Update Course Rewind: Lipiodol for Lung Metastases 2024

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm M Godoy from Cincinnati Children's Hospital Medical Center. Our 12th annual update course in pediatric surgery was held past August. In this video series, we'll recap the sessions and share the main highlights with you. This year, we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories. Green circle for established practice, blue square for promising newer practice, and black diamond for early adopter practice only. Today, we will explore the use of Lipiodol for marking lung metastasis nodules with Dr. Gloria Gonzalez, a pediatric surgeon from Santiago, Chile. This topic is classified as a blue square for a newer practice. I'm going to talk about an old update because this is a, it's a technique that is used in adults and I bring it to the children. And I I'm talking about Lipiodol in Mets. Up to 50% of the patients have lung metastasis during their disease. In many cases, they have only one or two nodules. So, what are we going to do with that? Surgery can improve survival, we know that. We know that we have to take out all those nodules, and if we have one or two, we can do it minimally invasive. Let's see our first poll question. Is a 1 cm nodule. What's the rate of conversion due to failure to localize subdural nodules during thoracoscopy? The answer is 47%. That means the conversion rate is really high. And if you can't get a double tuning there, it's much higher. So what we are doing now? We can do many things with radiology. Localization with imaging during thoracoscopy, meaning ultrasound or fluoroscopy like CT guidance. Preoperative localization techniques vary such as dice, contrast media, radio nucleids, colored adhesive or hook wire placement. So which one are you using now? Why I don't want to use thoracoscopy images. CT, you're exposing the patient for radiation all the time. Ultrasound is difficult when you have really small nodules. In case of the osteosarcoma, the calcified lesions, they're really difficult to see. So there's no use in doing that. So why not use hook wire? Dislodgement. The rate reported for dislodgement is 2.4 to 22%. And in my case, because I don't have the CT in my OR, the patients have to go to the CT scan under anesthesia and go to the OR. And in that case, the dislodgement is much higher. What about methylene blue with the wire? Can't we see them both? We have seen methylene blue all over the chest, but not in the nodules too many times. And what about ICG? It is a really good option, but if you have a deeper nodule, like 2 centimeters deep in nodule, you cannot use ICG. So what I'm doing? Lipiodol. The marking procedure is done under CT guidance. There interventional radiologist mark the nodule with Lipiodol, a dye that remains in place for up to 3 months. I don't do the surgery the same day, if I can't, for example, I can do it one week later. And this is Dr. Gonzalez's setting in the OR. I put the C-arm under the patient, put the laparoscope, there's always some hematoma or something in the surface, and I'm looking at the images in the radioscopy. Put the stapler on, take it under the C-arm, if I got the Lipiodol spot, fire my stapler and take it out. Then Dr. Gonzalez verifies complete resection by radioscopy and palpation of the pulmonary nodule in the resected lung. Here are their results. They use Lipiodol in 33 patients. We have three or four nodules per patient, and not all of them are osteosarcoma. We have a Ewing sarcoma, Willms, infectious disease, like many, many, many, many histologies. And we have done like I said, 50 nodules with 100% sensitivity. That's awesome. Now, the last question. Would you consider changing your practice? In summary, Lipiodol is being adapted from adult procedures to mark pulmonary nodules in children and stays in place for up to three months, allowing flexible surgery timing. Traditional methods like CT, ultrasound, and hook wires might have issues like radiation exposure, dislodgement, and difficulty with small or calcified nodules. Dr. Gonzalez's Lipiodol technique achieved 100% sensitivity in 33 patients, making it a reliable alternative for nodule localization and resection. Thank you for watching this video. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.