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Ann Thorac Surg 2002;74:1942-1947
© 2002 The Society of Thoracic Surgeons

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Original article: general thoracic

Diagnostic thoracoscopic lung biopsy: an outpatient experience

^a Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA

Accepted for publication August 5, 2002.

* Address reprint requests to Dr Iannettoni, Section of Thoracic Surgery, TC2120G, University of Michigan Medical Center, 1500 East Medical Center Dr, Ann Arbor, MI 48109-0344 USA
e-mail: mdi{at}umich.edu

Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
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.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Tissue diagnosis for patients with either indeterminate pulmonary nodules or diffuse interstitial lung disease is essential in determining a further course of treatment. Surgical lung biopsy has demonstrated proven accuracy when less-invasive diagnostic methods have been unsuccessful [1]. More recently, video-assisted thoracic surgical (VATS) lung biopsy has become an increasingly accepted approach for the diagnosis of patients with both indeterminate pulmonary nodules [2] and diffuse interstitial lung disease [3].

Despite recent reports demonstrating the safety of early extubation and early chest tube removal in patients undergoing thoracoscopic pulmonary wedge resection, patients are typically admitted for mean postoperative stays of 1 to 2 days [4, 5]. Open lung biopsy by limited anterolateral thoracotomy in selected patients with interstitial lung disease has been described in one series as an outpatient procedure [6]. We report our initial experience with patients undergoing outpatient VATS lung biopsy.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Between June 2000 and June 2001, 62 adult ambulatory patients with a clinical diagnosis of either diffuse interstitial lung disease or indeterminate focal pulmonary nodules were enrolled in this study. All patients underwent preoperative chest computed tomographic scanning and pulmonary function testing as well as preoperative education regarding outpatient procedures and pulmonary hygiene. Patients with indeterminate nodules included those with history of prior malignancy or referred for diagnosis of possible pulmonary metastases, as well as those with new solitary pulmonary nodules. Patients with pulmonary nodules considered for VATS lung biopsy included those with lesions located in the peripheral one third of the lung, measuring less than 3 to 4 cm in diameter on chest computed tomography. Informed consent was obtained from all patients. Approval of the study protocol was obtained May 17, 2001, from the Institutional Review Board of the University of Michigan, Ann Arbor, MI.

Procedures were performed using single-lung ventilation, with double-lumen general endotracheal anesthesia and the patient in the lateral decubitus position. All wedge resections were performed using the Endo-GIA (US Surgical, Norwalk, CT) surgical stapler with 3.5-mm staples. Patients with a preoperative diagnosis of interstitial lung disease underwent wedge biopsy of at least two pulmonary segments. Three port sites, including one for a 10-mm videothoracoscope, were used. Local subcutaneous infiltration of the skin incisions with 0.25% bupivacaine was administered to assist with postoperative analgesia. Dependent pleural drainage was obtained with a single 28F chest tube placed to -20 cm H₂O suction at the conclusion of each procedure. All patients were extubated in the operation room. Chest tubes were placed to water seal and removed in the recovery room or after admission if there was no air leak and postoperative chest radiograph demonstrated complete expansion of the lung. Patients were discharged home with an oral analgesic on the day of operation within 8 hours postoperatively or after overnight observation within 23 hours of operation, or were admitted. Patient follow-up was obtained by telephone within 1 week postoperatively, at routine 1 month postoperative visit, and by review of clinical records thereafter.

Cost analysis was performed using actual hospital costs accrued during the period of study. Direct costs reflect hospitalization, operating room, and instrument expenses, for example, whereas total costs also include indirect institutional costs. Professional charges include physician fees for surgery, anesthesia, and pathology consultations.

Statistical evaluation was performed using StatView for Windows, version 5.0.1 (SAS Institute, Inc., Cary, NC). The Mann-Whitney U test was applied for continuous variables; ² analysis and Fisher’s exact test were applied for comparison of dichotomous variables, with a p value of less than 0.05 considered significant. Any death occurring within 30 days of operation constituted operative mortality.

	Results

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
The preoperative and operative clinical characteristics of the study population are presented in Table 1. During the median follow-up of 9 months (range, 1 to 19 months), overall survival was 93.5% (58 of 62). There was no operative mortality. Four deaths occurred between 6 weeks and 6 months postoperatively of which none was directly attributable to the operation.

Of the remaining 17 patients, 14 (22.5%) were discharged the next day, within 23 hours of operation, and 3 patients (5%) were admitted. Reasons for observation or admission are enumerated in Table 2. Two patients were converted to muscle-sparing thoracotomy for resection of primary pulmonary malignancy, of whom 1 was discharged within 23 hours. Three patients were observed overnight after their operation was performed late in the day. There was no statistically significant difference in age, smoking status, pulmonary function, preoperative steroid use, or oxygen requirement between patients discharged on the day of operation and those requiring admission.

View larger version (25K): [in this window] [in a new window]   Fig 1. Histologic diagnosis for patients discharged on the same day of operation (black bars) or hospitalized for observation or admission (white bars). Numbers in parentheses indicate numbers of patients. (ILD = interstitial lung disease.)

	Comment

Top Abstract Introduction Patients and methods Results Comment Discussion References

Application of VATS lung biopsy has emerged as a valuable diagnostic modality in the identification of pulmonary nodules, solitary or multiple. Although other diagnostic alternatives, particularly image-guided needle biopsy, can determine malignancy accurately, identification of specific benign diagnoses can be unreliable, with a sensitivity of 18% and false-negative rate of 29%, when compared with the sensitivity and specificity of VATS lung biopsy [13]. In a retrospective review of 426 patients undergoing VATS pulmonary resection for new pulmonary nodules, the resected specimens were more likely to be malignant among patients with a history of prior malignancy. Although nearly 25% of nodules were found to be non–small-cell lung cancer, a significant number of resected nodules were of extrapulmonary origin, particularly breast, colorectal, sarcoma, or melanoma [12].

In several nonrandomized studies of VATS lung biopsy or pulmonary resection for indeterminate pulmonary nodules, investigators have noted significantly shorter median hospitalization of 3 to 5 days, when compared with median hospitalization of 6 to 8 days among patients undergoing thoracotomy [10, 14]. In one cost analysis, greater procedural-related costs for thoracoscopy offset any savings conferred by shorter admission [10]. Other investigators as well have reported that operating room costs appeared to be greater for patients undergoing VATS, rather than open lung biopsy through a limited thoracotomy [15]. Furthermore, despite the presumably less invasive nature of VATS lung biopsy, a recent randomized, controlled trial comparing thoracoscopy with thoracotomy for diagnosis of interstitial lung disease demonstrated no difference in duration of hospitalization, operative time, or postoperative analgesic requirements [7]. We demonstrate, not surprisingly, that the total costs of same-day diagnostic VATS lung biopsy are significantly less than the costs of hospitalization as brief as a single day. However, we did not perform a cost analysis comparing the patients of this study with those undergoing diagnostic open lung biopsy at our institution.

Recently, investigators have questioned whether the current inpatient postoperative management of patients undergoing VATS lung biopsy remains valid, particularly in the ambulatory population. Russo and colleagues [4] have suggested that patients undergoing elective VATS lung biopsy for diagnosis of either pulmonary nodules or interstitial lung disease be considered for early chest tube removal. In a prospective, nonrandomized trial they demonstrated that chest tube removal within 90 minutes of VATS lung biopsy, in selected patients, could be accomplished safely. In addition they reported a consequent reduction in analgesic requirements, without apparent increase in complications, particularly pneumothorax, when compared with patients undergoing traditional management of chest tubes. Further, when compared with the control group in which mean postoperative hospitalization was nearly 4 days, patients with early removal of chest tubes had significantly shorter mean postoperative hospitalization of 2 days.

Despite the trend toward shorter hospitalization and low morbidity associated with thoracoscopic procedures, same-day outpatient VATS lung biopsy for diagnosis of either pulmonary nodules or interstitial lung disease has not been reported previously. In this series of our initial experience, most patients diagnosed with metastatic disease were discharged on the day of operation without complication. These patients all were referred initially for evaluation of indeterminate pulmonary nodule. Blewett and colleagues [6] have reported their experience with outpatient open lung biopsy, performed through a limited left anterolateral thoracotomy, among patients referred for diagnosis of interstitial lung disease. Chest tube drainage was not used, and no complications were noted. However, in their study, given the constraints of the limited incision, biopsies were obtained only from the lingula. Although a diagnosis was obtained for all patients reported by Blewett and colleagues [6], others have speculated that VATS lung biopsy offers the surgeon the potential advantage of selecting multiple biopsy sites, guided by the thoracoscopic visualization of the most diseased portions of lung [5]. Whether this provides greater diagnostic yield over that of limited thoracotomy has not been established [7].

All outpatients referred for surgical lung biopsy, with suitable criteria for VATS resection as determined by preoperative chest computed tomography, were enrolled in this study, regardless of preoperative diagnosis, supplemental oxygen requirement, or geographic locale. Patients ultimately diagnosed with metastatic pulmonary nodules were more likely to be discharged home on the day of operation. However, regardless of preoperative diagnosis, strict adherence to postoperative criteria for chest tube removal and early discharge is important to assure patient safety. Postoperative pain remains a significant factor preventing same-day discharge, occurring in 4 (6.5%) of our patients. Although preoperative home oxygen therapy did not preclude consideration for outpatient VATS, patients with significant subjective dyspnea or chronic bronchitic cough, as was the case in the 1 patient requiring readmission for subcutaneous emphysema, should be considered for observation or admission. Our series demonstrates that outpatient VATS lung biopsy is effective and can be accomplished safely in a significant percentage of ambulatory patients requiring diagnostic lung biopsy.

	Discussion

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
DR STEVEN R. DEMEESTER (Los Angeles, CA): I enjoyed your presentation very much. I wondered whether you factored in at all the distance the patients had to travel. For example, if you had a patient who lived an hour away, were you as comfortable sending them home as the patient who lived two or three blocks away from the facility at Ann Arbor? How did the patients feel about being discharged the same day after what we would consider a relatively invasive operation even though it is done in a minimally invasive fashion? Were they comfortable with that, or did you have to spend some time with a nurse and so forth explaining the concept of going home the same day after that type of operation?

DR CHANG: In answer to your first question, although I did not map all of our patients out in Michigan or the referring geographic area, we have a very good network of local hospitals. Of note, the 1 patient in our series who had been readmitted was actually transferred from a referring hospital when his doctors there identified his subcutaneous emphysema as a potential problem. Regarding patient opinion, we have an excellent set of supplementary medical staff who, along with my attending staff, discusses with the patients the nature of the outpatient operation. We tell them that in a similar situation, such as thoracoscopic sympathectomy, patients tolerate the procedure very well. We counsel our patients preoperatively that postoperative pain can be an issue. Furthermore, every patient receives a follow-up phone call 1 and 5 days after operation, to assure that they are well.

DR JOSEPH B. SHRAGER (Philadelphia, PA): Nice presentation. We do a fair number of these procedures, as I am sure most of the people in this room do, and given the degree of postoperative pain that I think thoracoscopy patients have, I honestly cannot imagine sending somebody home the day of the procedure. I wonder if you have any particular tricks for pain control. For example, I tend to use intercostal nerve blocks while visualizing from within the chest at the end of the procedure, but even with that, I honestly cannot imagine these patients being pleased going home on the day of operation. In fact, I often feel bad encouraging these patients to go home on postoperative day number 1 and often they will stay for 2 days, not because they have an air leak or a chest tube still in place, but just because they are hurting so.

DR CHANG: I agree that postoperative pain is an issue, whether it is an open or a thoracoscopic lung biopsy. As I noted earlier, thoracoscopic biopsy does not reduce postoperative pain. We do not perform intercostal nerve blocks routinely, but we infiltrate the skin for all the cases with 0.25% Marcaine (bupivacaine), which is longer lasting, probably until they get home. We have not received many significant calls about postoperative pain. One of the initial reasons we thought that this study was feasible was that 1 patient with significant postoperative pain from his tube thoracostomy obtained such relief after the chest tube was removed on the day of operation that he refused admission, and we were able to discharge him the day of operation. That is only anecdotal evidence, but from our standpoint, patients tolerate the effects of the operation very well, and only a limited number have required overnight observation for pain management, as presented.

DR DANIEL L. MILLER (Rochester, MN): I enjoyed your presentation, but I have reservations with same-day dismissal for patients with interstitial lung disease. At our institution, especially for interstitial lung disease, we have had some problems with prolonged air leaks in patients who are on multiple immunosuppressive drugs. To suggest that someone with interstitial lung disease may go home the same day is somewhat scary. We do send our patients home the same day, however, that have undergone bilateral thoracoscopic sympathectomies. Dr Chang, you mentioned no chest X-ray results for the dismissal chest X-rays or for the 1-month postoperative films. Were there any space problems or infectious complications that occurred that could have been prevented with a routine chest X-ray at dismissal?

DR CHANG: To address the second part, in our group we did not have air space problems, except the 1 patient discussed earlier with subcutaneous emphysema. Postoperative complications occurred as presented. We do check the Pleur-Evac for air leak, of course, before removing it, and check before and after chest tube removal radiographs, and if there is any evidence of an air leak, we admit that patient.

DR LUKASZ GASIOROWSKI (Grand Forks, ND): I have two questions. First of all, do you use anything to reinforce the staple line, and do you have any experience or would you recommend doing mediastinal lymph node biopsy on an outpatient basis? Thank you.

DR CHANG: We do not reinforce our staple lines. We basically use the EndoGIA surgical stapler without pericardial strips or any other sort of reinforcement. Regarding outpatient mediastinal biopsy, we perform mediastinoscopy, but we do not do outpatient thoracoscopic mediastinal sampling at this time. It is not included in this series, but we have performed resection of some mediastinal masses on an outpatient basis.

DR SEPPO E. RAPO (Cape Cod, MA): Concerning mediastinoscopy, would you carry out a thoracoscopic mediastinoscopy for staging at the time of thoracoscopy if you encounter a non–small-cell lung carcinoma as your primary nodule? Would you consider resection at the time of thoracoscopy, or would you generally reschedule the patient for formal resection after staging is complete?

DR CHANG: In the 2 patients who were admitted, 1 was converted to thoracotomy because we did find a primary pulmonary malignancy, at which time mediastinal sampling was performed as well. In our experience, the thin-cut high-resolution chest computed tomography has been very sensitive for us for diagnosing mediastinal lymphadenopathy, particularly if there was a lymph node greater than 1 cm, if that answers your question. Thank you for your comments.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Andrew C. Chang John Yee Mark B. Orringer Mark D. Iannettoni Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chang, A. C. Articles by Iannettoni, M. D. Search for Related Content PubMed PubMed Citation Articles by Chang, A. C. Articles by Iannettoni, M. D. Related Collections Lung - other