# Pulmonary Metastases — GCMD Library living collection Everything in the library about pulmonary metastases — built automatically from dossiers that name it. Updated: n/a · 3 episodes · 66 cited statements ## Episodes ### Surgical Management - [Wilms Tumor Protocol Violations: 2018 Pediatric Surgery Practice Gap #3](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460) — video · [machine version](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460.md) - [Image Guided Surgery Video Series, Episode 2 - Lung Nodule Localization &...](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526) — podcast · 17:19 · [machine version](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526.md) - [Hybrid OR workflow for pediatric lung nodule localization and resection](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289) — podcast · 17:19 · [machine version](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289.md) ## Chapters - [0:00](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460?t=0) Wilms Tumor Protocol Violations Overview (Ep 1) - [0:00](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=0) Introduction and Pre-Hybrid OR Workflow (Ep 2) - [3:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=208) Intubation, Patient Transfer, and Wire Dislodgement Risk (Ep 2) - [6:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=388) Cone Beam CT Technique and Anesthesia Coordination (Ep 2) - [9:14](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=554) Complications, Multiple Lesions, and Image Resolution (Ep 2) - [11:47](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=707) Needle Advancement, 3D Rendering, and Visceral Pleura Puncture (Ep 2) - [16:40](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=1000) Closing Remarks (Ep 2) - [0:00](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=0) Introduction and pre-hybrid OR workflow (Ep 3) - [1:41](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=101) Localization techniques and wire dislodgement risk (Ep 3) - [5:06](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=306) Cone-beam CT imaging and respiratory coordination (Ep 3) - [8:15](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=495) Apnea technique, complications, and multiple lesions (Ep 3) - [11:47](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=707) Fluoroscopic guidance and 3D rendering (Ep 3) - [15:26](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=926) Draping strategy and visceral pleura puncture technique (Ep 3) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - Lymph nodes must be taken out during nephrectomy for Wilms tumor (guideline) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460?t=0) - Failure to take out lymph nodes automatically upstages Wilms tumor patients (guideline) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460?t=0) - There is both a local and systemic staging system for Wilms tumor (clinical) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460?t=0) - Pulmonary metastases do not preclude primary nephrectomy in Wilms tumor (guideline) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460?t=0) - Primary nephrectomy in metastatic Wilms tumor affects whether the patient receives radiation therapy (clinical) [Ep 1 · 0:00](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460?t=0) - There is a local stage for Wilms tumor and a patient staging for Wilms tumor — Erlick (clinical) [Ep 1 · 0:50](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460?t=50) - Omission of lymph node biopsies is a major protocol violation in Wilms tumor surgery — Erlick (opinion) [Ep 1 · 0:50](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-2018-pediatric-surgery-practice-gap-3-1460?t=50) - Pre-hybrid OR, lung nodule localization was done in CT scan downstairs, then patient brought upstairs to operating room, requiring movement of the patient. — Rajni Dasgupta (clinical) [Ep 2 · 1:17](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=77) - Localization typically done with Copan's breast localization needle and wire plus minus methylene blue blood patch. (clinical) [Ep 2 · 1:49](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=109) - More recently, localization done with microembolization coils, coils typically used for vascular embolization, advanced through Copan's needle with combination of microcoil and Copan's wire coming out in case wire becomes inadvertently pulled out during thoracoscopic resection. (clinical) [Ep 2 · 1:58](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=118) - Microcoil technique is very technically challenging; IR needs to practice beforehand to control the coil because it must be deployed in the right place. (clinical) [Ep 2 · 2:40](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=160) - Coils are smaller than guide needle for Copan; must be very careful and practice outside patient beforehand, must have holder for coils firmly established in hub, otherwise coil delivers in hub of Copan needle. (clinical) [Ep 2 · 2:40](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=160) - Patients always have double-lumen ET tube or bronchial blocker depending on size of patient. — Rajni Dasgupta (clinical) [Ep 2 · 3:45](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=225) - Pre-hybrid OR workflow: intubate in OR, transfer patient on stretcher down to CT, get off stretcher onto CT gantry/table, do CT scan and localization, get off CT table with wire in place protecting it hoping it won't get dislodged, transfer back up to OR, position in thoracoscopic position. — Rajni Dasgupta (clinical) [Ep 2 · 3:45](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=225) - There are a number of opportunities for wire to get dislodged in pre-hybrid OR workflow. (clinical) [Ep 2 · 4:35](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=275) - In hybrid OR, everything done more efficiently with less chance of wire becoming dislodged; when possible, position patient in thoracoscopic position to begin with so there's single prep and single draping. (clinical) [Ep 2 · 4:35](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=275) - Cone beam CT is a type of tomography where C-arm rotates around patient completely 360 degrees while capturing multiple images from different angles, basically like a CT but done with C-arm. — Denise Liu (clinical) [Ep 2 · 5:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=328) - Problems have been based on anesthesia staff not understanding the procedure. (clinical) [Ep 2 · 6:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=388) - One of most important aspects of chest procedures is respiration motion; anesthesia plays crucial role in controlling respiration and giving apnea at precise moment for targeting lung lesion. (clinical) [Ep 2 · 6:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=388) - Positioning important so procedure can be done in same position as thoracoscopy without having to re-drape. (clinical) [Ep 2 · 6:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=388) - To localize lesion, go to workstation, put green line on, click on lesion with mouse, click on skin, system draws the line; advantage is line can be adjusted to go directly through middle of intercostal space above ribs to avoid arteries and nerves below rib. (clinical) [Ep 2 · 6:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=388) - System arranges C-arm automatically in exactly the right position after planning line is drawn. (clinical) [Ep 2 · 6:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=388) - Put needle into pleura to check position and stabilize with blue towels; very important to do it quickly—don't put needle in, do scan, then wait and fiddle around or you get pneumothorax or other complications. (clinical) [Ep 2 · 6:28](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=388) - Really important to talk to anesthesiologist and explain need for same respiratory excursion whenever doing cone beam CT imaging, and that has to correspond to when actually advancing needle. (clinical) [Ep 2 · 7:54](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=474) - If cone beam CT done with full inspiration, location of nodule will be different in 3D than if done in full expiration; planned paths are planned from respiratory excursion from first CT, so unless same respiratory excursion when advancing needle, will be off target. (clinical) [Ep 2 · 7:54](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=474) - Even if complication occurs, most common one being pneumothorax, it's not a disaster—just put 5 French sheath or catheter and connect to low wall suction, which will take care of pneumothorax. (clinical) [Ep 2 · 9:14](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=554) - For lung biopsy, nodule has to be at least 1 centimeter because chasing after lung nodule is difficult. — Denise Liu (clinical) [Ep 2 · 9:40](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=580) - Cone beam CT can see nodules like traditional CT; for big nodules, turn dose down and use enough X-ray dose to get job done. (clinical) [Ep 2 · 10:23](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=623) - Cone beam CT has lung optimization module; able to see every small lesion seen on traditional CT downstairs diagnostically beforehand in hybrid OR upstairs. (clinical) [Ep 2 · 10:23](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=623) - Contrast resolution and spatial resolution of cone beam CT is just as good as traditional CT, in fact slightly better. (opinion) [Ep 2 · 10:23](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=623) - Can localize multiple lesions at same time; up to 3 have been done. (clinical) [Ep 2 · 11:04](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=664) - When doing multiple localizations, increased chance of pneumothorax, but just put small catheter in and suck it out. (clinical) [Ep 2 · 11:04](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=664) - If lesions all within same lobe, thoracic surgeon can take it all out; if in different lobes and worried they're of different etiology, can localize them, but usually just pick biggest one. — Denise Liu (clinical) [Ep 2 · 11:21](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=681) - Can give nodule segmentation coloring (e.g., little green dot) and do 3D rendering; can rotate image around in 3D space to understand nodule position relative to needle tip. (clinical) [Ep 2 · 12:59](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=779) - Actual imaging is super helpful, but also helpful to have interventionists in room for real-time discussion of needle position (medial, anterior, posterior) and confirmation. — Rajni Dasgupta (clinical) [Ep 2 · 13:24](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=804) - Radiologists and surgeons think slightly differently in 3D space; good to have trusted colleagues in all areas discussing together so it's very clear. (opinion) [Ep 2 · 13:50](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=830) - Interventionalists stay in room while positioning and surgery are done, or come back to room fairly frequently if must do something else. (clinical) [Ep 2 · 13:50](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=830) - Goal is to prep and drape once; rare occasion may require supine position rather than lateral decubitus depending on nodule location, but that's relatively rare. — Rajni Dasgupta (clinical) [Ep 2 · 15:00](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=900) - Limiting changing and movement helps ensure wire stays in place and saves time. — Rajni Dasgupta (clinical) [Ep 2 · 15:00](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=900) - Ideally, as advancing through parietal pleura and puncturing visceral pleura, inject a little methylene blue blood patch going down toward target. (clinical) [Ep 2 · 15:40](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=940) - For very peripheral nodules, if don't have decisive puncture through visceral pleura and are injecting fluid/methylene blue blood patch, can push away visceral pleural surface of lung; think you've got deep enough but haven't actually punctured through visceral pleura, so when deploy wire, wire won't be within lung. (clinical) [Ep 2 · 15:40](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=940) - Must be decisive when puncturing visceral pleura to avoid wire deployment outside lung. (clinical) [Ep 2 · 15:40](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=940) - Pre-hybrid OR, peripheral lung nodules that are deeper require localization in CT suite followed by patient transfer to OR upstairs — Rajni Dasgupta (clinical) [Ep 3 · 1:17](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=77) - Traditional localization uses Copan's breast localization needle and wire plus/minus methylene blue blood patch — John Riccadio (clinical) [Ep 3 · 1:49](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=109) - Deploying microcoils through Copan's needle is technically challenging and requires practice outside the patient; coil holder must be firmly established in hub or coil will deploy in the hub instead of the target — Neil Johnson (clinical) [Ep 3 · 3:08](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=188) - Patients undergoing lung nodule resection receive double-lumen endotracheal tube or bronchial blocker depending on patient size — Rajni Dasgupta (clinical) [Ep 3 · 3:39](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=219) - Pre-hybrid OR workflow: patient intubated in OR, transferred on stretcher to CT two floors down, moved onto CT table, scanned and localized, moved off CT table with wire protected, transferred back to OR, then repositioned for thoracoscopy — John Riccadio (clinical) [Ep 3 · 3:52](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=232) - Multiple transfer and repositioning steps create opportunities for wire dislodgement — John Riccadio (clinical) [Ep 3 · 4:35](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=275) - In hybrid OR, when nodule location permits, patient can be positioned in thoracoscopic position from the start, allowing single prep and drape with less chance of wire dislodgement — John Riccadio (clinical) [Ep 3 · 4:35](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=275) - Problems with chest procedures have been based on anesthesia staff not understanding the workflow — Neil Johnson (opinion) [Ep 3 · 6:23](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=383) - Positioning patient in same position as thoracoscopy from the start avoids need to re-drape — Neil Johnson (clinical) [Ep 3 · 6:46](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=406) - Trajectory planning is done at workstation by clicking on lesion and skin entry point; system draws the line and can adjust it to go through middle of intercostal space above the rib to avoid arteries and nerves below the rib — Neil Johnson (clinical) [Ep 3 · 6:57](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=417) - After trajectory planning, computer arranges C-arm automatically in exactly the right position — Neil Johnson (clinical) [Ep 3 · 7:26](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=446) - Needle is advanced to pleura and stabilized with blue towels; procedure must be done quickly without waiting or fiddling after needle insertion to avoid pneumothorax or other complications — Neil Johnson (clinical) [Ep 3 · 7:36](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=456) - Same respiratory excursion must be maintained during cone-beam CT imaging and during needle advancement; if respiratory excursion differs, needle will be off target because nodule location in 3D space changes with lung inflation — John Riccadio (clinical) [Ep 3 · 7:58](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=478) - Apnea without positive pressure (rather than CPAP of 20-25) is most reproducible and may reduce chance of pneumothorax — Neil Johnson (opinion) [Ep 3 · 8:59](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=539) - Cone-beam CT spatial and contrast resolution is just as good as traditional CT, possibly slightly better; every small lesion seen on diagnostic CT has been visible on hybrid OR cone-beam CT — Neil Johnson (clinical) [Ep 3 · 10:23](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=623) - Small nodules are not visible under plain fluoroscopy; without pre-procedure CT and live fluoroscopy superimposed with planned graphics, operator would be pushing blindly — John Riccadio (clinical) [Ep 3 · 12:04](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=724) - 3D rendering with nodule segmentation coloring allows rotation of image in 3D space to understand nodule position relative to needle tip — John Riccadio (clinical) [Ep 3 · 12:59](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=779) - Having interventional radiologist present in room during surgery for real-time discussion of wire position (anterior/posterior/medial) is helpful for confirming everyone is on same page — Rajni Dasgupta (opinion) [Ep 3 · 13:24](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=804) - Radiologists and surgeons think slightly differently in 3D space; having trusted colleagues from both specialties discuss together makes positioning very clear — Neil Johnson (opinion) [Ep 3 · 13:50](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=830) - Interventional radiologists stay in room during surgery when possible, or return frequently — Neil Johnson (clinical) [Ep 3 · 14:07](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=847) - Goal is to prep and drape patient once; positioning in lateral decubitus for thoracoscopy from the start limits movement and helps keep wire in place while saving time — Rajni Dasgupta (clinical) [Ep 3 · 15:00](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=900) - Rarely, nodule location may require supine positioning that differs from thoracoscopic position — Rajni Dasgupta (clinical) [Ep 3 · 15:05](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=905) - During needle advancement through parietal and visceral pleura, methylene blue blood patch is injected toward target — John Riccadio (clinical) [Ep 3 · 15:40](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=940) - For very peripheral nodules, if needle advancement is not decisive through visceral pleura and fluid is being injected, the visceral pleural surface can be pushed away; operator may think needle is deep enough when it has not actually punctured visceral pleura, resulting in wire deployment outside the lung — John Riccadio (clinical) [Ep 3 · 15:56](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=956) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - Radiographs are a shot in time, fluoroscopy gives real-time 2D images, and latest fluoroscopic machines can do cone beam CT which performs 360-degree scan of designated 3D volume, giving cross-section images. — Rod Gerardo summarizing the discussion [Ep 2 · 5:44](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=344) - Localization on CT is simple: draw line between skin surface and target on CT images; beauty of cross-sectional CT images is you can account for z-axis, giving 3D rendition or 3D space. — Rod Gerardo summarizing the discussion [Ep 2 · 5:44](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=344) - To ensure same respiratory effort, ask anesthesia colleagues to fully paralyze patient and disconnect tubes from ventilator so patient can exhale naturally and stop at very natural stopping point—most reproducible rather than having CPAP of 20 or 25. — Rod Gerardo summarizing the discussion [Ep 2 · 8:43](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=523) - Having no positive pressure reduces chance of pneumothorax. — Rod Gerardo summarizing the discussion [Ep 2 · 8:43](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=523) - If lesion is peripheral, high risk of pneumothorax; if lesion is more central, higher risk of pulmonary hemorrhage. — Anton Bash summarizing the discussion [Ep 2 · 10:03](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=603) - Under plain fluoroscopy, nodule that small can't be seen, so would be pushing blind without CT and planned graphics. — Anton Bash summarizing the discussion [Ep 2 · 11:47](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=707) - Display monitor shows live X-ray image with graphics and pre-op CT so can compare all images while doing procedure. — Rod Gerardo summarizing the discussion [Ep 2 · 12:27](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=747) - 3D rendering takes time; it's a tool in the armamentarium but may not be needed for every case. — Rod Gerardo summarizing the discussion [Ep 2 · 14:23](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=863) - Added benefit from technologist perspective: having surgeon and interventional radiologist in room helping staff physician so everyone's happy when they get in there. — Rod Gerardo summarizing the discussion [Ep 2 · 15:26](https://library.globalcastmd.com/watch/image-guided-surgery-video-series-episode-2-lung-nodule-localization-5526?t=926) - Dr. Johnson has started localizing with microembolization coils (typically used for vascular embolization) in combination with Copan's wire as backup in case wire is pulled out during thoracoscopic resection — John Riccadio summarizes what Dr. Neil Johnson said [Ep 3 · 2:09](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=129) - Cone-beam CT is performed by C-arm rotating 360 degrees around patient while capturing multiple images from different angles, creating cross-sectional images like traditional CT — Denise Liu summarizing the discussion [Ep 3 · 5:28](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=328) - CT localization accounts for z-axis by drawing a line between skin surface and target on cross-sectional images, providing 3D spatial information — Denise Liu summarizing the discussion [Ep 3 · 6:11](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=371) - Respiration motion control by anesthesia is crucial; anesthesia must provide apnea at precise moment for targeting lung lesion — Denise Liu summarizing the discussion [Ep 3 · 6:35](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=395) - To ensure reproducible respiratory effort, patient is fully paralyzed and ventilator tube is disconnected, allowing natural exhalation to a natural stopping point — Denise Liu summarizing the discussion [Ep 3 · 8:43](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=523) - Most common complication is pneumothorax, managed by placing 5-French sheath or UE catheter connected to low wall suction — Denise Liu summarizing the discussion [Ep 3 · 9:17](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=557) - Multiple lesions can be localized simultaneously; up to three have been done, though multiple localizations increase pneumothorax risk — Denise Liu summarizing the discussion [Ep 3 · 11:04](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=664) - If multiple lesions are in same lobe, thoracic surgeon can resect them together; if in different lobes with concern for different etiology, typically the largest lesion is targeted — Denise Liu summarizing the discussion [Ep 3 · 11:21](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=681) - Display monitor shows live X-ray image with graphics and pre-op CT for comparison during needle advancement — Rod Gerardo summarizing the discussion [Ep 3 · 12:36](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=756) - 3D rendering takes time; decision to use it is case-by-case based on whether it is needed or procedure can proceed efficiently without it — Denise Liu summarizing the discussion [Ep 3 · 14:23](https://library.globalcastmd.com/watch/hybrid-or-workflow-for-pediatric-lung-nodule-localization-and-resection-16289?t=863) ## Changelog - Oct 31: 3 items added automatically --- Educational content from recorded physician discussions — not medical advice. 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