1 00:00:00,000 --> 00:00:07,160 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child 2 00:00:07,160 --> 00:00:08,840 health around the globe. 3 00:00:08,840 --> 00:00:10,840 Hello pediatric surgery family. 4 00:00:10,840 --> 00:00:15,120 I'm Em Gootee from Cincinnati Children's Hospital Medical Center. 5 00:00:15,120 --> 00:00:20,320 Our 12th annual update course in pediatric surgery was held past August. 6 00:00:20,320 --> 00:00:24,760 In this video series, we'll recap the sessions and share the main highlights with you. 7 00:00:24,760 --> 00:00:29,240 This year, we introduced a new approach to classify practice-changing ideas at our update 8 00:00:29,240 --> 00:00:30,400 course. 9 00:00:30,400 --> 00:00:33,680 Presentations now fall into three categories. 10 00:00:33,680 --> 00:00:39,840 Green Circle for established practice, Blue Square for promising newer practice, and Black 11 00:00:39,840 --> 00:00:42,640 Diamond for early adopter practice only. 12 00:00:42,640 --> 00:00:48,080 Today, we will explore the use of Lepidol for marking lung metastasis nodules with Dr. 13 00:00:48,080 --> 00:00:52,240 Gloria Gonzalez, a pediatric surgeon from Santiago, Chile. 14 00:00:52,240 --> 00:00:55,720 This topic is classified as a blue square for a newer practice. 15 00:00:55,720 --> 00:01:02,320 I'm going to talk about an old update because this is a technique that is used in adults 16 00:01:02,320 --> 00:01:04,920 and I bring it to the children. 17 00:01:04,920 --> 00:01:08,240 And I'm talking about Lepidol in meds. 18 00:01:08,240 --> 00:01:12,960 Up to 50% of the patients have lung metastasis during their disease. 19 00:01:12,960 --> 00:01:16,140 In many cases, they have only one or two nodules. 20 00:01:16,140 --> 00:01:18,200 So what are we going to do with that? 21 00:01:18,200 --> 00:01:19,520 Surgery can improve survival. 22 00:01:19,520 --> 00:01:20,520 We know that. 23 00:01:20,520 --> 00:01:23,600 We know that we have to take out all those nodules. 24 00:01:23,600 --> 00:01:26,720 And if we have one or two, we can do it minimally invasive. 25 00:01:26,720 --> 00:01:28,480 Let's see our first poll question. 26 00:01:28,480 --> 00:01:30,160 It's a one centimeter nodule. 27 00:01:30,160 --> 00:01:35,620 What's the rate of conversion to the failure to localize subdural nodules during thoracoscopy? 28 00:01:35,620 --> 00:01:37,880 The answer is 47%. 29 00:01:37,880 --> 00:01:40,760 That means the conversion rate is really high. 30 00:01:40,760 --> 00:01:44,860 And if you can get a double to them there, it's much higher. 31 00:01:44,860 --> 00:01:50,080 So what we are doing now, we can do methods with radiology. 32 00:01:50,080 --> 00:01:55,880 Conversion with imaging during thoracoscopy, meaning ultrasound or fluoroscopy like CT 33 00:01:55,880 --> 00:01:56,880 guidance. 34 00:01:56,880 --> 00:02:02,880 Preoperative localization techniques vary, such as dyes, contrast media, radionuclease, 35 00:02:02,880 --> 00:02:06,760 color adhesive, or hook wire placement. 36 00:02:06,760 --> 00:02:09,880 So which one are you using now? 37 00:02:09,880 --> 00:02:15,200 Why I don't want to use thoracoscopy images. 38 00:02:15,200 --> 00:02:19,640 CT, you're exposing the patient for radiation all the time. 39 00:02:19,640 --> 00:02:23,660 Conversion is difficult when you have really small nodules. 40 00:02:23,660 --> 00:02:28,520 In case of the osteosarcoma, the calcified lesions, they're really difficult to see. 41 00:02:28,520 --> 00:02:30,860 So there's no use in for that. 42 00:02:30,860 --> 00:02:32,720 So why not use hook wire? 43 00:02:32,720 --> 00:02:33,720 Dislodgement. 44 00:02:33,720 --> 00:02:37,440 The rate reported for dislodgement is 2.4 to 22%. 45 00:02:37,440 --> 00:02:45,280 And in my case, because I don't have the CT in my OR, the patients have to go to the CT 46 00:02:45,280 --> 00:02:49,480 scan under anesthesia and go to the OR. 47 00:02:49,480 --> 00:02:52,720 And in that case, the dislodgement is much higher. 48 00:02:52,720 --> 00:02:54,920 What about methylene blue with the wire? 49 00:02:54,920 --> 00:02:56,400 Can't we see them both? 50 00:02:56,400 --> 00:03:03,200 We have seen methylene blue all over the chest, but not in the nodules too many times. 51 00:03:03,200 --> 00:03:04,200 And what about ICG? 52 00:03:04,200 --> 00:03:10,000 It is a really good option, but if you have a deeper nodule like 2cm deeper nodule, you 53 00:03:10,000 --> 00:03:11,540 cannot use ICG. 54 00:03:11,540 --> 00:03:13,680 So what I'm doing, DPIO though. 55 00:03:13,680 --> 00:03:16,960 The marking procedure is done under CT guidance. 56 00:03:16,960 --> 00:03:21,920 Where interventional radiologists mark the nodule with Lepidol, a dye that remains in 57 00:03:21,920 --> 00:03:24,880 place for up to three months. 58 00:03:24,880 --> 00:03:27,400 I don't do the surgery the same day. 59 00:03:27,400 --> 00:03:30,640 If I can't, for example, I can do it one way later. 60 00:03:30,640 --> 00:03:33,800 And this is Dr. Gonzalez's setting in the OR. 61 00:03:33,800 --> 00:03:37,480 I put the C-Arc under the patient, put the laparoscope. 62 00:03:37,480 --> 00:03:41,120 There's always some hematoma or something in the surface. 63 00:03:41,120 --> 00:03:48,840 And I'm looking at the images in the radioscopy, put the stapler on, take it under the C-Arc. 64 00:03:48,840 --> 00:03:54,960 If I got the Lepidol spot, fire my stapler and take it out. 65 00:03:54,960 --> 00:04:00,280 Then Dr. Gonzalez verifies complete resection by radioscopy and palpation of the pulmonary 66 00:04:00,280 --> 00:04:02,360 nodule in the resected lung. 67 00:04:02,360 --> 00:04:03,600 Here are their results. 68 00:04:03,600 --> 00:04:07,000 They use Lepidol in 33 patients. 69 00:04:07,000 --> 00:04:12,240 We have three or four nodules per patient and not all of them are osteosarcoma. 70 00:04:12,240 --> 00:04:18,840 We have adduasarcoma, Wilms, infectious disease, like many, many, many, many studies. 71 00:04:18,840 --> 00:04:24,120 And we have done, like I said, 50 nodules with 100% sensitivity. 72 00:04:24,120 --> 00:04:25,120 That's awesome. 73 00:04:25,120 --> 00:04:26,640 Now the last question. 74 00:04:26,640 --> 00:04:29,440 Would you consider changing your practice? 75 00:04:29,440 --> 00:04:34,200 In summary, Lepidol is being adapted from adult procedures to mark pulmonary nodules 76 00:04:34,200 --> 00:04:40,480 in children and stays in place for up to three months, allowing flexible surgery timing. 77 00:04:40,480 --> 00:04:45,080 Traditional methods like CT, ultrasound, and hook wires might have issues like radiation 78 00:04:45,080 --> 00:04:49,560 exposure, dislodgement, and difficulty with small or calcified nodules. 79 00:04:49,560 --> 00:04:56,480 Dr. Gonzalez's Lepidol technique achieved 100% sensitivity in 33 patients, making it 80 00:04:56,480 --> 00:05:00,280 a reliable alternative for nodule localization and resection. 81 00:05:00,280 --> 00:05:03,920 Thank you for watching this video. 82 00:05:03,920 --> 00:05:09,280 Double cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child 83 00:05:09,280 --> 00:05:34,480 health around the globe.