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Ann Thorac Surg 2001;71:1113-1115
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Open lung biopsy as an outpatient procedure

^a Department of Surgery, McMaster University, Hamilton, Ontario, Canada

Accepted for publication November 20, 2000.

Address reprint requests to Dr Bennett, St. Joseph’s Hospital, 50 Charlton Ave E, Hamilton, Ontario L8N 4A6, Canada
e-mail: urschelj{at}mcmaster.ca

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
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.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Lung biopsies are essential for the accurate diagnosis of diffuse interstitial lung diseases [1]. Transbronchial and percutaneous needle biopsy techniques are sometimes useful, but most patients require a surgical biopsy technique [2]. Thoracotomy for open lung biopsy has been a standard surgical approach for many years [1–3]. More recently, thoracoscopic lung biopsies have been used for the diagnosis of diffuse interstitial lung disease [4,5]. Irrespective of operative approach, there are no reports to date on the safety and feasibility of outpatient surgical lung biopsy.

One senior surgeon (WFB) at our institution started to perform outpatient open lung biopsies on selected patients in 1995. Starting in 1997 all ambulatory, non-oxygen dependent, patients requiring diagnostic open lung biopsy in this surgeon’s practice underwent open lung biopsy as an outpatient procedure. We report this series of patients that underwent outpatient open lung biopsy, and describe the important technical aspects of this approach.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between January 1997 and December 1999, 32 consecutive ambulatory, non-oxygen dependent patients with a clinical diagnosis of diffuse interstitial lung disease underwent outpatient open lung biopsy by one surgeon (WFB) at our institution. Patients who were oxygen dependent, hospitalized for acute illness, or suffering from focal (nondiffuse) lung disease were not considered for this biopsy approach. There was no upper age limiting patient selection. Patients were evaluated in the surgeon’s office and seen at our hospital’s preadmission clinic as previously described [6]. Single lumen endotracheal tube general anesthesia was used. Patients were positioned supine with a roll placed under their flank for a small (5- to 8-cm) left anterolateral thoracotomy. The anterior end of the incision was placed 2 to 3 cm lateral to the line of the nipple. Pleural space was entered above the fifth rib, but no rib retractors or spreaders were used. The lingula was gently delivered into the operative field with finger dissection. Unnecessary grasping of the lung with instruments was avoided; this minimized lung trauma and iatrogenic air leak. The lingula was then grasped once with a Duval-type lung clamp and a stapled wedge resection was done with a linear stapler (GIA 90 mm, US Surgical Corporation, Norwalk, CT). Buttressing of the staple line was not done. The staple line was inspected for hemostasis and air leak. A number 24 red rubber catheter was placed through the incision and the muscle layers were loosely closed with a running absorbable number 0 suture. The lungs were inflated with sustained ventilation by the anesthesiologist, and the catheter was removed (without applying suction) as the running suture was pulled snug and tied. The remainder of the wound was closed in layers with absorbable sutures and skin was closed with a subcuticular suture.

A portable upright chest radiograph was done in the recovery room and checked by the surgeon before transfer of the patient to the ambulatory surgery unit. The patients were discharged home several hours later with a prescription for oral analgesics, such as acetaminophen with codeine. They were instructed to call their surgeon or return to our hospital’s emergency room if their dyspnea worsened. The patients were seen in follow-up by the attending surgeon within 7 days of the procedure and a chest radiograph was done on that visit.

All lung biopsy specimens were processed according to our hospital’s lung biopsy protocol. In brief, the bulk of the specimen was delivered fresh to the pathologist for processing and inflation with formalin. Small portions of the wedge resection specimen were sent for various culture studies.

Pulmonary function data are presented as means ± standard deviations.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Thirty-two consecutive patients underwent open lung biopsy by one surgeon (WFB) as an outpatient procedure. During this period, the surgeon used the outpatient biopsy technique on all ambulatory non-oxygen dependent patients referred for biopsy of suspected diffuse interstitial lung disease. Mean age was 58 years with a range of 21 to 74 years. Preoperative forced expiratory volume in 1 second was 74.3% ± 7.0% of predicted and preoperative forced vital capacity was 82.9% ± 5.9% of predicted. Preoperative diffusion capacity was 60.0% ± 4.1% of predicted. Room air preoperative oxygen saturation was 94.5% ± 1.3%. One patient had undergone contralateral lobectomy for lung cancer several years before the open lung biopsy.

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. All patients were discharged home on the day of operation. In contrast to American hospitals, Canadian hospitals do not have "23-hour" units. No patient required a chest tube, overnight observation, or hospital admission. Wound infections, delayed appearance of pneumothorax, or other complications, did not occur. A chest radiograph was routinely obtained at the surgical follow-up visit.

Treatment of diffuse interstitial lung disease and long-term clinical follow-up was done by referring pulmonary physicians. We are unaware of any long-term complications or errors in diagnosis, but our lack of long-term surgical follow-up prevents us from being certain in this respect. However, our thoracic surgical unit is essentially the exclusive provider of thoracic surgical services in our region and our pathology department is a regional referral center for lung pathology. We are confident that the pathologic diagnoses given are accurate.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Diagnostic lung biopsy for diffuse interstitial lung disease can be accomplished using a limited thoracotomy or thoracoscopy approach [4, 5]. Most recent investigation in this area of surgery has focused on the relative merits of these two operative approaches. Many studies have compared the two techniques, but most are hampered by their nonrandomized study design [7–13]. Most of these nonrandomized studies have suggested some advantage for the thoracoscopic approach [7–11, 13]. Important outcomes that have been assessed include postoperative pain, length of hospital stay, adequacy of diagnostic biopsies, and cost [5]. Thoracoscopic biopsies are reportedly less painful [8, 9, 13], and involve a shorter length of hospital stay [7, 9, 11, 13], than biopsies done through a limited thoracotomy. Biopsies are generally adequate for diagnosis with either approach [7, 10–13]. Thoracoscopy may have greater equipment costs than thoracotomy [9, 12], but this is reportedly offset by a shorter duration of hospitalization [9]. A recent randomized controlled trial compared limited thoracotomy to thoracoscopy for diagnostic lung biopsy in diffuse interstitial lung diseases [14]. In contrast to the numerous nonrandomized studies cited, it did not show any significant difference in outcomes (pain, analgesic requirement, length of hospital stay, complications, and pulmonary function) for the two operative approaches.

Given the considerable interest in comparing thoracotomy and thoracoscopy for diagnostic lung biopsy, it is remarkable that no previous study has addressed the feasibility of outpatient lung biopsy. One report of thoracoscopic lung resection described a protocol of early chest tube removal and hospital discharge [15]. Our series shows that limited thoracotomy for diagnostic open lung biopsy is safe and effective as an outpatient procedure in ambulatory, non-oxygen dependent patients. However, proper patient selection is critical. Patients must be ambulatory, have diffuse lung disease, and they must not be oxygen dependent. If pleural adhesions are suspected (history of pleural infection, chest tube, or operation), postoperative air leak can be anticipated and outpatient biopsy will not be feasible. Patients with very acute presentations or rapidly deteriorating lung function are not suitable for open lung biopsy as an outpatient. The preoperative pulmonary function data from our patients are indicative of the type of patient that is a candidate for outpatient open lung biopsy; stable patients with diffuse, but not incapacitating, lung disease are ideal candidates.

Several technical aspects of outpatient open lung biopsy deserve emphasis. The lingula is our preferred site for biopsy in patients with diffuse interstitial lung disease. However, the lung disease must be truly diffuse, as seen on preoperative imaging studies, for lingular biopsies to be appropriate. Our results (no nondiagnostic biopsies) and those reported by other investigators [3] support this practice, although some researchers have raised concerns about the diagnostic value of lingular biopsies [16]. The lingula delivers through a mini-thoracotomy easily without the use of lung traction or rib retractors. However, it is very important to place the left anterolateral thoracotomy quite lateral (see Patients and Methods section) to facilitate easy finger delivery of the lingula into the wound. Many surgeons place the incision too far anteriorly. This exposes the pericardium instead of the lingula and the surgeon inevitably uses excessive traction to deliver the lingula into the operative field. Postoperative pain is minimized by avoidance of rib retractors and chest tubes. These technical points are critical for successful patient discharge within hours of operation.

The experience of one of us (WFB) has convinced other members of our thoracic surgical group to adopt the outpatient open lung biopsy procedure. However, those of us with less experience than the originating surgeon have placed a chest tube, and then removed it in the recovery room. Discharge several hours later is still feasible. This approach has also been successfully used by other groups [15].

Selected patients with a clinical diagnosis of diffuse interstitial lung disease can safely and effectively undergo diagnostic outpatient open lung biopsy at our center. The minimally insulting nature of outpatient lung biopsy has been well received by patients and pulmonary physicians. Our pulmonary medicine colleagues now refer patients for lung biopsy earlier in the course of their disease. Reports of outpatient open lung biopsy from other institutions are needed to confirm our results, and promote widespread use of this technique.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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