Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted Lung Cryobiopsies
Summary
This article aims to describe a stepwise approach to performing robotic-assisted bronchoscopy combined with fluoroscopy, radial endobronchial ultrasound, and cone beam computed tomography to obtain targeted transbronchial lung cryobiopsies.
Abstract
Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways under direct vision after establishing a pathway to a target lesion based on mapping performed on a 3-dimensional (3D) lung and airway reconstruction obtained from a pre-procedure thin-slice computed tomography chest. RAB has maneuverability to distal airways throughout the lung, precise catheter tip articulation, and stability with the robotic arm. Adjunct imaging tools such as fluoroscopy, radial endobronchial ultrasound (r-EBUS), and cone beam computed tomography (CBCT) can be used with RAB. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profiles in both malignant and non-malignant processes for the biopsy of peripheral pulmonary lesions (PPLs). A 1.1 mm cryoprobe combined with ssRAB has been shown to be safe and effective for the diagnosis of PPLs compared to a traditional bronchoscopy with forceps biopsy. This technique can also be used for targeted lung sampling in benign processes. The aim of this article is to describe a stepwise approach to performing RAB combined with fluoroscopy, r-EBUS, and CBCT to obtain targeted transbronchial lung cryobiopsies (TBLC).
Introduction
Flexible bronchoscopy with transbronchial lung biopsy (TBBX) is a diagnostic modality used for the evaluation of abnormal chest imaging, including masses, nodules, non-resolving infiltrates, or parenchymal lung diseases1. Diffuse parenchymal lung diseases (DPLD) can often be characterized by fibrosis and/or inflammation. While some patients can be diagnosed noninvasively with a thorough history, physical examination, relevant serologies, high-resolution computed tomography (HRCT) findings, and multi-disciplinary discussion (MDD), many patients need an invasive procedure to establish a diagnosis2. Conventional transbronchial lung biopsies with forceps are limited due to small biopsy size and crush artifacts; as a result, surgical lung biopsy has been considered the gold standard, although it has significant morbidity and mortality3,4.
Transbronchial lung cryobiopsy (TBLC) is a technique that can be used to diagnose interstitial lung disease (ILD) or diffuse parenchymal lung disease (DPLD) and might serve as an alternative to surgical lung biopsy (SLB)5. According to the European Respiratory Society guidelines, TBLC is recommended as a substitute for SLB in eligible patients6. Similarly, the American Thoracic Society guidelines offer a conditional recommendation for TBLC as an alternative to SLB in medical centers with the necessary expertise in performing and interpreting TBLC results7. TBLC has historically provided good accuracy in diagnosis compared to SLB but is limited by complications, including bleeding and pneumothorax8. A recent meta-analysis showed an overall diagnostic yield of 77% that improved to 80.7% with MDD, and reported a pneumothorax rate of 9.2% and bleeding rate of 9.9%9. TBLC is also used in the evaluation of PPLs10.
The development of robotic-assisted bronchoscopy (RAB) allows for targeted sampling in the lung by navigating through the airways under direct vision with easy catheter maneuverability, precise catheter tip articulation, stability, and the ability to maintain a bronchoscopic wedge in distal airways with the catheter using a robotic arm. The Ion endoluminal system utilizes shape-sensing technology for navigation to access specific targeted areas in the lung. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profile, primarily for PPLs suspicious of malignancy11,12,13,14. A 1.1 mm cryoprobe for TBLC combined with ssRAB has been shown to be safe and effective for the diagnosis of pulmonary nodules compared to transbronchial biopsy with forceps15. This technique can be used to obtain targeted lung biopsies larger than conventional transbronchial biopsies using forceps that are relatively free of crush artifacts.
Radial endobronchial ultrasound (r-EBUS) and cone beam computed tomography are used in conjunction with conventional bronchoscopy, electromagnetic, or robotic navigational systems for real-time confirmation prior to sampling PPLs16,17,18,19,20,21,22. R-EBUS has also been utilized during TBLC for DPLD to increase the pathologic confidence of lung specimens, decrease bleeding, and have a shorter procedure time23. The addition of CBCT has improved the safety profile of TBLC for DPLD by confirming the probe tip is in a safe zone for biopsy, allowing objective measurement of the distance from the pleura with the ability to visualize and avoid vasculature24,25,26.
This protocol will describe a procedure to obtain targeted TBLC in the setting of parenchymal lung disease for patients who are able to tolerate and benefit from the procedure using the Ion endoluminal system in conjunction with fluoroscopy, r-EBUS, and CBCT in a clinical setting under general anesthesia. This multimodal approach allows for precise sampling of targeted areas of interest.
Protocol
Representative Results
Discussion
This manuscript provides a stepwise approach for performing RAB with fluoroscopy, r-EBUS, and cone beam CT to obtain targeted TBLC.
There are several critical steps in this protocol. First, patient selection is imperative to ensure patients are both appropriate candidates (the biopsy procedure may have a direct impact on diagnosis and further care) and medically able to undergo the procedure5,6. Pre-procedure preparation includes…
Declarações
The authors have nothing to disclose.
Acknowledgements
The authors want to thank the interventional pulmonology team, endoscopy staff, anesthesia team, cytopathology team, and hybrid operating room radiology technicians at UT Southwestern Medical Center.
Materials
| 0.9% normal saline, 1000 mL | Any make | ||
| 10 mL Leuer lock syringes | Any make | ||
| 20 mL slip tip syringes | Any make | ||
| Bronchoscope | Intuitive | ||
| Bronchoscope processor and video screens | Intuitive | ||
| Carbon dioxide gas tank | |||
| Cone beam computed tomography system with c-arm and controller console | |||
| Disposable valve for biopsy channel | |||
| Disposable valve for suction | |||
| ERBECRYO 2 1-pedal footswitch AP & IP X8 Equipment US | Erbe | 20402-201 | |
| ERBECRYO 2 Cart | Erbe | 20402-300 | |
| ERBECRYO 2 Cryosurgical unit | Erbe | 10402-000 | |
| ERBECRYO 2 System | Erbe | ||
| Flexible Cryoprobe, OD 1.1 mm, L1.15 m with oversheath, OD 2.6 mm, L817 mm | Erbe | 20402-401 | |
| Flexible gas hose; L 1m for Erbokryo CA/AE/ERBECRYO 2 | Erbe | 20410-004 | |
| Gas bottle adapter H; CO2; Pin index | Erbe | 20410-011 | |
| Ion endoluminal system with robotic arm, controller console | Intuitive | ||
| Ion fully articulating catheter | Intuitive | 490105 | |
| Ion instruments and accessories | |||
| Ion peripheral vision probe | Intuitive | 490106 | |
| Laptop with PlanPoint planning software | Intuitive | ||
| Probe driving unit | Olympus | MAJ-1720 | |
| Radial EBUS Probe | Olympus | UM-S20-17S or UM-S20-20R-3 | |
| Radial endobronchial ultrasound system | |||
| Specimen containers with fixative per institution standards | |||
| Sterile disposable cups | |||
| Suction tubing | |||
| Topical 1:10,000 epinephrine, 10 mL | |||
| Topical tranexamic acid 1000mg, 10 mL | |||
| Universal ultrasound processor | Olympus | EU-ME2 | |
| Wire basket; 339 x 205 x 155 / 100 mm | Erbe | 20180-010 |
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