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Eur J Cardiothorac Surg 1999;16:624-627
© 1999 Elsevier Science NL

Videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease

Department of Thoracic Surgery, S. Giovanni Battista Hospital, University of Torino, v. Genova 3, 10126 Torino, Italy

Corresponding author. Tel.: +39-11-633-6635; fax: +39-1-696-0170
e-mail: caterina.casadio{at}unito.it

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Objective: Interstitial lung diseases (ILD) require lung biopsy for the diagnosis in more than 30% of patients. Open lung biopsy (OLB) was generally considered the most reliable method of biopsy and tissue diagnosis. This study tests the diagnostic accuracy and safety of the videothoracoscopic lung biopsy (VTLB) in the diagnosis of ILD. Methods: During the last 5 years, 58 patients were submitted to VTLB under general anesthesia. The mean age was 49.6±12.0 years (range 21–69). All the biopsies were performed by an endostapler EndoPath 30 or 45. Conversion to minithoracotomy was necessary in only one patient because of extensive pleural sinfisis. All the specimens were sent to the microbiology and pathology department for microbiological and histopathological diagnosis. One chest-tube (28F) was positioned and connected to a drainage-system and placed on suction. Results: The histopathological diagnosis was obtained for all patients and therefore the diagnostic accuracy of the procedure was 100%. No postoperative haemothorax occurred and only two patients experienced a prolonged air-leakage (3.4%). The median duration of the chest-drain was 3 days (range 1–7) and the median hospital stay was 4 days (range 2–7). Conclusion: VTLB provides adequate specimen volume for histopathologic diagnosis and achieves a very high diagnostic accuracy (100% in our series). The postoperative morbidity and mortality rates are lower than those related to OLB. We conclude that VTLB is an effective and safe procedure in the diagnosis of ILD.

Key Words: Video-assisted thoracoscopic surgery • Interstitial lung disease • Open lung biopsy • Transbronchial lung biopsy • Lung biopsy

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Diffuse interstitial lung disease (ILD) is a generic term representing an heterogeneous group of lung diseases classified together because of their several features in common [1].

Over 100 different pathologies remain in the differential diagnosis of ILD. A practical approach to managing these patients is to obtain a careful history and physical examination, lung-imaging, sputum analysis, blood serologic study and pulmonary function evaluation. If the specific etiology remains unknown, tissue sampling is necessary to establish a diagnosis and to identify potentially treatable causes of ILD.

When less invasive procedures are contraindicated or have failed, the surgical lung biopsy is often indicated. Videothoracoscopic lung biopsy (VTLB) or open lung biopsy (OLB) are usually required to obtain sufficient tissue in the ILDs. OLB has been considered the gold standard but it is an aggressive approach with significant morbidity and mortality rates [2–4].

VTLB is a less invasive, alternative procedure. The purpose of this study was to determine the efficacy and safety of VTLB in the diagnosis of ILD and to compare the results of this procedure with those obtained by OLB and transbronchial biopsy (TBB) performed by other surgical teams.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Fifty-eight patients with ILD of unknown etiology were referred to our department for lung biopsy between September 1993 and March 1999. All patients have been previously investigated with pulmonary function tests, chest high resolution computed tomography (HRCT)-scan, serological evaluation of rheumatoid factor, antinuclear antibody, antinuclear cytoplasmic antibodies and angiotensin-converting enzyme. Bronchoscopy and bronchoalveolar lavage (BAL) were carried out and specimens sent for cell count, cytological examination, lymphocyte subtyping and microbiological studies.

Mediastinoscopy was performed in seven patients (13%) affected by diffuse infiltrative lung disease associated with enlarged mediastinal lymphnodes.

The above mentioned studies did not ensure diagnosis and so lung biopsy was required.

The study population included 33 men (57%) and 25 women (43%). The mean age was 49.6±12.0 years (range 21–69). All VTLB were performed under general anesthesia using a double-lumen endotracheal tube for single-lung ventilation. Patients were placed in the lateral decubitus position and prepared for possible postero-lateral muscle-sparing thoracotomy.

A 12 mm trocar was placed in the 7th intercostal space on the middle-axillary line and the 10 mm, 0°-angled thoracoscope was introduced into the pleural space allowing inspection. After visual control, two trocars were placed in 5th intercostal spaces on the anterior and posterior axillary lines, respectively.

A suitable biopsy site was chosen using chest HRCT-scan abnormalities and intraoperative findings. Only one biopsy was carried out when a diseased portion of the lung was macroscopically detectable (care was taken to avoid the most severely affected areas since they might only show end-stage fibrosis). Three random biopsies were taken from different areas chosen using radiological findings in patients whose lung seemed to be macroscopically normal.

The lung was grasped with atraumatic forceps and V-shaped wedge resection was taken using an EndoPath 30 or 45 with 3.5 mm staples. The specimen was removed through the anterior port. The transected lung was inspected for bleeding, air-leakage and proper application of the staples. A section of the specimen was sent to the microbiology department for bacterial, viral and fungal cultures, while the remainder was sent to the pathology department for histopathological analysis.

At the completion of the procedure the lung was reinflated and all the suture lines were checked for haemostasis and aerostasis. One chest-tube (28F) was inserted through the inferior pleurotomy and connected to a Pleura-evac drainage system and placed on suction. The chest tube was removed when drainage was minimal, the air-leakage had resolved and the lung was reexpanded.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
The right side was operated on in 34 patients (58.6%). In 55 patients (94.8%) one biopsy was performed, multiple biopsies (three) were carried out in three patients (5,2%). The biopsy sites were located as follows: right-upper lobe, 16 patients (25%); middle lobe, five patients (7.8%); right-inferior lobe, 17 patients (26.6%); left-upper lobe, 14 patients (21.8%); left-inferior lobe, 12 patients (18.8%).

A 6-cm postero-lateral muscle-sparing thoracotomy was necessary in one patient (1.7%) because of an extensive pleural sinfisis.

The perioperative mortality rate was 0%. The postoperative complications were very rare. Two patients (3.4%) experienced a prolonged air-leak (more than 5 days). No haemothorax occurred postoperatively in our series. The median duration of chest-tube drainage was 3 days (range 1–7) and the median hospital stay was 4 days (range 2–7). The histologic diagnosis was obtained in 58 patients with a diagnostic accuracy of the procedure of 100% (Table 1).

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Patients with diffuse parenchymal pulmonary disease often require lung biopsy for diagnosis. This situation takes place when the patient's history, physical examination, laboratory studies, radiological findings and other invasive investigations (bronchoscopy and bronchoalveolar lavage, mediastinoscopy or gland biopsy) did not enable absolute certainty of diagnosis. Sometimes the conjunction of HRCT-scan and endoscopic sampling is only suspicious of specific ILD (in particular sarcoidosis or histiocytosis) but it does not allow an accurate diagnosis and therefore a lung biopsy is requested.

The histopathological diagnosis is reachable using progressively more invasive tests like transbronchial biopsy, transthoracic needle biopsy and finally surgical biopsies (videothoracoscopic or open lung biopsy).

Patients with ILD pose several problems: there are more than 100 different causes of ILD; the disease often does not involve the lung completely; the biopsy specimens may not be representative of the pathological process; small specimens may be inadequate to evaluate the pathological architecture of the lung [5].

The transthoracic needle biopsy and the transbronchial biopsy (TBB) introduced many diagnostic problems for the pathologist: the specimen are unselected, exceedingly small, the lung tissue is crushed and in TBB it comes from regions adjacent to bronchial tree where non-specific fibrosis and chronic inflammation are frequently present but not significant [6–8].

Needle biopsy allows only limited parenchymal tissue to be obtained, resulting in poor diagnostic accuracy (63–75%) and is associated with high morbidity (42–44%) and mortality rates (0.5–1.1%) [6,9,10].

TBB is often unreliable in chronic ILD and has a diagnostic accuracy of 37.7–70% [6,7,11–13].

This procedure has a complication rate of about 15%: iatrogenic pneumothorax rates of 1–5% and haemothorax rates of 2–9% were reviewed [12,14].

In the past OLB has been regarded as the best procedure achieving an accurate diagnosis in more than 90% of patients [2–4].

Many surgical teams perform OLB especially through a limited (usually axillary anterior) thoracotomy. This surgical access is more aesthetic, less pain-full and has lower postoperative morbidity than posterolateral thoracotomy [15]. However it reduces the exposure of the lung surface limiting the choice of the biopsy site.

The evolution of video technology allows videothoracoscopic surgery to be a useful procedure for the diagnosis or treatment of many intrathoracic pathologies. Videothoracoscopy reduces postoperative pain and pulmonary dysfunction [16]. Intrathoracic accessibility and visualization of the pleural cavity and of the lung surface are greater than those allowed by minithoracotomies. If the collapse of the lung is not feasible for an improper placement of the endo-tracheal tube or because the patients is not able to tolerate the single-lung ventilation (intraoperative arterial blood oxygen saturation <90% under single-lung ventilation) VTLB is realizable by alternating ventilation and short period of apnea. Pleural adhesions are generally submitted to electro-cautery and only when they are very extensive the video-assisted procedure has to be abandoned and converted to thoracotomy.

The endoscopic biopsy is feasible by endostaplers with a lower risk of persistent air-leak. The stapler resections are easier, faster and safer and associated with lower risk of postoperative prolonged air-leak (3.4% in our series). Others authors [17] reported lung biopsies performed by endoscopic forceps. We did not this technique because of the small dimension of the specimen obtained and the limited involvement to the subpleural parenchyma with lower diagnostic yield in some diffuse ILD such as bronchiolitis obliterans with organizing pneumonia (BOOP) or histiocytosis. We compared our results to those reviewed by others (Table 2).

Patients subjected to VTLB required lower time for both pleural drain and hospital stay than those subjected to OLB [18–20]. VTLB did not add operative time or intraoperative complication rate and has the same diagnostic accuracy of OLB in ILD [18–20].

Some authors [21,22] presented data suggesting that video assisted thoracoscopic (VATS) lung biopsy for ILD is more costly than traditional OLB. Allen and colleagues [23] similarly analyzed costs for patients undergoing stapled wedge resections using either VATS or thoracotomy. In that study the median operating room charge for VATS was significative higher than for thoracotomy but a reduction in the postoperative length of stay in the VATS group makes the total charges equivalent between the two procedures. Moreover Molin [22] estimated the time before returning to normal activity in patients in the VATS group and in thoracotomy group and noted that patients operated on by VATS required a significantly lower number of days to return subjectively to the preoperative functional level than those subjected to OLB.

Videothoracoscopic stapler lung biopsy in diffuse ILD is an effective and safe alternative to OLB and is a well-tolerated procedure with low postoperative complication rate and high diagnostic yield.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 

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