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Ann Thorac Surg 2007;83:1145
© 2007 The Society of Thoracic Surgeons
Division of Thoracic Surgery, St. Joseph’s Hospital, 50 Charlton Ave E, Hamilton, Ontario, Canada L8N 4A6
(Email: jmiller{at}mcmaster.ca).
Kreider and colleagues [1] have reported their experience with video-assisted thoracotomy (VAT) lung biopsies in the diagnosis of interstitial lung disease. Their report emphasizes that surgical lung biopsy is not without risk. They stress that their clinically significant mortality rate of 4.4% is related to several factors, most, if not all of which reflect the severity of the patient’s disease. Not surprisingly the authors identify supplemental oxygen need and pulmonary hypertension as being the significant risk factors. Other authors have included poor pulmonary functional studies of vital capacity and advancing age as also being of significance. As the severity of disease advances, the risk also increases.
In an effort to assign causality (a very difficult task in a small retrospective review like this), the authors report an autopsy finding of diffuse alveolar damage (DAD) a short time after surgical lung biopsy identified usual interstitial pneumonia (UIP). This finding was seen in two of the three deaths in this study. The authors speculate that the sequential appearance of DAD after biopsy suggests that surgical biopsy is responsible for "triggering" an exacerbation. Surgical biopsy as a responsible cause of exacerbation of the underlying lung disease is an idea worthy of further evaluation, but it is far from being confirmed by the observations made in this report.
Nonetheless the risks associated with surgical lung biopsy are real. Reports of the mortality rate range from 0% to 6% for elective nonventilator-dependent patients. Although this report has selected a group of patients to undergo VATS biopsy, our article [2] from 2000 shows that there is very little difference in morbidity and mortality between open lung biopsies and VATS lung biopsies. Patient pain scores as well as the immediate postoperative pulmonary function studies were almost identical between the two surgical approaches. One might expect similar outcomes from a surgical biopsy performed by either method. Adverse outcomes are more likely associated with the severity of the patient disease than that of surgical technique.
Recent reports have emphasized that as radiologic techniques improve, and with careful clinical selection, the ability to diagnose UIP without a surgical biopsy is now commonplace for the majority of patients. Hunninghake and colleagues [3] reported that the sensitivity and specificity of making a diagnosis of UIP on clinical and radiologic grounds can reach 78% and 90%, respectfully. These researchers concluded that surgical lung biopsy is indicated mainly for patients in whom the diagnosis is not certain after careful clinical evaluation, and it is not needed in patients with typical clinical and radiologic features.
By subjecting all patients with presumed UIP to surgical biopsy the relative risk would be reduced; however by unnecessarily delaying surgical biopsy until the patient suffers advanced disease, the risk to each patient would surely increase. The appropriate time to intervene with surgical biopsy requires an assessment of the risks and benefits for each patient in the context of each center’s ability to diagnose UIP clinically. This report reminds us all to review our own centers’ clinical acumen and to select carefully the patients we subject to the risk of surgical biopsy.
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