Diagnostic Video-Assisted Thoracoscopic Procedures

3

Diagnostic Video-Assisted Thoracoscopic Procedures Chung-Ping Hsu, M.D., Ivo Hanke, M.D., and James M. Douglas, Jr., M.D. From the Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina

Objective The authors evaluated the effectiveness and the limitations of video-assisted diagnostic thoracoscopy.

Summary Background Data The initial successes achieved with the use of video-assisted diagnostic thoracoscopic techniques has lead to an enthusiastic propagation of its use by thoracic surgeons as well as by some pulmonologists. However, detailed analyses of the diagnostic yield and potential limitations of this technique in relation to the roentgenographic and pathologic presentations of the patients are necessary to ensure its safe and effective application.

Methods From July 1991 to December 1993, 102 diagnostic video-assisted thoracoscopic procedures were performed. All patients received other preoperative diagnostic workups without a definitive diagnosis. The initial roentgenographic presentations of these patients included 42 pulmonary nodules, 23 interstitial processes, 1 1 parenchymal infiltrates, 6 pleural effusions, 10 mediastinal tumors, and 10 mediastinal lymphadenopathies. If the procedure was completed without minithoracotomy or extension of any port site, then it was defined as an exclusive thoracoscopic biopsy (ETB); if the procedure was completed with the assistance of minithoracotomy (4-6 cm), then it was defined as a supplementary thoracoscopic biopsy (STB).

Results Ninety-two of the pathology reports (90.2%) were interpreted as conclusive. Of these, 35 tumors were malignant and 67 benign. Ten pathology reports were inconclusive and on initial roentgenography had presented as pulmonary infiltrates (4 cases), pulmonary nodule (2), pleural effusion (2), interstitial process (1), and mediastinal lymphadenopathy (1). Seventy-six procedures (74.5%) were completed thoracoscopically and were classified as ETB. The remaining 26 procedures (25.5%) were completed with minithoracotomy and were classified as STB. The underlying diseases in the STB group were carcinoma (8 cases), Hodgkin's lymphoma (3), sarcoidosis (3), tuberculosis (2), interstitial pneumonitis (2), organizing pneumonia (2), mesothelioma (1), and miscellaneous disease (5). The reasons given for minithoracotomy were diffuse intrapleural adhesion (10 cases), technical inexperience (8), inability to localize the lesion (5), problems with anesthesia (1), poor patient tolerance (1), and unknown (1). Four patients (3.9%) experienced complications and three (2.9%) died while in the hospital.

Conclusions Diagnostic thoracoscopy provides high diagnostic yield with very low risk. However, 25.5% of the procedures require minithoracotomy to obtain adequate tissue for definitive diagnosis. This finding supports the assertion that diagnostic thoracoscopy should be performed only by experienced thoracic surgeons who can extend the procedure when indicated. 626

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It has been more than 80 years since Jacobaeus introduced thoracoscopic technique for treatment of pulmonary tuberculosis.' Although Kux and Wittmoser used thoracoscopy to resect the sympathetic and vagus nerves,2'3 thoracoscopic surgery never became part ofthe mainstream in general thoracic surgery. During the past 3 years, with improvement of the optical transmission system and development of new thoracoscopic instruments, the number of thoracoscopic procedures has grown steadily.4 The advantages of this minimally invasive approach include less pain-related morbidity and shortened hospital stay.5'6 Despite the emphasis placed by proponents of thoracoscopic procedures on therapeutic interventions, most procedures are still performed for diagnostic purposes. We reviewed the 2'2-year experience of this institution (DUMC) with thoracoscopic biopsy and focused on the issues regarding diagnostic thoracoscopic procedures.

The initial roentgenographic presentations, diagnostic rates, and incidence of malignancy are listed in Table 1. Parenchymal infiltrates had the lowest diagnostic rate.

METHODS

Supplementary Thoracoscopic Biopsy

From July 1991 to December 1993, 102 thoracoscopic procedures were assessed. One hundred two of these procedures were performed for diagnostic purposes, which was defined as an intention to obtain tissue diagnosis thoracoscopically without further surgical resection at that time, even if the lesion was malignant. An equal number of men and women (51 each) took part in the study, and the mean age was 49.1 years (range, 3-78 years). All patients underwent a preoperative workup, including either bronchoscopic biopsy or computed tomography-guided transthoracic percutaneous fine-needle aspiration biopsy, but no definitive diagnoses were made. The operative procedure was conducted under general anesthesia by double lumen endobronchial tube with selective lung ventilation. The tube's location was checked by bronchoscopy. The patient was placed in a lateral decubitus position with the hip dropped down to form the "jackknife" posture. This position cause the spread of the intercostal space, thus facilitating manipulation of the endosurgical instruments. The port site for thoracoscope introduction and access sites for instruments were decided individually. Basic principles included triangulation of the thoracoscope and instruments and avoidance of mirror-image manipulation, as has been suggested by others.7'8 In Figures 1 to 4, four approaches to different intrathoracic diseases using video-assisted thoracoscopy are shown. If the procedure was completed without minithoracotomy or extension of any port site,

Seventy-six procedures (74.5%) were classified as ETB, and the remaining 26 (25.5%) were classified as STB. The determination of classification and the presence of underlying diseases in the latter group are discussed in Tables 2 and 3. Diffuse intrapleural adhesion was the condition that most commonly required minithoracotomy for diagnosis. Malignancies were the most common underlying disease in the STB group. The rate of STB was highest during the first 6 months of patient acquisition. Thereafter, the incidence decreased to a constant level

then it was classified as an exclusive thoracoscopic biopsy (ETB); if the procedure was completed with minithoracotomy (4-6 cm), then it was classified as a supplementary thoracoscopic biopsy (STB). The indications for the procedure were classified according to the initial chest x-ray presentation, and the diagnostic rate was computed for each group. The roentgenographic presentations of inconclusive diagnoses were reviewed, and the reasons for minithoracotomy, including underlying diseases, were analyzed.

RESULTS Roentoenoarainhic Patterns

Exclusive Thoracoscopic Biopsy or

(Fig. 5). Pathologic Distribution Ninety-two of these procedures (90.2%) were considered to be conclusive, and malignant diseases accounted for 35 (34.3%) of the total cases. The leading two benign processes in this series were sarcoidosis and various types of interstitial pneumonitis. Table 4 lists the distribution of each disease entity.

Hospital Course The duration of chest intubation ranged from 0 to 16 days (mean, 3.2 days). The hospital stay ranged from 1 to 20 days (mean, 4.7 days). Four patients experienced complications (3.9%) and three patients died while in the hospital (2.9%) (Table 5).

DISCUSSION Address reprint requests to James M. Douglas, Jr., M.D., P.O. Box 3261, Duke University Medical Center, Durham, NC 277 10. Accepted for publication June 17, 1994.

Traditionally, open lung biopsy is the last resort for diagnosis of intrathoracic lesions, even though thoracos-

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have suggested that thoracoscopic wedge resection for T I pulmonary malignancy is as effective as standard lobectomy,9"'0 yet the current data associate wedge resection with higher rates of local recurrence and significant lymph node involvement.' I,12 We prefer to perform open thoracotomy with standard lobectomy for lung cancer if the general condition of the patient permits. New surgical innovations must not compromise fundamental oncologic principles, despite claims of less pain or shortened hospital stay. Our 25.5% incidence of minithoracotomy is consistent with the experience reported in a large collective review.4 The most common circumstance leading to minithoracotomy is diffuse intrapleural adhesions. Only 3 of the 10 pleural adhesions were found on preoperative chest film or computed tomography scan. Eight procedures were not completed thoracoscopically due to various intraoperative complications, technical problems, surgeon inexperience, or instrument failure. Most of

.. .....

Figure 1. Removal of anterior mediastinal mass. The thoracoscope is introduced through the sixth intercostal space in the posterior axillary line. Graspers and scissors positioned in the fourth intercostal space posteriorly and the fifth intercostal space anteriorly allow dissection of the mass from surrounding tissues. copy has been recommended since the turn of the century.' With improved video-optical transmission and better design of endoscopic instruments, more thoracic surgeons are willing to use thoracoscopy to perform di-

agnostic procedures. Several advantages are associated with the new-generation thoracoscope and its accessories. First, the entire pleural cavity can be accessed easily, which is not possible through a limited rib-spreading thoracotomy. Second, with the high-resolution camera and imaging system, surgeons can manipulate the instruments with precision and perform the operation with confidence. Third, this instrument is an excellent tool for educational purposes. Finally, video-assisted thoracoscopic procedures permit the direct participation of the assistant. Malignant disease was diagnosed in one third of patients in our series. Excluded from this review, however, were patients who underwent procedures specifically converted to thoracotomy for curative resection (i.e., supplementary therapeutic thoracoscopy). Some authors

Figure 2. Biopsy of aortopulmonary window. The thoracoscope is introduced through the seventh intercostal space in the posterior axillary line. The lung is retracted anteriorly with a fan retractor. The pleura is opened with scissors to expose the subaortic area. The recurrent laryngeal nerve is identified and avoided during lymph node dissection.

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A Figure 3. Thoracoscopic lung biopsy. The area of interest in the left upper lobe is lifted with a grasper. The endoscopic stapler is applied for cutting of the lung tissues.

these problems occurred in our first year of experience. With improvement of instrument design, surgeon experience, and nursing familiarity with the procedure, the number of failed procedures can be reduced. Five procedures were completed as STB due to inability to identify the lesion during operation. We do not routinely use preoperative computed tomography-guided fine-wire localization or methylene-blue stain, because we have found that most lesions can be identified either by direct thoracoscopic inspection or by instrument palpation. However, when the lesion is small or seated beneath the pleura, preoperative localization may be worthwhile. During operation, direct digital palpation or ultrasound may detect the lesion"3" 4; however, in certain circumstances minithoracotomy is unavoidable. With experience, improved instrument design, and localization techniques, the need for minithoracotomy can be reduced to less than 10%. The three patient deaths encountered in this series merit discussion. The first patient had breast cancer and had undergone a left modified radical mastectomy in

B

Figure 4. Excision of posterior mediastinal tumor. (A) The thoracoscope is introduced through the fifth intercostal space in the midaxillary line. The lung is retracted anteriorly with a fan retractor. The upper posterior mediastinal tumor is pulled aside to facilitate the subpleural dissection. (B) A slight tilting of the patient toward the ventral side will allow the lung to shift anteriorly, thereby improving the endoscopic visual field.

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Table 3. UNDERLYING DISEASES THAT REQUIRED MINI-THORACOTOMY FOR DIAGNOSIS

Table 1. INITIAL ROENTGENOGRAPHIC PRESENTATION, DIAGNOSTIC YIELD, AND INCIDENCE OF MALIGNANCY X-Ray Pattern

Conclusive (%)

Lung Mass/nodule Interstitial process Parenchyma infiltrates Effusion Mediastinum Mass Lymph node

73 (89.0) 40 (95.2) 22 (95.7) 7 (63.6) 4 (66.7) 19 (95.0) 10 (100.0) 9 (90.0)

9 2 1 4 2

0 1

26 (31.7) 23 (54.8) 1 (4.4) 0 (0.0) 2 (33.3) 9 (45.0) 8 (80.0 1(10.0)

Total

92 (90.2)

10

35 (34.3)

Inconclusive

1

Malignant (%)

No. of Total 82 42 23 11 6

20 10 10

102

Disease Requiring Mini-Thoracotomy

Patients (%)

Carcinoma Hodgkin's lymphoma Sarcoidosis Interstitial pneumonitis Organizing pneumonia Tuberculosis Mesothelioma Miscellaneous

8 (30.8) 3(11.5) 3(11.5) 2 (7.7) 2(7.7) 2(7.7) 1 (3.9) 5(19.2)

Total

1991. Subsequently, she underwent several courses of chemotherapy and bone marrow transplantation. She underwent thoracoscopy because of progressive bilateral pulmonary interstitial changes associated with unrelenting dyspnea and died of acute respiratory failure on the 2nd day after surgery. The pathology report showed interstitial fibrosis consistent with drug-induced toxicity. The second patient had bilateral parenchymal infiltrates and required ventilatory support. To rule out the possibility of Wegener's granuloma, we performed a thoracoscopic left upper lobe wedge resection. Ten days after thoracoscopic biopsy, we again operated on the patient because of spontaneous large-bowel perforation. The patient died 9 days later of respiratory failure and sepsis. The pulmonary pathology report revealed emphysema with nonspecific vasculitis. The third patient had developed metastatic non-small cell lung cancer in the brain. He underwent thoracoscopy for diagnosis of a right hilar mass and died of central nervous system failure 6 days after the thoracoscopic biopsy. The specimen showed poorly differentiated squamous cell carcinoma. None of the deaths were attributable directly to thoracoscopy. Two ofthese patients had required ventilator support be-

26 (100.0)

fore undergoing thoracoscopic procedures. It was difficult to maintain the hemodynamic stability in these patients during one-lung ventilation, which led to prolonged operation time. For critically ill patients such as these, open thoracotomy can be done without endotracheal tube manipulation for one-lung ventilation and its attendant risks. We have found that thoracoscopic diagnostic biopsy to be an inherently low-risk procedure. However, patients on mechanical ventilation are not ideal candidates for thoracoscopy, and open lung biopsy, if needed, should be used instead. Although our diagnostic yield was high, 10 diagnoses were interpreted as inconclusive. The majority of these inconclusive diagnoses (90%) occurred in the pulmonary biopsy group, whose preoperative roentgenographic presentations were pulmonary infiltrates (4 cases), pulmonary nodule (2), pleural effusion (2), interstitial process (1), and mediastinal lymphadenopathy (1). The patho-

Jul-Dec, 93 Jan-Jun, '93

Table 2. REASONS FOR MINITHORACOTOMY IN STB GROUP

Reason for Mini-Thoracotomy

No. of Patients (%)

Jul-Dec, '92

Jan-Jun, '92 Jul-Dec, 91

Pleural adhesions Technical inexperience Unable to identify lesion Anesthetic problem Poor patient tolerance Unknown

10(38.5)

Total

26 (100.0)

8 (30.8) 5 (19.2) 1 (3.9) 1 (3.9) 1 (3.9)

Figure 5. The distribution of STB (n = 26) and ETB (n = 76) at the 6month interval. The relative number of exclusive thoracoscopic biopsies (ETBs) vs. supplementary thoracoscopic biopsy (STB) performed at 6month intervals over the course of this study is depicted. This demonstrates the learning curve associated with the development of thoracoscopic surgery.

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Table 4. PATHOLOGIC DIAGNOSES No. of Patients Diagnosis

(%)

Conclusive Malignancy Sarcoidosis Interstitial pneumonitis Lymphoma Fibrosis Miscellaneous infections Noncaseating granuloma Organizing pneumonia Tuberculosis Others Inconclusive

92 (90.2) 25 (24.5) 13(12.8) 11(10.8) 10(9.8) 6(5.9) 5 (4.9) 4 (3.9) 4 (3.9) 3 (2.9) 11 (10.8) 10 (9.8)

102 (100.0)

Total

631

highest incidence (36.4%) of inconclusive results, due perhaps to the inability to always perform a biopsy on the most suitably diagnostic portion of the lesion within the pulmonary infiltrates group. The guidelines and basic requirements for performing thoracoscopic surgery must be uncompromising and in accordance with the statement of the American Association of Thoracic Surgeons/Society of Thoracic Surgeons joint committee.'5 Most thoracoscopic procedures can be completed without extension of the incision. However, a minority of these procedures will inevitably be converted to standard open thoracotomies, which occurred in 25.5% of our series. This decision-making process requires a fully trained thoracic surgeon who can anticipate and manage every possible contingency by performing the appropriate surgical procedure when necessary.

References logic findings were interpreted as normal lung parenchyma in 6 cases, normal pleura in 2, and nonspecific inflammation in 2. Two (1 lung biopsy and 1 pleural biopsy) procedures in this group were completed with minithoracotomy, however, the specimens were still nondiagnostic. One patient underwent open lung biopsy 3 days after inconclusive diagnostic thoracoscopy. The pathology report suggested pulmonary infection of unknown origin (still inconclusive). We presume that some of the "inconclusive" diagnoses reported in this series were actually conclusive. For example, four patients had undergone thoracoscopy due to clinical suspicion of pulmonary metastasis from previously treated extrapulmonary malignancies. The pathologic findings were interpreted as evidence of normal lung tissue, that is, a benign condition. Because a true-negative result could not be differentiated from a false-negative result due to biopsy at the nonlesion site, these results were classified as inconclusive in this study, that is, the true incidence of inconclusive thoracoscopy should have been less than 10%. Our data suggest that pulmonary infiltrates bear the

Table 5. ETIOLOGY OF COMPLICATIONS AND DEATHS Sequelae

Complications Bleeding Prolonged air leak Mortalities Respiratory failure Central nervous system failure

No. of Patients 4

2 2 3 2 1

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