Video-assisted thoracoscopic lung biopsy in the diagnosis of diffuse interstitial lung disease. A prospective study

AIM: Video-assisted thoracoscopic lung biopsy is commonly performed for diagnosis of diffuse interstitial lung disease. This study reports our experience with this technique in terms of diagnostic accuracy, complications and appropriate site for biopsy. METHODS: A prospective non-randomized study. SETTING: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait. PATIENTS AND INTERVENTION: 79 consecutive patients undergoing thoracoscopic lung biopsy for diffuse interstitial lung disease from January 1995 to December 2001. Patients were divided into 2 groups; 34 patients with single biopsy from lingula or right middle lobe (RML) and 45 with 2 biopsies from other sites. Measures: comparison of operative and postoperative data, diagnostic accuracy, and complications between the two groups. RESULTS: The mean age of the patients was 38.9 years (range 15-75 years). There was no difference in the groups in operative time, 24 hours postoperative pleural drainage, chest tube drainage days, and hospital stay. Histologic diagnosis was achieved in 76/79 patients (96%). The diagnostic yield of each group was comparable (32/34 from lingula/RML; 44/45 other sites), (p=0.3). Postoperative complications occurred in 4/34 of patients with single biopsy from lingula or RML and 4/45 patients with 2 biopsies from other sites (p=0.6). There was 1 death in this series. CONCLUSIONS: Video-assisted thoracoscopic lung biopsy is an effective procedure. Single lung biopsy from lingula or RML compared to other anatomic sites has an equivalent diagnostic yield.     

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.     

Efficacy of video assisted thoracoscopic lung biopsy: an historical comparison with open lung biopsy.

BACKGROUND--Video assisted thoracoscopic lung biopsies were compared with historical controls undergoing open lung biopsy to determine the diagnostic accuracy, effect on length of postoperative stay, and cost effectiveness of the new thoracoscopic technique. METHODS--The first 25 video assisted thoracoscopic lung biopsies performed in the Edinburgh Thoracic Unit were compared with 25 historical controls for complications, diagnostic accuracy, and length of postoperative stay. RESULTS--Statistical comparison showed equal diagnostic accuracy in both groups (96% v 92%), but mean (SD) inpatient stay was reduced in the video assisted thoracoscopic group (1.4 (0.7) days) compared with those undergoing open lung biopsy (3.1 (1.8) days). No postoperative complications were reported in the group which underwent video assisted thoracoscopic lung biopsies but three patients had postoperative complications in the open lung biopsy group. CONCLUSIONS--Video assisted thoracoscopic lung biopsy is as effective in providing histological diagnosis as is open lung biopsy. All postoperative complications were related to post thoracotomy pain and occurred only in patients undergoing open lung biopsy. Reduced postoperative disability in the video assisted thoracoscopic group decreased hospital stay, offsetting the increased cost in disposables. The overall cost of video assisted thoracoscopic and open lung biopsy was 712 pounds and 1114 pounds, respectively.     

Thoracoscopic lung biopsy in the diagnosis of diffuse lung disease

The diagnosis of diffuse lung disease can only be made accurately by performing a thoracoscopic lung biopsy. We evaluated the safety and efficacy of thoracoscopic lung biopsy in diffuse lung disease. Between May 1999 and April 2003, 34 patients were referred to us for thoracoscopic lung biopsy. We compared the clinical characteristics, number of biopsies, operation times, postoperative course, complications, and mortality in 19 patients with dyspnea and 15 patients who were asymptomatic. Although the number of biopsies, operation times, duration of chest drainage, and postoperative stay did not differ significantly between the 2 groups, postoperative oxygen support was needed for significantly longer in the dyspnea group (p =0.038). A pathological diagnosis was established in all patients. Postoperative complications developed in 4 patients. A prolonged air leak in 1 patient and a wound infection in another resolved conservatively, but 2 patients died of acute exacerbation. Thus, we conclude that the indications for surgery must be carefully considered in dyspneic patients with diffuse lung to prevent acute exacerbation.     

Video-assisted thoracoscopic biopsy in the diagnosis of idiopathic interstitial lung disease

Surgical lung biopsy is indicated in the diagnosis of idiopathic interstitial lung disease in more than 30% of patients. Our study analyses the technical evolution of the surgery during recent years in our department and the results of thoracoscopic lung biopsy. We retrospectively analysed 31 consecutive patients who underwent thoracoscopic lung biopsy from Jan. 1 2000 to Dec. 31 2004; 16 were male and 15 female with a mean age of 58.17 +/- 11.84 years. From September 1991 to December 1999 we performed another 40 lung biopsies. The SPSS software package was used to process the data. All patients but one underwent bronchial lavage and transbronchial biopsy preoperatively, without obtaining a correct diagnosis. Surgical biopsy findings were diagnostic in all patients. The conversion rate to thoracotomy was 20.7%. The mean operative time was 67.9 +/- 16.7 minutes and a mean number of 2.4 +/- 0.8 wedge lung biopsies were performed. The mean chest drain duration and hospital stay were 6.0 +/- 4.7 days and 7.9 +/- 4.7 days, respectively. The perioperative minor complication rate was 6.9% and the mortality rate 0%. Our results confirm that thoracoscopy has a diagnostic accuracy of 100% with low complication and mortality rates. These results compare well with those of open lung biopsy.     

Thoracoscopic lung biopsy in infants and children with endoloops allows smaller trocar sites and discreet biopsies

BACKGROUND: Thoracoscopy is replacing open lung biopsies because it is less invasive. However, most surgeons obtain biopsies with an endostapler, which requires a 12-mm trocar and a minimum of 4.5 cm of intrathoracic space to open, making its use in patients less then 10 kg impractical. This report describes the use of the Endoloop (Ethicon Endosurgery, Cincinnati, OH) in small pediatric patients undergoing thoracoscopic lung biopsies. MATERIALS AND METHODS: From 1993 to February 2007, 69 patients underwent thoracoscopic lung biopsy for diagnosis and therapy. Ages ranged from 2 weeks to 4 years and weight from 2 to 22 kg. One 5- and two 3-mm trocars were used in all cases. In all cases, two Endoloops were placed proximal to the segment of lung being biopsied and the lung was divided sharply distal to the Endoloops. The specimen was removed through the 5-mm trocar site. The lung was reexpanded and no chest drains were left in postoperatively. RESULTS: All 69 procedures were successfully completed thoracoscopically. Two biopsy specimens were obtained, in most cases. Operative time ranged from 10 to 35 minutes (average, 20). There were no intraoperative complications. One patient required reintubation and ventilator support on postoperative day 1 and developed a pneumothorax on postoperative day 2, requiring a chest tube. There were no other complications. CONCLUSIONS: The thoracoscopic approach to lung biopsy is the preferred method of obtaining lung tissue for diagnosis. The use of the Endoloop technique is a safe, effective technique in small pediatric patients, avoiding problems with the limited size of the chest cavity in patients less than 10 kg, and avoids the use of large incisions in a small child.     

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.     

Changing the way we think about medical technology policy

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.     

Surgical lung biopsy for diffuse pulmonary disease: experience of 196 patients

OBJECTIVE: Surgical lung biopsy is considered the final method of diagnostic modality in patients with undiagnosed diffuse pulmonary disease. Nevertheless, the effect of surgical lung biopsy on the diagnosis, treatment, and outcome of the patient still remains controversial. This study reviewed the experiences of surgical lung biopsies in 196 consecutive patients during the past 7 years. METHODS: Surgical lung biopsy was performed after achievement of general anesthesia through video-assisted thoracoscopic surgery or a 7-cm minithoracotomy. Biopsy specimens were swabbed for aerobic and anaerobic bacterial, fungal, and mycobacterial cultures. The sections of specimens were routinely stained with hematoxylin and eosin, and acid-fast, Gomori methenamine silver, Gram stain, or other special stains were added if necessary. RESULTS: The pathologic diagnosis after surgical lung biopsy included infection (30.6%), interstitial pneumonia or fibrosis (21.9%), diffuse alveolar damage (17.3%), neoplasm (13.3%), autoimmune diseases (8.2%), and others (8.2%). After surgical lung biopsy, 165 (84.2%) patients had changes in their therapy, 124 (63.3%) patients had clinical improvement of their conditions, and 119 (60.7%) patients survived to hospital discharge. Comparison between immunocompromised and immunocompetent patients showed that diagnosis of infection was significantly higher ( P < .01) in the former group (41.2% vs 20.2%). In addition, there was no significant difference in the distribution of diagnosis and rate of change in therapy between the respiratory failure and nonrespiratory failure groups. However, the rates of response to therapy and patient survival were significantly lower in the respiratory failure group (51.2% and 41.5%) than in the nonrespiratory failure group (71.9% and 78.1%, P < .05). There was no surgical mortality directly related to the procedure. The surgical morbidity rate was 6.6%. CONCLUSION: Surgical lung biopsy is a safe and accurate diagnostic tool for diffuse pulmonary disease. For a large proportion of the patients, change of therapy and then clinical improvement can be achieved after surgical lung biopsy. Surgical lung biopsy should be considered earlier in patients with undiagnosed diffuse pulmonary disease, especially when the respiratory condition is deteriorating.     

Does lung biopsy help patients with interstitial lung disease?

OBJECTIVES: The decision to perform lung biopsy in the evaluation of interstitial lung disease (ILD) is based on the probability that this examination will yield a specific diagnosis, leading to a change in treatment. The purpose of this study was to identify factors that influence the diagnostic yield of lung biopsy for ILD. METHODS: One hundred patients underwent lung biopsy for ILD over a 5-year period. There were 59 men and 41 women; with a median age of 51.5 years. Thirty percent underwent open lung biopsy, while 70% had videothoracoscopic biopsy. Patient and disease characteristics, prior diagnostic studies, pre-operative therapy, biopsy type, site, size, number, and laterality were compared to identify factors that might influence diagnostic yield. RESULTS: Forty-two percent had a specific diagnosis, while 58% had a non-specific diagnosis. Right side was selected in 57.1% of patients with a specific diagnosis and 48.3% of patients without a specific diagnosis (P=0.381). Right lower lobe was the main site for biopsy in the specific diagnosis group compared to the non-specific group (35.7 versus 20.7%, P=0.095). Left upper lobe was the main site for biopsy in the non-specific diagnosis group compared to the specific diagnosis group (41.4 versus 23.8%, P=0.067). Mean volume of biopsy was 12.3 cm(3) in the specific diagnosis group and 12 cm(3) in the non-specific diagnosis group (P=0.373). Two or more biopsies were carried out in 38.1% of the specific diagnosis group compared to 25.9% of the non-specific diagnosis group (P=0.192). There were no significant factors in predicting a diagnostic yield. Of those patients with a specific diagnosis, 59.5% had therapy altered, compared to 55.2% of those with a non-specific diagnosis (P=0.664). CONCLUSIONS: Lung biopsy does not always provide a specific diagnosis and does not always change therapy. The site, size, number, and laterality of the biopsy specimen have no definite influence on diagnosis. There is a trend to improve diagnostic yield by carrying out two or more biopsies on the right lung.     

Videothoracoscopic wedge excision of the lung.

Recent advances in video technology and endoscopic instrumentation have expanded the use of thoracoscopy from diagnosis to treatment of pulmonary parenchymal disease. We recently performed 14 pulmonary wedge excisions using videothoracoscopic techniques in 10 patients (7 women and 3 men). Median age was 60 years (range, 21 to 82 years). Indications were small peripheral solitary pulmonary nodules in 4 patients, diffuse pulmonary infiltrates in 4, and recurrent pneumothoraces in 2. Thoracoscopic wedge excisions were accomplished using double-lumen endotracheal anesthesia and a percutaneous stapling device. Tissue diagnosis was obtained in all patients; 6 had benign disease, 3 had metastatic cancer, and 1 had diffuse bronchoalveolar cell carcinoma. Median operating time was 90 minutes (range, 40 to 140 minutes). There were no operative deaths. The single complication was a prolonged air leak. Median hospitalization was 5 days (range, 3 to 16 days). All patients returned to full activity within 10 days of discharge. Median follow-up was 6 months (range, 5 to 8 months). We conclude that videothoracoscopic wedge excision is a safe and effective procedure for selected small peripheral indeterminate pulmonary nodules, diffuse interstitial lung diseases, and recurrent spontaneous pneumothoraces. Further evaluation and prospective studies are indicated.     

Minimally invasive lung and pleural biopsies using 2-mm and standard thoracoscopic equipment.

Videoendoscopic surgery is commonly used to obtain a definitive diagnosis in a patient with pleural lesions or pulmonary infiltration of unknown etiology. We have performed minimally invasive pleural and lung biopsies, using 2-mm mini-videoscopic instruments supported by standard thoracoscopy via one 11.5-mm port, in 10 patients. These involved 8 patients with diffuse pulmonary infiltration, and two with diffuse pleural thickening. They underwent thoracoscopic pulmonary wedge resection and pleural biopsy using one 11.5-mm port and two or three 2-mm mini-ports. The mean operating time was 37 minutes. This procedure was successful in establishing a definitive diagnosis in each patient. Complications included subacute acceleration in pulmonary infiltration in one patient. No patient complained of pain or discomfort at the 2 mm-thoraco port sites. Healing of this port site resulted in excellent cosmesis. Mini-videoscopic surgery supported by standard thoracoscopic equipment can be used to perform lung or pleural biopsy less invasively than standard thoracoscopic approach.     

Prospective randomized study of open lung biopsy versus empirical antibiotic therapy for acute pneumonitis in nonneutropenic cancer patients

Diffuse pulmonary infiltrates and acute respiratory compromise frequently occur in patients with cancer who are undergoing chemotherapy, and treatment remains controversial. We initiated a prospective randomized trial in 22 nonneutropenic patients to compare the efficacy of immediate open lung biopsy with that of empirical trimethoprim-sulfamethoxazole and erythromycin therapy with delayed open lung biopsy if no clinical improvement occurred after 4 days of therapy. Diagnoses included non-Hodgkin's lymphoma (15 patients), T-cell lymphoma (2), acute lymphoblastic leukemia (3), Hodgkin's disease (1), and breast cancer (1). The median age was 40 years, and fever (18) and tachypnea (13) were the most frequent signs. Median room air arterial oxygen tension in 18 hypoxic patients was 53 mm Hg; 19 patients had diffuse pulmonary infiltrates. Eight of the 10 patients randomized to empirical antibiotic therapy showed improvement after 4 days. The 2 patients whose condition did not improve and who underwent delayed open lung biopsy had Pneumocystis carinii pneumonia. One of them did show improvement, and the other died of respiratory failure. Time to clinical resolution in the 9 surviving patients was 14 days; 4 required prolonged ventilation (longer than 24 hours). Findings for the 12 patients randomized to immediate open lung biopsy were P. carinii pneumonia in 7 and nonspecific pneumonitis in 5; there were 3 deaths related to open lung biopsy. Time to resolution in the surviving patients was 13 days for those with P. carinii pneumonia and 5 days for those with nonspecific pneumonitis; 7 required prolonged ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary lung cancer incidentally diagnosed in lung biopsy for diffuse pulmonary disease

We here presented 2 cases of interstitial pneumonia with lung adenocarcinoma incidentally diagnosed by partially resected lung for diffuse pulmonary disease. CASE 1: A 78-year-old female was admitted to the hospital complaining of productive cough and general fatigue. The chest computed tomography (CT) revealed diffuse honey comb pattern in bilateral lung field especially in the right lower lung. Video-assisted thoracoscopic lung biopsy was performed and was diagnosed as diffuse spreading well differentiated adenocarcinoma. CASE 2: A 59-year-old male was admitted to the hospital complaining of dyspnea and general fatigue. The chest X-ray revealed right pneumothorax and chest CT revealed diffuse honey comb pattern and bullae in bilateral lung field and fibrous tumor-like lesion in the right middle lung. Video-assisted thoracoscopic lung biopsy was performed and was diagnosed as pulmonary fibrosis with papillary adenocarcinoma. CONCLUSION: It is important to examine carefully the specimen obtained from thoracoscopic lung biopsy even if interstitial pneumonia is strongly suspected.     

Inter-observer variation between pathologists in diffuse parenchymal lung disease

BACKGROUND: There have been few inter-observer studies of diffuse parenchymal lung disease (DPLD), but the recent ATS/ERS consensus classification provides a basis for such a study. METHODS: A method for categorising numerically the percentage likelihood of these differential diagnoses was developed, and the diagnostic confidence of pathologists using this classification and the reproducibility of their diagnoses were assessed. RESULTS: The overall kappa coefficient of agreement for the first choice diagnosis was 0.38 (n = 133 biopsies), increasing to 0.43 for patients (n = 83) with multiple biopsies. Weighted kappa coefficients of agreement, quantifying the level of probability of individual diagnoses, were moderate to good (mean 0.58, range 0.40-0.75). However, in 18% of biopsy specimens the diagnosis was given with low confidence. Over 50% of inter-observer variation related to the diagnosis of non-specific interstitial pneumonia and, in particular, its distinction from usual interstitial pneumonia. CONCLUSION: These results show that the ATS/ERS classification can be applied reproducibly by pathologists who evaluate DPLD routinely, and support the practice of taking multiple biopsy specimens.     

Video-assisted thoracoscopic surgery for diagnosis, staging, and management of lung cancer with suspected mediastinal lymphadenopathy

The aim of this report was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) in staging, diagnosis, and treatment of lung cancer. Fifty-two patients were scheduled for mediastinal lymph node VATS biopsy at the Oncologic Thoracic Surgery Department of the National Cancer Institute in Milan. Fifty patients underwent lymph nodal thoracoscopic biopsy (96%), whereas for the other 2 patients, histologic diagnosis was done by pleural metastatic nodule thoracoscopic biopsy (4%). We performed 17 lymph nodal biopsies in level 5 (33%), 14 in level 6 (27%), 12 in level 7 (23%), and 7 in level 8 (13%). No postoperative complications were observed, and 19 subjects (36%) underwent open lung resection. The histologic diagnosis was adenocarcinoma in 25 cases (48%), epidermoid carcinoma in 14 (27%), microcytoma in 9 (17%), and giant-cell lung carcinoma in 4 (8%); 10 patients were at stage I (19%), 9 at stage II (17%), 31 at stage III (60%), and 2 at stage IV (4%). The use of VATS allowed diagnosis of the suspected involved mediastinal lymph nodes in lung cancer patients and obviated the need for painful thoracotomy, enabling accurate staging and thus selection of the optimal treatment.     

Trephine biopsy of the lung and pleura

During the last five years 140 biopsies of the lung or pleura have been performed with a high-speed air-drill. A specially designed trephine, 2·1 mm. in bore, proved effective in obtaining adequate specimens from patients with diffuse lung lesions. With this method 111 out of 119 (93%) consecutive lung biopsies were successful in producing specimens of lung tissue for histological examination and 101 (85%) of these biopsies were diagnostically significant. Conditions such as sarcoidosis, berylliosis, alveolar proteinosis, polyarteritis nodosa, asbestosis, and diffuse interstitial pulmonary fibrosis were conclusively diagnosed. Complications were not serious and the commonest, pneumothorax, which occurred in 26% of the lung biopsies, was usually asymptomatic. The procedure is rapid and painless and breath-holding is unnecessary. It is performed under local anaesthesia and can be repeated, if required, thus having many advantages over biopsy by open thoracotomy. However, full thoracic surgical cover should be available. Indications include diffuse and localized lesions of the lung or pleura where a definitive diagnosis is required for the purpose of treatment, prognosis, or a claim for industrial compensation.     

Perivascular inflammation in pulmonary infections: implications for the diagnosis of lung rejection.

Transbronchial lung biopsy is rapidly becoming the procedure of choice for diagnosing lung rejection, and diagnostic criteria are evolving. The presence of perivascular lymphocytic infiltrates has been stated to be sufficient for this diagnosis, although the specificity of this histologic finding has not been determined. In a review of 42 cases of pneumocystis and cytomegalovirus pneumonia diagnosed by open (33 cases) and by transbronchial lung biopsy (nine cases) from immunosuppressed patients (excluding those with underlying non-Hodgkin's lymphoma), perivascular lymphocytic infiltrates similar to those observed in lung rejection were identified in 26% of cases overall, 21% of pneumocystis cases (n = 33), 42% of cytomegalovirus cases (n = 7), and 50% of cases of combined pneumocystis and cytomegalovirus pneumonia (n = 2). The presence of a perivascular infiltrate did not correlate with the pattern of lung histology (diffuse alveolar damage, mononuclear interstitial pneumonia, or organizing pneumonia) or with overall cellularity of the specimens. As cytomegalovirus and pneumocystis are the two most common nonbacterial pathogens in lung transplant recipients, these findings support a multimodal approach to the diagnosis of lung rejection and argue for caution in interpreting the presence of perivascular inflammation on transbronchial biopsies in this setting until a diagnosis of infection is excluded.     

Thoracoscopic surgery for diseases of the lung and pleura. Effectiveness, changing indications, and limitations.

OBJECTIVE: This study compared the results of video-assisted thoracic surgery (VATS) with thoracoscopic surgery (TS) for diseases of the lung and pleura. SUMMARY BACKGROUND DATA: No studies exist that compare the capabilities of VATS with advanced video systems and instrumentation to that of TS which has been done for 80 years. METHODS: A retrospective study was done comparing the effectiveness, indications, complications, and limitations of TS and VATS done for four categories of pleural disease: 1) pleural fluid problems, 2) diffuse lung disease, 3) lung masses, and 4) pneumothorax. The TS period was 1981-1990. The VATS period was 1991-1992. RESULTS: Eighty-nine consecutive TS cases and 64 consecutive VATS cases were reviewed. TS for resolution of pleural fluid problem was successful in 29 of 34 patients (85%), and VATS was successful in 18 of 20 (90%). Diffuse lung disease was diagnosed by TS using a cup biopsy on end-stage patients in respiratory failure. Since 1991 the diagnosis has been made with VATS using stapled wedge excisions on ambulatory patients. Surgical mortality decreased from 33% (10 of 30) to 9% (1 of 11) and the postoperative stay from 16.6 +/- 2.4 days to 8.2 +/- 2.2 days. Lung masses were diagnosed entirely by incisional biopsies using TS. Diagnosis was made in 83% and postoperative stay was 5.3 +/- 1.0 day. VATS allowed excisional biopsies permitting diagnosis in 100% with a postoperative stay of 3.0 +/- 0.2 days (p = 0.05). However, 20% required conversion to thoracotomy to locate the subpleural mass. TS was performed for spontaneous pneumothorax in only 26% (5 of 19) of the total pneumothorax cases, whereas, VATS was used for spontaneous pneumothorax in 67% (12 of 18). CONCLUSION: VATS has continued the effectiveness of TS for treating pleural fluid problems, has resulted in earlier surgical diagnostic intervention in diffuse lung disease and earlier therapeutic intervention in primary pneumothorax states, and has markedly expanded the safety, efficacy and indications for lung mass biopsy.