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Ann Thorac Surg 1995;59:348-351
© 1995 The Society of Thoracic Surgeons

The Role of Thoracoscopy in the Diagnosis of Interstitial Lung Disease

Division of Thoracic and Cardiovascular Surgery and Departments of Radiology and Pathology, The University of Maryland Medical School, Baltimore, Maryland

Accepted for publication August 24, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
A study was undertaken to evaluate the safety and efficacy of thoracoscopic lung biopsy for interstitial lung disease. The relation between operative findings, pathologic findings, and preoperative computed tomographic scan findings was examined. Twenty-six patients, 10 male and 16 female, underwent thoracoscopic lung resection to diagnose interstitial lung disease. Sixteen patients were outpatients for an elective procedure; 10 were inpatients including 2 who were ventilator dependent. The mean length of operation was 54 minutes and the mean length of chest tube duration, 1.3 days. There were no deaths. Staphylococcal pneumonia developed in 1 patient postoperatively. One patient with systemic pulmonary hypertension was ventilator dependent for 48 hours. A double-lumen endotracheal tube was used in all but 2 patients. Twelve-millimeter trocar ports were used to allow easy interchange of staplers and endoscopic instruments. Biopsy of at least two lobes was performed in each patient with resection of a piece of grossly abnormal lung. A single chest tube was left routinely. The pathologic diagnosis was usual interstitial pneumonitis in 7 patients. Four patients had interstitial fibrosis and 4, granulomas. Three patients had diffuse alveolar damage and 3, Wegener's granulomatosis. Two patients had bronchiolitis obliterans with organizing pneumonia. One patient each had lymphangioleiomyomatosis, eosinophilic granuloma, and cytomegalovirus. Sixteen patients underwent preoperative computed tomographic scanning. The scans were assessed by 2 radiologists who were blinded to the surgical results. Computed tomography accurately predicted the site of disease in most instances. Four patients had at least one lobe with no evidence of disease on computed tomography but with interstitial lung disease found at thoracoscopy. One of these patients had no evidence of disease on computed tomographic scans. Thoracoscopy allows selective biopsy of multiple lung segments, thereby increasing the diagnostic yield in interstitial lung disease.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 351.

Thoracoscopy has proved to be an excellent method for the diagnosis and treatment of intrathoracic disease. Recent studies [1–6] have demonstrated the safety and utility of thoracoscopic procedures for a variety of intrathoracic diseases. The term interstitial lung disease (ILD) includes a variety of pathologic diagnoses that have similar clinical and radiographic manifestations. Specific treatment of patients is often possible if an exact pathologic diagnosis can be made. Conversely, by excluding certain specific entities, such as opportunistic infection, the physician can avoid unnecessary and potentially harmful therapy [7].

We undertook this study to investigate the role of thoracoscopy in establishing a diagnosis in patients seen with ILD. In addition, we examined the efficacy of computed tomographic (CT) scanning in predicting the segments from which to obtain biopsy specimens to reach a diagnosis.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients with suspected ILD on the basis of worsening clinical symptoms, radiographic findings, or both were studied. All patients underwent thoracoscopic resection of at least two segments of the lung. Biopsy of the right lung was done whenever possible. Right lung biopsy is technically easier because there are more fissures and therefore segments that are more easily accessible. When possible, biopsies were done of three different areas to obtain representative specimens of early, active, and healing stages of the underlying disease.

Technique
Patients were intubated with a double-lumen tube for one-lung ventilation during thoracoscopic lung resection. Two patients were ventilator dependent and the procedure was performed with single-lumen tubes. In these patients, carbon dioxide insufflation was used to produce pressures lower than 10 mm Hg and flow rates of less than 2 L/min to facilitate exposure. These levels have been shown to be safe for clinical thoracoscopy in a recent report [8]. By coordinating the procedure with the anesthetist who used ``hand ventilation,'' we were able to achieve adequate lung resection by intermittently stopping ventilation.

Patients were placed in the lateral decubitus position, and three 12-mm trocars were placed: one in the sixth interspace posterior axillary line (thoracoscope), one in the fifth interspace anterior axillary line (lung grasper), and one in the eighth interspace midaxillary lines (linear stapler). An Endo-GIA 30 stapler (U.S. Surgical Corp, Norwalk, CT) with 3.5-mm staples (blue cartridge) was used to achieve a V-shaped wedge resection. When necessary, the instruments were exchanged among the ports to allow safe, easy application of the stapler (Fig 1). On occasion (especially when there were many adhesions), we employed a ``two-stick'' approach using only two trocar ports. A single 24F chest tube was left through the anterior incision, and the other wounds were closed with subcuticular sutures.

View larger version (76K): [in this window] [in a new window]   Fig 1. . Setup and stapler application for thoracoscopic lung resection. ( ICS = intercostal space; RLL = right lower lobe; RML = right middle lobe; RUL = right upper lobe.) (Reprinted from Krasna MJ, Mack MJ. Atlas of thoracoscopic surgery. St. Louis: Quality Medical Publishing, Inc, 1994:98.)

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
One hundred forty-six thoracoscopic procedures were performed from December 1990 to May 1993. Of the 146 patients, 66 underwent thoracoscopic lung resection; the procedures included blebectomy and wedge resection for solitary pulmonary nodules and ILD. Twenty-six consecutive patients underwent thoracoscopic lung resection to diagnose ILD. Ten of them were male and 16, female. Sixteen were outpatients for an elective procedure, and 10 were inpatients who were in intensive care units preoperatively. Two patients were ventilator dependent preoperatively.

The mean operating room time was 53.7 minutes (range, 15 to 75 minutes). The mean length of chest tube duration was 1.3 days (range, 1 to 4 days). The mean length of hospital stay from the day of operation for patients having an elective procedure was 1.8 days (range, 1 to 4 days). The mean length of treatment with parenteral narcotics was 1.0 day for the patients who were not ventilator dependent.

There were no deaths in this series. No patient had a staple line complication. There were no bleeding complications or air leaks. A postoperative methicillin sodium–resistant staphylococcal pneumonia with parapneumonic effusion developed in 1 patient. The patient was readmitted, treated with intravenous vancomycin, and discharged home on a 1-week regimen of antibiotics. One patient was ventilator dependent for greater than 24 hours. This patient had pulmonary hypertension with supersystemic pulmonary artery pressures. Once extubated on postoperative day 1, she was discharged within 48 hours.

The pathologic findings for the resected specimens were as follows: usual interstitial pneumonitis, 7 patients; granulomas or end-stage interstitial fibrosis, 4 patients each; diffuse alveolar damage or Wegener's granulomatosis, 3 patients each; bronchiolitis obliterans with organizing pneumonia, 2 patients; and lymphangioleiomyomatosis, eosinophilic granuloma, and cytomegalovirus alveolitis, 1 patient each.

Preoperative CT and high-resolution CT scans were available for 16 patients. In 12 (75%), there was good correlation to the findings at thoracoscopy. In 4 patients (25%), at least one lobe interpreted as ``normal'' on CT scan demonstrated ILD at thoracoscopic lung resection. One of these patients had a completely normal preoperative CT scan, but pathologic examination revealed usual interstitial pneumonitis on the biopsy specimens.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
It is important to establish a specific diagnosis in patients with ILD to select the proper management approach. Steroid therapy is associated with many side effects and therefore must be used cautiously. Appropriate choice of antibiotics, antifungal medication, and antiviral medication is necessary to avoid superinfection with hospital-acquired organisms that may be resistant to standard regimens. A definitive diagnosis obtained at operation can help to predict prognosis or, in the case of lung transplantation, direct appropriate surgical interventions that may affect outcome.

Since the first report of the use of open lung biopsy to diagnose ILD, this technique has gained widespread acceptance. In patients with ILD, Gaensler and Carrington [9] suggested that the most effective diagnostic strategy is to avoid the most involved segments and do a biopsy of averagely involved lung tissue. They recommended avoiding the lingula and right middle lobe. Their series, however, did report a number of patients with ``nonspecific fibrosis'' (without a specific diagnosis). Conversely, Miller and colleagues [10] wrote that the lingula and middle lobe are easily accessible and useful in making a diagnosis. They pointed out, however, that a deep biopsy of the lung parenchyma is required to obtain a diagnostic result. Also, they found that in nonimmunosuppressed patients, areas of average involvement are adequate, whereas in immunosuppressed patients, the most diseased segment is preferable for diagnosis. Chechani and coauthors [11] showed that moderately diseased tissue from the radiographically most involved lobe is the most useful for diagnosis. Open lung biopsy allows palpation and inspection of the lobe and allows avoidance of fibrotic, nondiagnostic segments. In their series, four of 20 specimens were nondiagnostic. They reported that the chest radiogram was normal in about 10% of patients. In their opinion, computed tomography was not helpful in the instances when it was used.

Use of thoracoscopy for lung resection has increased with the advent of the Endo-GIA stapler [12]. In comparison with open lung biopsy, the purported advantages of thoracoscopic lung resection are less pain, a shorter hospital stay, and better cosmetic results. In a recent study of postthoracoscopy pain [13], however, no advantage was shown in decreasing chronic pain after 1 year compared with standard thoracotomy.

Dowling and associates [14] have reported that visual inspection by thoracoscopy allows one to choose the optimal segment for biopsy in patients with ILD. On the basis of this technique, they perform lung biopsies of only one segment. McKeown and co-workers reported using thoracoscopic lung resection to diagnose interstitial fibrosis in 4 patients; no specific diagnosis was made except in one case of postradiation pneumonitis [15]. A recent report by Ferson and associates [16] that compared historical controls who had open lung biopsy with patients treated with thoracoscopy found a shorter hospital stay and less postoperative complications in the latter group.

In our experience, thoracoscopic lung resection is a safe procedure for the diagnosis of ILD. There was minimal morbidity and no mortality despite the inclusion of patients who were quite ill, including several patients in the intensive care unit and 2 ventilator-dependent patients. Patients tolerated the procedure well, generally requiring parenteral narcotics for only a short period. In most instances, chest tubes were removed by day 1, and most patients having an elective procedure were sent home by day 2. Most importantly, thoracoscopy allowed careful assessment of the lung and selection of appropriate segments for biopsy. Multiple biopsies of patients with ILD resulted in demonstration of fibrotic, inflamed, and mildly diseased segments in each case. We believe that the use of multiple biopsies obviates the concerns about using the middle lobe or lingula routinely for biopsy specimens. We agree with Dowling [14], Ferson [16], and their co-workers that instead of routine biopsies of the middle lobe or lingula, after careful inspection of the lung, biopsy should be performed of appropriate segments that otherwise would not be accessible through a routine inframammary incision.

Sixteen patients underwent evaluation of CT scans with grading of each lobe for severity of disease. Each scan was assessed for the presence of ILD by 2 radiologists who were blinded to the pathologic diagnosis. In the majority of patients, computed tomography accurately predicted appropriate segments for biopsy, as shown by thoracoscopic lung resection. However, five lobes in 4 patients including an entire lung in 1 patient were misinterpreted as normal. In our series, the CT scan was a useful preoperative guide to the most appropriate segment, but it did underestimate the extent of disease in some instances.

In conclusion, we believe thoracoscopic lung resection is safe as a diagnostic tool for ILD. The associated minimal morbidity and short length of hospitalization indicate that the procedure is well tolerated. Although cost was not analyzed in this study, a quicker return to work could potentially reduce total costs to the health care system. Thoracoscopic visualization adds the ability to select appropriate segments for biopsy and complements radiographic selection of involved lung. Although thoracoscopy can be done occasionally in ventilated patients, we generally recommend open lung biopsy for such patients to avoid the dangers of one-lung ventilation and manipulation of the endotracheal tubes.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Krasna, General Thoracic Surgery, The University of Maryland School of Medicine, 22 S Greene St, Room N4W87, Baltimore, MD 21201.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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