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Original Articles: General Thoracic

Invited Commentary

Department of Surgery, Wright State University, Boonshoft School of Medicine, One Wyoming St, 7801 WCHE, Dayton, OH 45409

(Email: alex.little{at}wright.edu).

This article 1] is particularly useful because it addresses a specific subset of patients who are potential candidates for surgical lung biopsy. It includes only patients with interstitial lung disease (ILD). What it does not include is patients with acute respiratory distress syndrome (ARDS) or patients with pulmonary masses who are candidates for a wedge resection for either diagnosis or treatment. Focusing solely on this particular subset of patients allows conclusions that are not confounded by the inclusion of these other types of patients. Therefore, the observations and conclusions for patients with ILD are credible and useful.

Their findings are that the clinical diagnosis was changed in 73% of their patients and the revised diagnosis resulted in treatment changes in 53% of patients. The cost for this was a modest morbidity and an in-hospital mortality rate of 4.1%. Consistent with previous reports, these results document a significant positive impact on clinical care as a result of these biopsy findings. However, another perspective is that the procedure did not affect the clinical care of half the patients, and while the mortality and morbidity rates seem low, they are not absent.

In this context, I agree with the author's suggested algorithm for the approach to patients with ILD. The initial diagnostic evaluation, in addition to the patient's history, should begin with a high resolution computed tomographic scan of the chest and a transbronchial biopsy. According to the authors' experience, this will be diagnostic in 78% of patients. This leaves a small number of patients to be considered for surgical biopsy, which should be performed when patients are not responding appropriately to the ongoing management based on their clinical diagnosis. For the biopsy procedure, either a limited thoracotomy or a video-assisted thoracic surgical (VATS) procedure is a reasonable option. Although not shown in this study, video-assisted thoracic surgery is probably superior (both in terms of pain control and access to multiple lung areas) for biopsy. However, there is sufficient morbidity and mortality that even a VATS procedure should not be performed simply out of curiosity, but only if patient management might be affected.

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1. Sigurdsson MI, Isaksson HJ, Gudmundsson G, Gudbjartsson T. Diagnostic surgical lung biopsies for suspected interstitial lung diseases: a retrospective study Ann Thorac Surg 2009;88:227-232.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Alex G. Little Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Little, A. G. Search for Related Content PubMed PubMed Citation Articles by Little, A. G. Related Collections Lung - other Related Article