Puncture frequency predicts pneumothorax in preoperative computed tomography-guided lung nodule localization for video-assisted thoracoscopic surgery

Abstract

Background: Iatrogenic pneumothorax is the most frequent complication in preoperative CT-guided localization (POCTGL) of lung nodules. We aimed to determine the predictive factors of iatrogenic pneumothorax.

Methods: We retrospectively analyzed data of consecutive POCTGL procedures in patients who received video-assisted thoracoscopic surgery (VATS) at our hospital between May 2015 and October 2019. All of our patients utilized laser angle guide assembly to aid in the localization procedures.

Results: In 610 consecutive POCTGL procedures, 40 (6.6%) patients developed iatrogenic pneumothorax, and complications occurred in 8.5%. Univariate analyses revealed that puncture frequency, male gender, puncture depth, left decubitus position, and nodule near fissure were factors associated with pneumothorax, while multivariate analysis showed that only male gender (odds ratio 3.58, p = 0.012) and puncture frequency (odds ratio 2.39/time, p = 0.0004) determined development of pneumothorax. Further collective analysis on puncture frequency revealed that tumor in a difficult zone (1.33 ± 0.71 vs. 1.19 ± 0.45, p = 0.002), especially adjacent to the mediastinum (1.41 ± 0.75 vs. 1.21 ± 0.52, p = 0.002), angle difference of plan-to-practice (r = 0.209, p = < 0.001), depth to skin (r = 0.152, p < 0.001), and depth to pleura (r = 0.164, p < 0.001) were factors related to increased puncture frequency in univariate analyses. Only angle difference of plan-to-practice was associated in multivariate analysis (odds ratio: 1.158, p = 0.008).

Conclusions: Puncture frequency was the key factor in the development of iatrogenic pneumothorax from POCTGL. Other associated factors, especially angle difference, may have affected the puncture frequency and subsequently have some influence on the incidence of iatrogenic pneumothorax.

Keywords: iatrogenic pneumothorax; preoperative CT guided localization; pulmonary nodule; video-assisted thoracoscopic surgery.

FIGURE 1

The laser angle guide assembly (LAGA) system was used to aid in the angle precision of puncture. (a) Angle of the LAGA was established according to the computed tomography (CT) scan. (b) Precise puncturing of the needle was achieved along the intersection of the two laser lines

FIGURE 2

Computed tomography (CT) scan demonstrating the puncture angle to be identical to the planned angle (green laser beam), in reference to the gravity line (red laser beam)

FIGURE 3

The dimpling of visceral pleura during preoperative CT‐guided localization (POCTGL). (a) A hookwire with the sheath needle punctured through the pleura and pleura dimpling occurred. (b) The sheath needle was withdrawn, and the dimpled visceral pleura returned attached firmly with the parietal pleura without air in the pleural space. (c) A spinal needle was used to try to puncture through the visceral pleura in the case with iatrogenic pneumothorax. The visceral pleura lost its negative pressure, outward support, strength, and showed a deep dimple