The role of thoracoscopy in the diagnosis of interstitial lung disease

[Consensus guideline on the interdisciplinary diagnosis of interstitial lung diseases]

The evaluation of a patient with interstitial lung disease (ILD) includes assessment of clinical, radiological, and often histopathological data. As there were no specific recommendations to guide the evaluation of patients under the suspicion of an ILD within the German practice landscape, this position statement from an interdisciplinary panel of ILD experts provides guidance related to the diagnostic modalities which should be used in the evaluation of ILD. This includes clinical assessment rheumatological evaluation, radiological examinations, histopathologic sampling and the need for a final discussion in a multidisciplinary team.

The value of virtual bronchoscopic navigation and radial endobronchial ultrasound-guided transbronchial lung cryobiopsies for pulmonary lymphangitic carcinomatosis

Background

Pulmonary lymphangitic carcinomatosis (PLC) is characterized by malignant infiltration into lung lymphatic channels from a primary site and is often observed in advanced malignant tumors. This study aimed to evaluate the diagnostic yield of transbronchial lung cryobiopsy in PLC guided by radial endobronchial ultrasound and virtual bronchoscopic navigation (VBN).

Methods

This prospective study enrolled 40 patients with clinical and radiologic features indicating PLC. The radial endobronchial ultrasound probe was initially advanced to the region of interest of the desired lobe near the pleura with guidance by VBN. Transbronchial lung biopsy and transbronchial lung cryobiopsy were both performed in the same ROI of all patients with the obtained samples being sent to the pathology laboratory for diagnostic analysis. Procedural complications were recorded.

Results

The average number of transbronchial lung biopsy and transbronchial lung cryobiopsy specimens were 4 (3 to 6) and 2 (1 to 3), respectively (t=10.43, P<0.01), with the corresponding mean diameters per biopsy being 3.7 and 8.7 mm (t=12.37, P<0.01). The diagnostic yields of transbronchial lung biopsy and transbronchial lung cryobiopsy were 70% (28/40) and 92.5% (37/40), respectively. The final positive predictive values of transbronchial lung cryobiopsy and transbronchial lung biopsy for PLC were 94.4% (34/36) and 77.8% (28/36), respectively (χ²=23.94, P<0.01). Further, 52.2% (12/23) and 81.5% (22/27) of the patients in the transbronchial lung biopsy and transbronchial lung cryobiopsy groups, respectively, were diagnosed with non-small lung cancer after further molecular analysis (χ²=19.56, P<0.01). Only 2 (5%) cases presented postoperative pneumothorax. Moreover, 0 (0%), 3 (7.5%), and 17 (42.5%) patients presented severe, moderate, and mild bleeding, respectively. There were no other adverse events or deaths.

Conclusions

Transbronchial lung cryobiopsy with the guidance of radial endobronchial ultrasound and VBN without fluoroscopy has a good diagnostic yield for PLC; moreover, it allows one to obtain adequate and intact tissue samples for further molecular analysis.

Tissue Continues to Be the Issue: Role of Histopathology in the Context of Recent Updates in the Radiologic Classification of Interstitial Lung Diseases

CONTEXT.—

High-resolution computed tomography (HRCT) imaging has an increasingly important role in clinical decision-making in patients with interstitial lung diseases. The recent Fleischner Society white paper on the diagnostic criteria for idiopathic pulmonary fibrosis highlights the advances in our understanding of HRCT imaging in interstitial lung diseases.

OBJECTIVE.—

To discuss the evidence and recommendations outlined in the white paper as it pertains to the radiologic diagnosis of interstitial lung disease, specifically highlighting the current limitations of HRCT in confidently predicting histopathologic findings.

DATA SOURCES.—

The recent Fleischner Society white paper and other studies pertaining to the role of HRCT in predicting histopathology in interstitial lung diseases are reviewed.

CONCLUSIONS.—

High-resolution computed tomography is highly predictive of a usual interstitial pneumonia (UIP) pattern on histopathology when the HRCT shows a typical UIP pattern on a "confident" read by the radiologist. A probable UIP pattern is also very predictive of a UIP pattern on histopathology, and histopathologic confirmation is not needed for most patients demonstrating this pattern in the appropriate clinical setting. A UIP pattern may be seen in a substantial proportion of patients with an "indeterminate UIP" pattern on HRCT and in many patients for whom the HRCT suggests an alternative diagnosis; histopathologic confirmation should be considered in patients demonstrating these patterns whenever feasible.

Transbronchial cryobiopsy validity in diagnosing diffuse parenchymal lung diseases in Egyptian population

Objectives

We aimed to evaluate the efficacy, safety, and diagnostic utility of transbronchial cryobiopsy (TBCB) in diagnosing diffuse parenchymal lung diseases (DPLDs) in an Egyptian population and to identify common DPLD pathologies among them.

Methods

This prospective interventional study enrolled 25 Egyptian patients presenting to the Main Alexandria University Hospital who had clinical and radiological features of DPLD, but insufficient elements to achieve definite features of usual interstitial pneumonia on chest high-resolution computed tomography. Twelve patients were subjected to TBCB and 13 to forceps transbronchial lung biopsy (TBLB).

Results

The diagnostic yield was significantly higher among the TBCB group (83.3%), and increased to 100% with clinicopathological correlation vs the TBLB group (38.5%, P=0.041). Granulomatous diseases (24%, either sarcoidosis or hypersensitivity pneumonitis) were the commonest pathology, followed by malignancy (12%) in both groups. TBCB sizes were 2.5–5 mm vs 1-3 mm in TBLB (P<0.001), with preserved tissue architecture (91.7% vs 38.5%, respectively; P=0.011). Only 8.3% were complicated by insignificant bleeding grade 2 after TBCB, but no pneumothorax was detected.

Conclusion

TBCB is a safe, tolerable procedure with high diagnostic yield for evaluating DPLD with indefinite usual interstitial pneumonia pattern on high-resolution computed tomography.

Transbronchial Lung Cryobiopsy in the Diagnosis of Interstitial Lung Disease: A Retrospective Single-center Experience

BACKGROUND

Surgical lung biopsy (SLB) is the gold standard to aid diagnosis of interstitial lung disease (ILD). Complication rates are restrictive as routine approach for all patients with ILD. Transbronchial lung cryobiopsy (TBLC) is presumed to be a safe, less invasive alternative to assist multidisciplinary discussions regarding the diagnosis of ILD. Varying practice patterns and lack of consistent guidelines prohibit wide support of this technique. The purpose of this study was to evaluate safety and diagnostic yield of TBLC, with highlight of distinct technical features, in ILD.

METHODS

Retrospective study of patients with ILD on the basis of high-resolution chest computed tomography who underwent TBLC.

RESULTS

Of 121 TBLC, 40 patients (mean age, 57.2±13 y; 28 men) with ILD were referred for biopsy. Procedures were performed in endoscopy suite (60%) or operating room by using 1.9-mm cryoprobe. Biopsies were performed in 2 lobes with at least 3 to 5 specimens >5 mm in diameter. The average diameter and area of specimens were 5.7±2 mm and 40±2 mm, respectively. The most common diagnosis was nonspecific interstitial pneumonitis; usual interstitial pneumonia was diagnosed in 1 patient. Of 6 nondiagnostic specimens, 2 underwent SLB with subsequent diagnoses. Final histopathologic diagnostic rate was 85%. Bleeding was the most frequent complication.

CONCLUSION

We provided a detailed description of our TLBC technique and highlighted areas of similarity and differences among comparative studies and attest that TBLC is a safe alternative to SLB in the diagnosis of ILD. Our data also indicated the tendency for moderate-to-severe bleeding occurred more in the endoscopy suite.

Safety and Diagnostic Yield of Transbronchial Lung Cryobiopsy in Diffuse Parenchymal Lung Diseases: A Comparative Study versus Video-Assisted Thoracoscopic Lung Biopsy and a Systematic Review of the Literature

BACKGROUND

A diagnosis of interstitial lung diseases (ILDs) may include surgical lung biopsy (SLB), which is associated with significant morbidity and mortality and also appreciable costs. Transbronchial lung cryobiopsy (TBLC) is adopting an important role.

OBJECTIVES

The aim of this study was to compare the diagnostic yield (DY) and safety of TBLC and SLB in a large cohort of patients and to perform a systematic review of the literature as well as a meta-analysis.

METHODS

We performed a retrospective analysis of 447 cases with ILD undergoing TBLC and/or SLB and a systematic review of the literature (MEDLINE and Embase for all original articles on the DY and safety of TBLC in ILDs up to July 2015).

RESULTS

A total of 150 patients underwent SLB and 297 underwent TBLC. The median time of hospitalization was 6.1 days (SLB) and 2.6 days (TBLC; p < 0.0001). Mortality due to adverse events was observed for 2.7% (SLB) and 0.3% (TBLC) of the patients. Pneumothorax was the most common complication after TBLC (20.2%). No severe bleeding was observed. TBLC was diagnostic for 246 patients (82.8%), SLB for 148 patients (98.7%, p = 0.013). A meta-analysis of 15 investigations including 781 patients revealed an overall DY of 0.81 (0.75-0.87); the overall pooled probability of developing a pneumothorax, as retrieved from 15 studies including 994 patients, was 0.06 (95% CI 0.02-0.11).

CONCLUSION

Cryobiopsy is safe and has lower complication and mortality rates compared to SLB. TBLC might, therefore, be considered the first diagnostic approach for obtaining tissue in ILDs, reserving the surgical approach for cases in which TBLC is not diagnostic.

Cryobiopsy in the diagnosis of diffuse interstitial lung disease: yield and cost-effectiveness analysis

BACKGROUND

Assessment of patients with suspected interstitial lung disease (ILD) includes surgical lung biopsy (SLB) when clinical and radiological data are inconclusive. However, cryobiopsy is acquiring an important role in the ILD diagnostic process. The objective of this study was to evaluate the diagnostic yield, safety and economic costs of the systematic use of cryobiopsy in the assessment of patients with suspected ILD.

METHODS

This was a retrospective observational study of patients who had undergone transbronchial cryobiopsy for evaluation of ILD from January 2011 to January 2014. The procedures were performed with a video bronchoscope using a cryoprobe for the collection of lung parenchyma specimens, which were analyzed by pathologists. Diagnostic yield, complications and economic costs of this technique were analyzed.

RESULTS

Criobiopsy specimens from a total of 33 patients were included. A specific diagnosis was obtained in 26, producing a diagnostic yield of 79%. In 5 patients, SLB was required for a histopathological confirmation of disease, but the procedure could not be performed in 4, due to severe comorbidities. The most frequent complications were pneumothorax (12%) and gradei (9%) or gradeii (21%) bleeding. There were no life-threatening complications. The systematic use of cryobiopsy saved up to €59,846.

CONCLUSION

Cryobiopsy is a safe and potentially useful technique in the diagnostic assessment of patients with ILD. Furthermore, the systematic use of cryobiopsy has an important economic impact.

VATS biopsy for undetermined interstitial lung disease under non-general anesthesia: comparison between uniportal approach under intercostal block vs. three-ports in epidural anesthesia

OBJECTIVE

Video-assisted thoracoscopic (VATS) biopsy is the gold standard to achieve diagnosis in undetermined interstitial lung disease (ILD). VATS lung biopsy can be performed under thoracic epidural anesthesia (TEA), or more recently under simple intercostal block. Comparative merits of the two procedures were analyzed.

METHODS

From January 2002 onwards, a total of 40 consecutive patients with undetermined ILD underwent VATS biopsy under non-general anesthesia. In the first 20 patients, the procedures were performed under TEA and in the last 20 with intercostal block through a unique access. Intraoperative and postoperative variables were retrospectively matched.

RESULTS

Two patients, one from each group, required shift to general anesthesia. There was no 30-day postoperative mortality and two cases of major morbidity, one for each group. Global operative time was shorter for operations performed under intercostal block (P=0.041). End-operation parameters significantly diverged between groups with better values in intercostal block group: one-second forced expiratory flow (P=0.026), forced vital capacity (P=0.017), oxygenation (P=0.038), PaCO2 (P=0.041) and central venous pressure (P=0.045). Intraoperative pain coverage was similar. Significant differences with better values in intercostal block group were also experienced in 24-hour postoperative quality of recovery-40 questionnaire (P=0.038), hospital stay (P=0.033) and economic expenses (P=0.038). Histology was concordant with radiologic diagnosis in 82.5% (33/40) of patients. Therapy was adjusted or modified in 21 patients (52.5%).

CONCLUSIONS

Uniportal VATS biopsies under intercostal block can provide better intraoperative and postoperative outcomes compared to TEA. They allow the indications for VATS biopsy in patients with undetermined ILD to be extended.

Bronchoscopic cryobiopsy for the diagnosis of diffuse parenchymal lung disease

BACKGROUND

Although in some cases clinical and radiographic features may be sufficient to establish a diagnosis of diffuse parenchymal lung disease (DPLD), surgical lung biopsy is frequently required. Recently a new technique for bronchoscopic lung biopsy has been developed using flexible cryo-probes. In this study we describe our clinical experience using bronchoscopic cryobiopsy for diagnosis of diffuse lung disease.

METHODS

A retrospective study of subjects who had undergone bronchoscopic cryobiopsy for evaluation of DPLD at an academic tertiary care center from January 1, 2012 through January 15, 2013 was performed. The procedure was performed using a flexible bronchoscope to acquire biopsies of lung parenchyma. H&E stained biopsies were reviewed by an expert lung pathologist.

RESULTS

Twenty-five eligible subjects were identified. With a mean area of 64.2 mm(2), cryobiopsies were larger than that typically encountered with traditional transbronchial forceps biopsy. In 19 of the 25 subjects, a specific diagnosis was obtained. In one additional subject, biopsies demonstrating normal parenchyma were felt sufficient to exclude diffuse lung disease as a cause of dyspnea. The overall diagnostic yield of bronchoscopic cryobiopsy was 80% (20/25). The most frequent diagnosis was usual interstitial pneumonia (UIP) (n = 7). Three of the 25 subjects ultimately required surgical lung biopsy. There were no significant complications.

CONCLUSION

In patients with suspected diffuse parenchymal lung disease, bronchoscopic cryobiopsy is a promising and minimally invasive approach to obtain lung tissue with high diagnostic yield.

Surgical biopsy of suspected interstitial lung disease is superior to radiographic diagnosis

BACKGROUND

Different modalities are used to diagnose interstitial lung disease. We compared the effectiveness of minimally invasive surgical biopsy versus high-resolution computed tomography for the diagnosis of interstitial lung disease and report the mortality of the procedure.

METHODS

We reviewed 194 patients undergoing video-assisted thoracoscopic lung biopsies for the suspicion of interstitial lung disease from January 2003 to February 2012 at Emory University. Demographics and patient characteristics were analyzed in addition to final diagnoses and clinical outcomes.

RESULTS

Concordance of radiographic diagnosis with final diagnosis was poor, matching pathologic diagnosis in 15% of cases, and specific diagnoses were included in the radiographic differential in only 34% of cases. A specific diagnosis was made after surgical biopsy in 88% of cases. Overall mortality of surgical biopsy was 6.7% (13/194). Major risk factors for death were preoperative supplemental oxygen, ventilator dependence, and age (p < 0.0001, p < 0.0001, and p = 0.03, respectively). Among patients with ventilator dependence preoperatively, the mortality rate was 100% versus 4.8% in patients not ventilator dependent. All biopsy specimens were concordant 91% of the time, and the first two biopsy specimens were concordant 96% of the time.

CONCLUSIONS

Surgical biopsy should remain the gold standard for diagnosis of interstitial lung disease. The mortality is low with proper patient selection. More than two surgical biopsy specimens may not be needed because the concordance rates among pathologic specimens are very high.

Complications of Video-Assisted Thoracoscopic Lung Biopsy in Patients with Interstitial Lung Disease

BACKGROUND

Current guidelines recommend surgical lung biopsy for diagnosis of interstitial lung diseases (ILDs) in selected patients. To shed light on the risk-benefit ratio for this recommendation, we examined the morbidity and mortality associated with video-assisted thoracoscopic surgical (VATS) lung biopsy in a group of outpatients.

METHODS

A retrospective cohort study was conducted of 68 consecutive ambulatory patients with radiographically apparent interstitial lung disease (ILD) referred for VATS biopsy during a 6-year period. Incidence of postoperative mortality, prolonged air leaks, pneumonias, and re-admissions were calculated. Risk factors for complications of surgery were examined.

RESULTS

Three deaths occurred within 60 days after biopsy for a mortality rate of 4.4% (95% confidence interval [CI], 1% to 12%), and 19.1% (95% CI, 11% to 31%) experienced one or more complications of surgery. Risk factors for morbidity included preoperative dependence on oxygen therapy and pulmonary hypertension. The three patients who died had usual interstitial pneumonia on their biopsy specimen and were reintubated postoperatively for acute lung injury. Aggregation of articles published over the past 10 years reporting on surgical lung biopsy for the diagnosis of ILD yielded a postoperative mortality rate of 2% to 4.5%.

CONCLUSIONS

VATS lung biopsy for diagnosis of ILD, even in ambulatory patients, is not an entirely benign procedure. Biopsy rarely may trigger an acute exacerbation of usual interstitial pneumonitis. The risk of postoperative complications appears to be greatest in those dependent on oxygen and those who have pulmonary hypertension. This information may be used in weighing the risk-benefit ratio of biopsy in individual patients.

Role of Thoracic Surgeons in the Diagnosis of Idiopathic Interstitial Lung Disease

The interstitial lung disorders are a heterogenous group of pulmonary disorders in which the interstitium is the predominant tissue type involved in the disease process. The idiopathic interstitial pneumonias represent a subgroup of these disorders that can be distinguished by unique clinical, radiologic, and pathologic features. Recent changes have been made in the classification system, with important distinctions between idiopathic pulmonary fibrosis and the other idiopathic interstitial pneumonias. Surgical lung biopsy remains the gold standard for diagnosis. However, controversy exists regarding the methods and indications for biopsy. In this article, we review the salient clinical, radiologic, and pathologic features of these unique disorders as well as the updated classification scheme. We also discuss the current methods, approaches, and indications for biopsy.

A survey of 150 video-assisted thoracoscopic procedures in Kuwait

OBJECTIVE

To review our experience of indications, technique, and complications as they relate to video-assisted thoracoscopic surgery (VATS) in the diagnosis and management of intrathoracic diseases.

SUBJECTS AND METHODS

One hundred and fifty consecutive VATS procedures, which were performed over a 3-year period, were retrospectively evaluated. Indications included recurrent or persistent primary spontaneous pneumothorax (n = 73 patients), lung biopsies for diagnosis of diffuse lung disease (n = 33), pleural biopsies (n = 18), wedge resections of pulmonary nodules (n = 8), bilateral thoracic sympathectomy (n = 6), decortication (n = 5), mediastinal tumor biopsies (n = 5), excision of bullous emphysema (n = 1), and removal of a foreign body from the pleural cavity (n = 1). An alternative method of manipulating thoracoscopic instruments without using a trocar is described.

RESULTS

Of the 150 VATS procedures, 127 (85%) were successfully performed, 6 (4%) were converted to thoracotomy and 17 (11%) had complications. The most common complication was prolonged air leak, which occurred in 9 patients. The average postoperative hospital stay was 4 days (range: 2-17). Diagnostic procedures were considered successful in 32 out of 33 lung biopsies and in all 18 patients with pleural diseases, 8 lung nodules, or 5 mediastinal tumor biopsies. The other 86 therapeutic VATS procedures were effective in 82 (95%) patients. Four (5%) patients had a recurrence of the pneumothorax after VATS.

CONCLUSION

Thoracoscopy and the use of a nontrocar technique is a safe and effective method for the diagnosis and treatment of intrathoracic diseases.

Diagnostic thoracoscopic lung biopsy: an outpatient experience

BACKGROUND

Tissue diagnosis of either interstitial lung disease or indeterminate pulmonary nodules can be obtained by either limited thoracotomy or thoracoscopic lung biopsy. Both procedures traditionally have required hospital admission. We report a series of patients undergoing outpatient thoracoscopic lung biopsy to demonstrate the safety and efficacy of this practice.

METHODS

Sixty-two ambulatory patients with a clinical diagnosis of either interstitial lung disease or indeterminate pulmonary nodule(s) underwent thoracoscopic lung biopsy between June 2000 and June 2001. All procedures were performed with double-lumen endotracheal anesthesia and stapled wedge resection. Chest tubes were removed if no air leak was present and if chest radiograph demonstrated no residual pneumothorax.

RESULTS

Of 62 patients undergoing thoracoscopic lung biopsy, 45 (72.5%) were discharged home within 8 hours of observation on the day of operation. Fourteen (22.5%) were discharged within 23 hours of their operation. Reasons for 23-hour observation included significant comorbidity (8), pain management (4), postoperative air leak (1), and conversion to muscle-sparing thoracotomy (1). Three (5%) required admission for prolonged air leak (2) or conversion to muscle-sparing thoracotomy (1). Diagnoses were obtained in 61 patients, including neoplasm (25), interstitial lung disease (18), granulomatous disease (7), and other (11). One patient was readmitted for pneumothorax. Patients diagnosed with nonbronchogenic pulmonary metastases were more likely to be discharged on the day of operation. No differences in age, smoking status, or preoperative pulmonary function testing were observed between patients requiring short-stay observation and those discharged immediately after operation.

CONCLUSIONS

Outpatient thoracoscopic lung biopsy is safe and effective, and has become our procedure of choice for diagnosis of either interstitial or focal lung disease.

Safety and efficacy of a technique for thoracoscopically guided pulmonary wedge resection in horses

OBJECTIVE

To evaluate the safety and efficacy of thoracoscopically guided pulmonary wedge resection in horses.

ANIMALS

10 horses (5 control horses and 5 horses affected with recurrent airway obstruction [ie, heaves]).

PROCEDURE

Each horse underwent a thoracoscopically guided pulmonary wedge resection. Before, during, and after surgery, heart rate, respiratory rate, arterial blood gases, and systemic and pulmonary arterial pressures were measured. Physical examination, CBC, and thoracic radiography and ultrasonography were performed 24 hours before and 2 and 48 hours after surgery. Pulmonary specimens were assessed by histologic examination. A second thoracoscopic procedure 14 days later was used to evaluate the resection site.

RESULTS

The technique provided excellent specimens for histologic evaluation of the lung. Heart and respiratory rates decreased significantly after horses were administered sedatives. A significant transient decrease in Pao2 was detected immediately after pulmonary wedge resection, but we did not detect significant effects on arterial pH, Paco2, or mean arterial and pulmonary arterial pressures. All horses except 1 were clinically normal after thoracoscopic surgery; that horse developed hemothorax attributable to iatrogenic injury to the diaphragm. The second thoracoscopy revealed minimal inflammation, and there were no adhesions.

CONCLUSIONS AND CLINICAL RELEVANCE

Thoracoscopically guided pulmonary wedge resection provides a minimally invasive method for use in obtaining specimens of lung tissues from healthy horses and those with lung disease. This technique may be useful for the diagnosis of diseases of the lungs and thoracic cavity.

Fast Track Video-Assisted Thoracic Surgery

Video-assisted thoracic surgery (VATS) has been advocated as one of the primary diagnostic modalities for suspicious pulmonary nodules and diffuse interstitial lung disease. The aim of our study was to evaluate the cost and safety of VATS lung wedge resection(s) as an “overnight” hospital admission. We retrospectively reviewed all 37 charts of patients who underwent VATS wedge resections for these indications from August 1999 to April 2001. There was a slight female predominance with mean age of 56.8 years (range 33–88). Eighteen patients had interstitial disease and 19 patients had pulmonary nodules. The duration of chest tube drainage was one day in the majority (92%). Length of hospital admission was overnight in 70 per cent whereas 22 per cent remained two days. This latter group from the earlier period of the trial had characteristics identical to those of an overnight stay. This creates a potential overnight stay in 87 per cent. Five complications occurred in three patients, which extended the length of stay. No mortality was reported. The overall hospital charges for the overnight-stay VATS were nearly half the charges for the open thoracotomy counterpart. Diagnostic VATS wedge biopsy is a cost effective and safe procedure allowing an overnight hospital stay in the majority of cases.

Open lung biopsy as an outpatient procedure

BACKGROUND

Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. Both limited thoracotomy (open lung biopsy) and thoracoscopy can be used for lung biopsies, but both procedures have traditionally required hospital admission. We report a series of patients that underwent outpatient open lung biopsy to show the safety and effectiveness of this practice.

METHODS

We reviewed records of ambulatory, nonoxygen dependent patients with a clinical diagnosis of diffuse interstitial lung disease that underwent outpatient open lung biopsy between January 1997 and December 1999. All procedures were done by a senior surgeon using single lumen endotracheal anesthesia, a small anterolateral thoracotomy without rib spreading, stapled wedge resection, and no chest tube. Patients were discharged the same day.

RESULTS

Thirty-two patients with a clinical diagnosis of diffuse interstitial lung disease underwent outpatient open lung biopsy. Mean age was 58 years (range, 21 to 74 years). Preoperative forced expiratory volume in 1 second was 74.3%+/-7.0% of predicted. A pathologic diagnosis was established in all patients: usual interstitial pneumonia, 26 patients; sarcoidosis, 2; metastatic carcinoma, 2; desquamative interstitial pneumonia, 1; and mixed dust pneumoconiosis, 1 patient. No patient required a chest tube, overnight observation, or hospital admission. No complications occurred.

CONCLUSIONS

Selected patients with a clinical diagnosis of diffuse interstitial lung disease can safely and effectively undergo diagnostic outpatient open lung biopsy. However, careful patient selection and attention to operative detail are essential.

A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease

BACKGROUND

Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done.

METHODS

Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected.

RESULTS

A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups (p = 0.397). Total morphine dose was 50.8 +/- 27.3 mg in the thoracoscopy group and 52.5 +/- 25.6 mg in the thoracotomy group (p = 0.86). Spirometry (FEV1) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 (p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 +/- 30 minutes, thoracotomy 37 +/- 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 +/- 28 hours, thoracotomy 31 +/- 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 +/- 82 hours, thoracotomy 69 +/- 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients.

CONCLUSIONS

There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.

Pulmonary adiaspiromycosis: report of two cases

Two cases of human pulmonary adiaspiromycosis are reported. Patients were 29 and 54-year-old males, farm workers, with "grippe-like" symptoms and radiographic findings suggestive of granulomatous interstitial disease. Transthoracoscopic and transbronchial biopsies were performed. Pulmonary function was measured by spirometry. One patient used ketoconazole. Possibility of misdiagnosed pulmonary adiaspiromycosis is emphasized.

Thoracoscopy: window to the pleural space

Thoracoscopy has provided chest physicians and surgeons with an opportunity to rethink their approach to patients with pleural and pulmonary disease. In this brief review, several methods pertaining to videothoracoscopic procedures are described, followed by a summary of the major indications for this procedure. The question of whether a thoracoscopic approach to diagnosis or treatment could replace more conventional approaches is addressed for several disease processes. Finally, a few thoughts about future directions of this emerging technology are shared.

Thoracoscopic procedures for intrathoracic diseases: the present status

Thoracoscopic operations, alternatively termed as video-assisted thoracic surgery (VATS), are replacing the variety of surgical procedures which have been otherwise performed by open thoracotomy. The minimally invasive nature of the procedure, reduced postoperative pain, shortened hospital stay, and reduced cost, are the potential advantages of VATS. While these merits are being proven, the limits to this technique are also getting clearer. In fact, VATS has already become a standard treatment of choice in several diseases, such as bullectomy for spontaneous pneumothorax and biopsy for indeterminate nodule and diffuse interstitial lung disease, while others, such as major video-assisted lung resection for lung carcinoma and resection of metastatic lung tumour, await further evaluation of their roles in terms of oncological and technical aspects. Three issues that currently need to be addressed as the present role of thoracoscopy evolves are instrumentation, economics, indication, and end results in certain procedures.

Videothoracoscopic lung biopsy in diffuse infiltrative lung diseases: a 5-year surgical experience

BACKGROUND

To establish an accurate diagnosis of diffuse infiltrative lung disease, a surgical lung biopsy may be required. We report our experience with video-thoracoscopic lung biopsy over a period of 5 years.

METHODS

From March 1992 through December 1996, videothoracoscopic lung biopsy was performed in 64 patients (17 were women [26.5%]; age, 50.5+/-13 years) with a diagnosis of diffuse infiltrative lung disease of an unknown cause. All patients except one received general anesthesia. Single lung ventilation was used in 61 patients. All lung biopsies were obtained with an endoscopic stapler.

RESULTS

Single lung biopsies were performed in 39 patients (61%), two biopsies in 23 patients (36%), and three biopsies in 2 patients. Minithoracotomies were necessary in 10 patients (15.6%) owing to an iatrogenic pulmonary wound (1 patient), extensive pleural adhesions (6 patients), and a stiff lung (3 patients). Postoperative complications were rare and included five discrete pneumothoraces (7.8%), all resolving spontaneously, one prolonged air leak (1.6%), and one hemothorax requiring reoperation. Three preoperatively debilitated patients died (4.7%), 2 with progression of respiratory failure and 1 owing to septic shock. Average chest tube duration was 2.4+/-2 days and average hospital stay was 4.6+/-2.5 days. Lung biopsy contributed to the diagnosis in 59 patients (92%).

CONCLUSIONS

Videothoracoscopic lung biopsy using an endoscopic stapler is a safe and effective procedure in most cases and should be performed by trained thoracic surgeons.

[Disseminated pulmonary adiaspiromycosis. A case report]

A case of thoracoscopic lung biopsy proven diffuse human adiaspiromycosis is reported. The patient, a 26-year-old male farm worker presented with a three-week history of fever, sweating, dyspnea and unproductive cough. Radiographic findings were those of granulomatous pulmonary interstitial disease. Treated with ketoconazole he improved very well, resuming work normal activities a month later.

A safe high-yield technique for cutting needle biopsy of the lung in patients with diffuse lung disease

The approach to the diagnosis and management of patients with diffuse infiltrative lung disease (DILD) is controversial. The results of transbronchial biopsy are often unsatisfactory. The role of open lung biopsy is highly variable. Percutaneous cutting needle biopsy (CNB) is not recommended because of its reported high morbidity/mortality relative to its low diagnostic yield. We report a technique for CNB with a high diagnostic yield and a low morbidity and no mortality in 228 patients with DILD over the past 23 years.

METHODS

The salient features of the technique for CNB are as follows: the anesthetic needle does not enter the pleural space; a Franklin Silverman needle is inserted into the intercostal space posteriorly at outer one-third of chest wall; the biopsy is performed with the breath held at normal end expiration; the plane of pleural space is broken with sudden insertion of needle 8 to 15 cm into lung; and the pathway of the needle is maintained parallel to the lateral chest wall.

RESULTS

A diagnosis was established in 129 of 145 biopsies (89%) performed by a trained operator (A.H.N.). There were 36 pneumothoraces (25%), four minimal hemoptyses (3%), and two chest tube placements (1%). There were no deaths (0%).

CONCLUSION

With meticulous attention to technique and careful selection of patients, the procedure offers a relatively safe alternative to open lung or thoracoscopic lung biopsy in patients with DILD.

Efficacy and safety of videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease

OBJECTIVE

The aim of this study was to determine the efficacy and safety of videothoracoscopic lung biopsy (VTLB) in the diagnosis of infiltrative lung disease (ILD) and compare the results of VTLB with the results previously obtained in patients with open lung biopsy at the same institution.

METHODS

Forty-one patients undergoing VTLB between May 1991 and December 1994 were retrospectively studied and compared with 25 patients who have undergone OLB during the period from January 1987 to April 1991. The two groups were comparable with respect to age, sex, and severity of lung disease.

RESULTS

Three of 41 patients (7%) who underwent VTLB with minithoracotomy. There was no significant difference between the group of VTLB (38 patients) and the group OLB (25 patients) with regard to, the number of biopsies (VTLB 1.8 +/- 0.4 versus OLB 2 +/- 0.6), or diagnostic yield (VTLB 37/38 versus OLB 25/25). In contrast, patients who underwent VTLB demonstrated a significant reduction of the operative time (VTLB 45.3 +/- 12.2 min), length of chest tube drainage (3.55 +/- 1.2 days), hospital stay (5.5 +/- 1.3 days), and analgesia (buprenorphine 0.85 +/- 0.44 mg; paracetamol 5.9 +/- 2.5 g) compared to patients who underwent OLB (55.6 +/- 11.2 min, 5.2 +/- 1.5 days; 7.1 +/- 2.3 days; buprenorphine 1.17 +/- 0.5 mg, paracetamol 8.9 +/- 2.3 g). Morbidity and mortality were similar in the two groups (morbidity VTLB 10.5%, OLB 12%; mortality VTLB 5.2%, OLB 8%). Regardless of the biopsy technique, the most serious complications and deaths occurred with the same frequency in those patients with a severe underlying disease.

CONCLUSIONS

VTLB is a valid alternative to OLB in most cases. Along with a comparable efficacy, VTLB has several advantages that should make it the method of choice for patients with only minimally impaired respiratory function. In contrast, the role and advantages of VTLB compared to OLB in patients with severe lung disease, require further investigation.

Results of video-assisted thymectomy in patients with myasthenia gravis

OBJECTIVE

The efficacy of video-assisted thoracic surgery for thymectomy with myasthenia gravis has not been examined.

METHODS

Thirty-three consecutive patients underwent total thymectomy by video-assisted techniques between 1992 and 1995. There were 13 male and 20 female patients with a mean age of 38.42 +/- 16.88 years (range 9 to 84 years). The procedures were performed by either a right (n = 11) or left (n = 22) thoracoscopic approach and all anterior mediastinal tissue was removed.

RESULTS

There was no perioperative mortality or long-term morbidity. One patient required conversion of the video-assisted technique to a lateral thoracotomy. All patients except one were extubated immediately. The mean hospital stay was 4.12 +/- 6.07 days (range 1 to 37 days) with a median of 3 days. Mean follow-up is 23.39 +/- 11.72 months (range 4 to 47 months). Clinical improvement was seen in 87.9% (29/33): one of two patients (50%) in stage I, 17 of 19 (89.4%) in stage IIA, eight of nine (88.8%) in stage IIB, and three of three (100%) in stage III. Metaanalysis of these results compared with results in nine published series in which other techniques were used showed no difference in clinical improvement after thymectomy between series.

CONCLUSION

We conclude that video-assisted thymectomy is as effective as the traditional open surgical approaches for performance of thymectomy in the management of patients with myasthenia gravis. In addition, the improved cosmesis of the video-assisted approach ideally will lead to earlier thymectomy in patients with myasthenia gravis.

Complications of thoracoscopy

BACKGROUND

The revolution in video technology has led to the acceptance of thoracoscopy as an important tool in thoracic surgery.

METHODS

A review of all patients undergoing thoracoscopy at the University of Maryland between November 1991 and March 1995 was performed to identify the incidence of intraoperative and postoperative complications. In addition, the role of computed tomography for predicting intraoperative complications was analyzed.

RESULTS

Three hundred forty-eight procedures were performed in 321 patients. Twenty-seven patients required conversion to thoracotomy for various indications. In 12 patients further resection was required after frozen section diagnosis confirmed lung carcinoma. Six patients were opened due to adhesions. Two patients were opened due to inability to find the lesion (this represents 1.6% of all solitary pulmonary nodules). Three cases were converted to thoracotomy for lesions that were too large to remove (representing 2.5% of all solitary pulmonary nodules resected). Two patients required conversion to thoracotomy because of inability to obtain one-lung ventilation. One case required a limited thoracotomy for a lost needle used for needle localization of a solitary intraparenchymal nodule, and 1 patient had emergent exploration for bleeding. Early postoperative complications developed in 10 patients. There were two explorations in the immediate postoperative period for bleeding. Prolonged air leak occurred in 3 patients, empyema in 2, and recurrent pneumothorax, pulmonary edema, and pneumonia in 1 patient each. Computed tomography failed to diagnose adhesions in the majority of patients requiring conversion to thoracotomy.

CONCLUSIONS

Thoracoscopy is a safe and effective procedure with low intraoperative and postoperative complication rates.

[Pulmonary biopsy in diffuse interstitial disease: videothoracoscopy versus thoracotomy]

The aim of this work was to evaluate and compare the results of lung biopsies performed by videothoracoscopy (VT) and minithoracotomy (MT) in diffuse interstitial disease between 1992 and 1994, during which period 45 lung biopsies were performed on patients (20 women) with a mean age of 56 years. Thirty-one biopsies were performed by VT (group I) and 14 by MT (group II). For all patients we recorded duration of procedure, days to discharge after surgery, total time with a pleural drain in place, and volume of tissue sample. Diagnosis was possible in all cases. Mean duration of surgery was 49.3 minutes for group I and 58.2 minutes for group II. Mean time to discharge was 6.7 days for group I and 10.1 for group II. Mean time of pleural drainage was 3.8 days for group I and 5.9 days for group II. Mean volume of tissue sample was 6.5 cm3 for group I and 5.18 cm3 for group II. One patient died in group I from causes unrelated to surgical technique. In conclusion, lung biopsy with VT is effective and useful for diagnosing diffuse interstitial lung diseases. The sample obtained is in every way comparable to that obtained by thoracotomy. Mean hospital stay and mean time of postoperative drainage decreases significantly (p < 0.05) with VT.

Influence of sample number and biopsy site on the histologic diagnosis of diffuse lung disease

BACKGROUND

Although open biopsy is considered the optimal method for obtaining lung tissue for the diagnosis of diffuse infiltrative pulmonary disorders, there are no universally established guidelines concerning biopsy site selection and the ideal number of tissue samples. Relatively few investigations have been devoted to the influence exerted by the site and number of biopsy samples on the histologic diagnosis.

METHODS

Seventy-seven open biopsy samples obtained from different lobes of 28 patients with idiopathic pulmonary fibrosis were analyzed. The histopathologic features were evaluated semiquantitatively and the results from each sample compared with those of the other samples obtained from each patient.

RESULTS

Statistically significant differences in histopathologic features were not observed between samples.

CONCLUSIONS

A single generous (2 cm or greater diameter) sample, obtained from a representative region of the radiographically most involved lobe, will suffice for diagnostic and evaluation purposes.