＜0.01

3.3 Surgical data of the two groups

The operation time, hospital stay, and postoperative extubation time were longer in Group A than in Group B, but the differences were not statistically significant (P > 0.05), as shown in Table 3. All patients successfully completed the operation and were discharged safely without serious adverse events.

Tab. 3 Comparison of surgical data between the two groups

Group	A（n=100）	B（n=100）	t	P
Operation time（min）	119.23±38.21	112.75±36.89	0.66	0.64
Postoperative extubation time（day）	3.84±1.42	3.55±1.48	1.41	0.55
Length of postoperative hospital stay（day）	5.70±1.91	4.80±1.51	3.69	0.051

In recent years, an increasing number of multiple small nodules in both lungs have been frequently detected. Studies have shown that approximately half of patients screened for lung cancer have multiple pulmonary nodules (MPNs)[4]. Most of these patients have no obvious symptoms or signs, making it difficult to determine the nature of MPNs through imaging and other auxiliary examinations. Surgical resection is currently the best method for diagnosing and treating suspected malignant pulmonary nodules. However, for small nodules and deep nodules within the lung parenchyma, it is challenging to determine their specific positions through macroscopic observation, finger palpation, or instrument clamps during endoscopy, especially for multiple pulmonary nodules. To achieve complete resection of multiple high-risk nodules, accurate preoperative positioning is particularly important. It helps doctors preserve patients' lung function as much as possible, reduces unnecessary trauma, and facilitates quick recovery postsurgery, thereby shortening hospital stays and improving patients' postoperative quality of life[5].

Currently, CT-guided percutaneous puncture positioning with a hookwire needle under local anesthesia is widely used clinically. This method is fast and simple, but potential complications such as pneumothorax, intrapulmonary hemorrhage, and pleural reaction are possible. These complications are related to patients' psychological and physiological conditions, underlying diseases, and iatrogenic factors[6]. Relevant studies have confirmed that patients often experience anxiety, panic, and other negative emotions before localization. During localization, a series of neuroendocrine effects may be induced, leading to a vagal reflex, which may result in pleural reactions and even endanger life[7]. Additionally, anxiety and pain can lead to rapid and deep breathing, increasing the difficulty of accurate positioning and the incidence of complications such as pneumothorax, bleeding, and positioning needle dislodgement. Compared with the preoperative localization of isolated pulmonary nodules, the incidence of these complications increases during the localization of multiple pulmonary nodules[8].

Basic anesthesia combined with local anesthesia aims to use the systemic analgesia and sedation provided by basic anesthesia to reduce patients' pain and the occurrence of mental and psychological adverse events, thereby achieving a safe and effective anesthetic effect[9]. Currently, dexmedetomidine is commonly used in various surgeries and endoscopic procedures, including breast surgery. Commonly used drugs include dexmedetomidine, propofol, remifentanil, oxycodone, and midazolam[10, 11]. Dexmedetomidine is a highly selective α2-adrenergic receptor agonist with excellent anesthetic effects and no significant respiratory inhibition. However, it may cause sinus bradycardia and decreased blood pressure[12]. Oxycodone is both an opioid receptor agonist and a κ receptor agonist that effectively reduces visceral pain and suppresses cough[13]. The injection of methylene blue stain during positioning can be irritating, inducing severe coughing in some patients, which complicates the release of the positioning needle for remaining nodules and increases the likelihood of complications such as pneumothorax, positioning needle displacement, and intrapulmonary hemorrhage. Studies have confirmed that oxycodone combined with dexmedetomidine can effectively relieve irritative cough and provide satisfactory sedation and analgesia without significant effects on the respiratory or circulatory system[14]. The results of this study also support this point.

In this study, dexmedetomidine combined with oxycodone basic anesthesia was applied for the preoperative localization of multiple pulmonary nodules. Patients did not experience hypotension, arrhythmia, respiratory depression, or other related anesthetic adverse reactions. The number of needle adjustments, pain scores, and positioning complications in Group A were significantly greater than those in Group B. This may be because patients in Group A could not maintain a fixed position due to pain and tension during positioning, causing the positioning needle to shift. Moreover, studies have confirmed that the incidence of pneumothorax and pleural reactions increases with the number of needle insertions[15]. This finding suggested that pain, fear, and tension were effectively relieved in patients under basic anesthesia combined with local anesthesia, accelerating the localization process and shortening the localization time. In this study, the localization time and success rate of Group B were significantly better than those of Group A, confirming this point.

According to clinical research reports from several medical institutions, patients positioned with Hookwire needles should remain as still as possible after positioning. Moving and changing body position may cause the positioning needle to shift, leading to unhooking, intrapulmonary bleeding, and increased patient pain. Therefore, VATS should be performed as soon as possible after positioning[16]. Hookwire positioning in a hybrid operating room can shorten the time from positioning to VATS and effectively reduce the incidence of related complications[17]. However, this application is limited by the small number of hybrid operating rooms and resource constraints[18–20]. In our hospital, the use of mobile CT positioning within the operating room greatly shortened the waiting time after positioning. Patients could enter the operating room for surgery within 5 minutes after positioning, reducing complications and improving patient comfort.

In summary, using basic anesthesia combined with local anesthesia for the preoperative localization of multiple pulmonary nodules under mobile CT is safe and reliable. Compared with traditional local anesthesia, this method has a greater localization success rate, a lower incidence of localization complications, and improved patient comfort. This method has significant clinical value.

The limitations of this study are as follows. First, it is a retrospective study with selection bias. Second, this was a single-center study with a small sample size. Despite these shortcomings, to our knowledge, this study is the first to apply basic anesthesia in combination with local anesthesia for the preoperative localization of pulmonary nodules.

Availability of date and materials

Any additional information can be obtained from the corresponding author on request.

Ethics approval and consent to participate

Not applicate.

Consent for publication
Not applicate.

Competing interests
The authors have declared that no competing interests exist.

Funding:

This research was supported by the Nanjing Special Fund for Key Research Projects (No. ZKX19046) and the Nanjing Medical University University-level Fund (No. NMUB20210228).

Author Contribution

The concept and the search strategy conducted by JSY, SF and SYG. The methodology was designed by JSY, SF, SYG. SF and ZQ performed the data extraction. JSY, SF and SYG wrote and edited the manuscript. All authors contributed to the article and approved the submitted version. All authors read and approved the final manuscript.

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No competing interests reported.

Clinical application of mobile CT combined with basic anesthesia in the preoperative localization of multiple pulmonary nodules

Status:

Version 1

Abstract

Figures

Introduction

Materials and methods

Results

Discussion

Declarations

Availability of date and materials

Ethics approval and consent to participate

Consent for publication
Not applicate.

Competing interests
The authors have declared that no competing interests exist.

Funding:

Author Contribution

References

Additional Declarations

Status:

Version 1

Clinical application of mobile CT combined with basic anesthesia in the preoperative localization of multiple pulmonary nodules

Status:

Version 1

Abstract

Figures

Introduction

Materials and methods

Results

Discussion

Declarations

Availability of date and materials

Ethics approval and consent to participate

Consent for publication Not applicate.

Competing interests The authors have declared that no competing interests exist.

Funding:

Author Contribution

References

Additional Declarations

Status:

Version 1

Consent for publication
Not applicate.

Competing interests
The authors have declared that no competing interests exist.