Video-assisted thoracoscopic lung biopsy in children

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Video-assisted thoracoscopic lung biopsy in children

S. N. Oak, T. Akhtar, N. Viswanath, R. Pathak

Department of Paediatric Surgery, Nair Hospital, Mumbai, India

Correspondence: Dr Sanjay N Oak, Department of Paediatric Surgery, T.N.M.C and B.Y.L. Nair Hospital, Mumbai - 400 008, India. E-mail: drtanveerakhtar@

ABSTRACT

Minimal invasive surgical techniques have gained high acceptance in thoracic surgery during the last 10 years. Video-assisted thoracoscopy (VATS) is less invasive than open thoracotomy and its development is associated

from with expansion of indication for lung biopsies. Lung biopsy remains an important investigation in the diagnosis

of few of the lung disorders despite improved diagnostic yield of high resolution computed tomography

d scanning. Thoracoscopic lung biopsy is becoming the procedure of first choice for the diagnosis of many a ns localized and diffuse lung diseases. We report a small series of eight patients who underwent VATS lung nlo tio biopsy to demonstrate the safety and efficacy of this procedure. ow lica KEY WORDS: Lung biopsy, video-assisted thoracoscopic surgery

r free dw Pubm). INTRODUCTION

le fo kno .co Tissue diagnosis is essential in determining the further d w course of treatment in selected patients with lung ilab e no disorders. The desire to obtain definitive diagnosis before M k commencing potent long term medical drugs such as va by ed corticosteroids or immunosuppressive drugs has a increased the demand for lung biopsy.[1,2] Surgical lung is ted .m biopsy has demonstrated proven accuracy when nonw invasive diagnostic methods have been unsuccessful DF os w (must have references). More recently, Video-assisted P h (w thoracoscopic surgery (VATS) lung biopsy has become is ite an increasingly accepted approach for the diagnosis in a h s few lung disorders like interstitial lung disease, T a indeterminate pulmonary nodules and non-resolving

to treatment. The age group varied from 3 months to 14 years [Table 1]. Pre-operative evaluation includes relevant hematology, arterial blood gases, chest X-ray, high resolution computed tomography thorax and pulmonary function tests.

VATS lung biopsy technique General anesthesia with endotracheal intubation was used. The patient was placed in a full lateral position. A 5 mm trocar was inserted in mid-axillary line in seventh intercostal space for the telescope. CO2 insufflation was done with 1-liter flow and pressure of 6 cm of water. Two 5 mm secondary trocars were inserted under vision, one in anterior axillary line and other in the posterior axillary line in 4th or 5th intercostal space keeping in mind

pneumonia. Video-assisted thoracoscopic techniques the principle of triangularization. In four cases we used

allow operative access to the pleural cavity without endoloops of vicryl and in two we used endostapler to

thoracotomy.[3] Video-assisted thoracoscopic lung biopsy obtain the biopsy. Endoloop was prepared with Vicryl(R)

reduces post-operative pain and functional disability, 2-0 suture. Endoloop was mounted on 5 mm knot

allowing earlier discharge. We present our experience of pusher. Endoloop with knot pusher was inserted. Using

eight cases of video-assisted thoracoscopic lung biopsy. a 5 mm atraumatic grasper, biopsy site of the lung was

grasped through the endoloop. The site of the biopsy

METHODS

AND

RESULTS

was decided by the findings of computed tomography

scan. Endoloop was tightened and the lung biopsy taken

In a period of 2 years between June 2003 and June 2005, after cutting with 5 mm endoscissors [Figure 1]. In four

eight children underwent VATS lung biopsy. All the cases where endostapler was used, one of the secondary

children were admitted with history of chronic cough trocars was of 12 mm. A 10 mm endoscopic stapling

and breathlessness. The patients were completely device (TR 35W Ethicon(R)) was placed across the part of

evaluated by paediatrician and chest physician and were lung to be biopsied and fired, transecting the lung with

referred for lung biopsy in view of their failure to respond placement of double staple line [Figure 2]. The specimen

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J Indian Assoc Pediatr Surg / Oct-Dec 2006 / Vol 11 / Issue 4

Oak SN, et al.: Video-assisted thoracoscopic lung biopsy in children

Table 1: Showing summarized case details

Age (years)

History

Chest X-ray and CT thorax

Loop/stapler

Time for

HPD

surgery (min)

12

Chronic cough and

Bilateral reticular opacities

Endostapler

40

SRD

breathlessnes

6

Chronic cough, fever

Persistent right upper lobe

consolidation

Endoloop

45

TB

3

Chronic cough

Bilateral reticular opacities [Figure 3]

Endoloop

45

ILD

3 months

Fever, chronic cough Persistent left upper lobe consolidation Endostapler

35

TB

breathlessness

4

Fever, chronic cough Persistent right upper lobe

Endoloop

45

TB

consolidation

14

Fever, chronic cough Persistent right upper lobe

Endostapler

45

TB

consolidation

11

Fever, chronic cough Bilateral reticular opacities

Endoloop

45

ILD

breathlessness

8

Chronic cough and

Bilateral reticular opacities

Endostapler

m breathlessness

fro HPD: Histopatological diagnosis, SRD: Sarcoidosis, ILD: Interstitial lung disease, TB: Tuberculosis, CT: Computed tomography

40 mins

is avateiladbbley fMo.uolbomlaic)da. tions Figure 1: Endoloop of Vicryl applied

Figure 2: Endostapler applied

DF os ww was removed through 5 mm port. The biopsy site was P h (w inspected for bleeding and air leak. An intercostal drain is ite (ICD) was placed in the midaxillary line trocar site and h s the other two-trocar sites were sutured. ICD was removed T a 24 hours post-operatively after confirming the non-

ILD

occurrence of pneumothorax and air leak. Patient was

kept for observation for 48 hours. None of our patients

had air leak or bleeding and there was no mortality.

DISCUSSION

Initially, the applications of thoracoscopy were confined primarily to diseases of the pleura due to the limitations of available equipment.[4] Fiona et al concluded that the sufficient tissue could be provided for both microbiologic and histologic study such that the diagnostic accuracy of the two techniques was essentially equal.[5] In VATS lung biopsy, there is a reduction in operative time, analgesic requirement, duration of hospitalization and post-operative morbidity associated with muscle-cutting thoracotomy. In addition, VATS offers the surgeon the

Figure 3: CT thorax showing bilateral infiltrates

potential advantage of selecting biopsy site guided by the thoracoscopic visualization of the most diseased portion of lung.[6] The typical "non-invasive" methods of obtaining the diagnosis, which include percutaneous

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Oak SN, et al.: Video-assisted thoracoscopic lung biopsy in children

aspiration needle biopsy, percutaneous cutting needle biopsy and transbronchial biopsy, have tissue yields of only 29-59% in these patients. Thus, surgical lung biopsy is often required.[7]

patients had less post-operative pain.

CONCLUSION

Blewtt et al have reported their experience with open lung biopsy performed through a limited left anterolateral thoracotomy. They did not use chest tube drains and did not encounter any complications. Given the constraints of the limited incision, biopsies were obtained only from the lingual.[8] Despite the presumably less

In our experience with five children, post-operative recovery was quick; there were no complications and hospitalization was short with VATS. With the refinement in the endoscopic surgery and the introduction of endoscopic stapling instruments, VATS lung biopsy is a better alternative to thoracotomy.

invasive nature of VATS lung biopsy, Miller et al REFERENCES

demonstrated no clinical or statistical difference in

outcomes in terms of duration of hospitalization, 1. Turner-Warwick M, Burrows B, Johnson A. Cryptogenic

operative time or post-operative analgesic requirement

m for thoracoscopic and thoracotomy approaches.[9] fro According to Miller et al, both thoracoscopy and

thoracotomy are acceptable procedures for diagnostic

ad s lung biopsy. According to Qureshi and Soorae et al, the nlo tion duration of chest drain is less in VATS compared to that

in open biopsy (1 day in VATS compared to 2 days in

w a open group). Even the length of stay was shorter in VATS o lic (3 days in VATS and 4 days in open group).[10] free d Pub ). In the series of Ayed and Raghunathan median operative

time was 45 min for the thoracoscopic biopsies and

r w m 60 min for the open biopsies.[11] In our series, mean le fo kno .co operating time for VATS lung biopsy was 42.5 min.

Analgesic requirement in VATS in the first 24 hours

b ed ow post-operatively is half than that required for open ila n biopsies. Median duration of insertion of a chest tube in a y M dk days and 24 hours of pleural drainage was not v b e statistically significant between the two groups.[11] In our is a d .m series mean duration of chest tube drainage was te 24 hours. Duration of hospital stay was less for VATS F s w (3 days) compared with an open biopsy (5 days). The D o w diagnostic yield of each method was comparable P h (w (thoracoscopic biopsy 31/32; open biopsy 27/29). Multiple is ite studies have shown the diagnostic yield of surgical lung h s biopsy to be more than 90%, with a resulting T a management change in 27-73% of patients.[12] In our

fibrosing alveolitis: Response to corticosteroid treatment and its effect on survival. Thorax 1980;35:593-9. 2. Winterbauer RH, Hammar SP, Hallman KO, Hay JE, Neeley E, Morgan EH, et al. Diffuse interstitial pneumonitis: Clinicopathological correlations in 20 patients treated with prednisolone azathioprine. Am J Med 1978;65:661-72. 3. Bateman ED, Turner-Warwick M, Haslam PI, Adelmann-Grill BC. Cryptogenic fibrosing alveolitis: Prediction of fibrogenic activity from immunohistochemical studies of collagen types in lung biopsy specimens. Thorax 1983;38:93-101. 4. Swain JA. Surgical techniques in the diagnosis of pleural disease. Clin Chest Med 1987;8:43-51. 5. Carnochan FM, Walker WS, Cameron EW. Efficacy of video assisted thoracoscopic lung biopsy: An historical comparison with open lung biopsy. Thorax 1994;49:361-3. 6. Chang AC, Yee J, Orringer MB, Iannettoni MD. Diagnostic thoracoscopic lung biopsy: An outpatient experience. Ann Thorac Surg 2002;74:1942-7. 7. Burt ME, Flye MW, Webber BL, Wesley RA. Prospective evaluation of aspiration needle, cutting needle, transbronchial and open lung biopsy in patients with pulmonary infiltrates. Ann Thorac Surg 1981;32:146-53. 8. Blewtt CJ, Bennet WF, Miller JD, Urschel JD. Open lung biopsy as an outpatient procedure. Ann Thorac Surg 2001;71:1113-5. 9. Miller JD, Urschel JD, Cox G, Olak J, Young JE, Kay JM, et al. A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease. Ann Thorac Surg 2000;70:1647-50. 10. Qureshi RA, Soorae AA. Efficacy of thoracoscopic lung biopsy in interstitial lung diseases: Comparison with open lung biopsy. J Coll Physicians Surg Pak 2003;13:600-3. 11. Ayed AK, Raghunathan R. Thoracoscopy versus open lung biopsy in the diagnosis of interstitial lung disease: A randomized

series with VATS, diagnostic yield was 100%.

controlled trial. JR Coll Surg Edinb 2000;45:159-63. 12. Walker WA, Cole FH Jr, Khandekar A, Mahfood SS, Watson

DC. Does open lung biopsy affect treatment in patients with

Rocco et al use uniportal VATS technique for lung biopsy and lung resection: through a single port incision, a videothoracoscope, a lung grasper and a roticulating endostapler are introduced into the pleural cavity.[13] The

diffuse pulmonary infiltrates? J Thorac Cardiovasc Surg 1989;97:534-40. 13. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726-8.

technique of VATS lung biopsy is more efficient as it

saves operative time and provides excellent visualization

of lung. Reduced post-operative disability in VATS patients further shortened post-operative stay. VATS

Source of Support: Nil, Conflict of Interest: None declared.

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