Retrospective outcomes analysis of 99 consecutive uniportal awake lung biopsies: a real standard of care?

Abstract

Background: Surgical lung biopsy for interstitial lung disease (ILD) is traditionally performed through video-assisted thoracic surgery (VATS) and general anesthesia (GA). The mortality and morbidity rates associated with this procedure are not negligible, especially in patients with significant risk factors and respiratory impairment. Based on these considerations, our center evaluated a safe non-intubated VATS approach for lung biopsy performed in ILD subjects.

Methods: Ninety-nine patients affected by undetermined ILD were enrolled in a retrospective cohort study. In all instances, lung biopsies were performed using a non-intubated VATS technique, in spontaneously breathing patients, with or without intercostal nerve blockage. The primary end-point was the diagnostic yield, while surgical and global operating room times, post-operative length of stay (pLOS), numeric pain rating scale (NPRS) after surgery and early mortality were considered as secondary outcomes.

Results: All the procedures were carried out without conversion to GA. The pathological diagnosis was achieved in 97 patients with a diagnostic yield of 98%. The mean operating room length-of-stay and operating time were 73.7 and 42.5 min, respectively. Mean pLOS was 1.3 days with a low readmissions rate (3%). No mortality in the first 30 days due to acute exacerbation of ILD occurred. Both analgesia methods resulted in optimal feasibility with a mean NPRS score of 1.13.

Conclusions: In undetermined ILD patients, surgical lung biopsy with a non-intubated VATS approach and spontaneous ventilation anesthesia appears to be both a practical and safe technique with an excellent diagnostic yield and high level of patient satisfaction.

Keywords: Awake surgery; interstitial lung disease (ILD); non-intubated video-assisted thoracic surgery (NIVATS); surgical lung biopsy (SLB); tubeless anesthesia.

Figure 1

Uniportal NIVATS procedure for lung biopsy. Division of Thoracic Surgery, “A. Businco” Oncology Hospital, Cagliari (IT). NIVATS, non-intubated video-assisted thoracic surgery.

Figure 2

Main baseline characteristics and post-operative outcomes of patients who underwent NIVATS uniportal lung biopsy. NIVATS, non-intubated video-assisted thoracic surgery.

Figure 3

Global operating room (OR) length of stay and surgical operating time comparison between patients treated with or without intercostal nerve blockage anesthesia.

Figure 4

Histopathologic hallmark of usual interstitial pneumonia (UIP). (A) HE 10×. Architectural remodelling as a result of patchy dense fibrosis in peripheral area inside the lobule and the perivenular area. Microscopic honeycombing cysts noted; (B) HE 40×. The fibroblastic focus consists of fibroblasts and myofibroblasts and are covered by type II pneumocytes or cuboidal metaplastic epithelia. Histopathology Department, “A. Businco” Oncology Hospital, Cagliari (IT).