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645: Invasive Biopsy Is Effective and Useful after Lung Transplant
Abstract
Transbronchial biopsy (TBB) is widely used after lung transplant but may not be diagnostic. Our group has used invasive approaches, open lung biopsy (OLB) or video-assisted thoracoscopy (VAT), to establish a definitive diagnosis in unexplained clinical deterioration. We sought to demonstrate the risks and benefits of this approach.
A retrospective review was made of the case notes of the patients undergoing OLB or VAT during a 12-year period from August 1996.
During a 12-year period in 442 recipients, there were 51 invasive biopsies in 45 patients (6 had 2 procedures), of which 41 (80%) were OLB and 10 (20%) were VAT. Time of biopsy ranged from 7 days to 11 years after transplant. Thirty-seven (73%) took place in the first year, including 12 (24%) within the first 30 days. Nine patients died within 30 days of biopsy; 7 of them were already ventilated. Overall, biopsy provided a new unsuspected diagnosis in 37% of patients and confirmed the diagnostic suspicion in 47%. In only 16% of patients did it fail to provide a result that was clinically useful. The results of 29 (57%) biopsies led to a change in treatment. Sixty-three percent of new diagnoses and 71% where clinical suspicion was confirmed resulted in a treatment change. In all but 2 cases, a change was made to medication.
In this large series of invasive biopsies, there was a high rate of useful results, with a frequent change in treatment. Invasive biopsies are a safe intervention in ambulatory patients.
... Histological biopsy is the most commonly used method for micro structures observation. But this is invasive and usually nonrepeatable [8][9][10]. As one of the non-invasive methods, conventional radiography has been based purely on absorption contrast. ...
... In this regard, it has the potential to be used in clinical diagnosis. When it comes to studying the architecture of micro-structures in lung, histological biopsy is the most commonly used method [9]. But it is invasive and can not be repeated [10,23]. ...
Early detection of lung cancer is known to improve the chances of successful treatment. However, lungs are soft tissues with complex three-dimensional configuration. Conventional X-ray imaging is based purely on absorption resulting in very low contrast when imaging soft tissues without contrast agents. It is difficult to obtain adequate information of lung lesions from conventional X-ray imaging.
In this study, a recently emerged imaging technique, in-line X-ray phase contrast imaging (IL-XPCI) was used. This powerful technique enabled high-resolution investigations of soft tissues without contrast agents. We applied IL-XPCI to observe the lungs in an intact mouse for the purpose of defining quantitatively the micro-structures in lung.
The three-dimensional model of the lung was successfully established, which provided an excellent view of lung airways. We highlighted the use of IL-XPCI in the visualization and assessment of alveoli which had rarely been studied in three dimensions (3D). The precise view of individual alveolus was achieved. The morphological parameters, such as diameter and alveolar surface area were measured. These parameters were of great importance in the diagnosis of diseases related to alveolus and alveolar scar.
Our results indicated that IL-XPCI had the ability to represent complex anatomical structures in lung. This offered a new perspective on the diagnosis of respiratory disease and may guide future work in the study of respiratory mechanism on the alveoli level.
... In one retrospective cohort of 340 heart transplantation or HLT patients, 21 cardiothoracic procedures were carried out (6.2%), of which 6 were TS (10): TS for lung cancer represented half of the TS indications (n=3), while the other were pneumonia (n=2) and lung torsion (n=1). In another heterogenic study, 10% (45/442) of LT or HLT patients underwent TS, of which 80% were open lung biopsies and only 20% VATS (11), not representing the questions of major thoracic surgery in LT. ...
Background: Lung cancer following lung transplantation (LT) may require thoracic surgery (TS). There is
an urgent need for data on surgical feasibility, clinical and surgical characteristics, as well as outcome data.
Methods: We reviewed the medical records of LT patients who had undergone TS at the University
Hospital Leipzig between the years 2000 and 2022. Data on medical and surgical history, pulmonary function
test, arterial blood gas analysis, six-minute walking distance test, and surgical approach, perioperative
management, anesthesiologic, and surgical procedures were analyzed.
Results: Among 248 LT patients, 13 patients (5.2%) developed lung cancer after 4.2 years on average and
on 6 of them (46.2%), major TS procedure was performed for the resection of lung cancer. In one patient
who underwent TS for a suspicious pulmonary nodule, it turned out to be a parenchymal scar. TS was
carried out in 57.1% on the native lung and 42.9% on the transplant lung. Pneumonia and acute renal failure
were predominantly observed postoperative complications. We found that the capacity of gas exchange either
before or after TS was related to the degree of postoperative complications. The in-hospital survival was
71.4%.
Conclusions: Incidence of lung cancer is increased after LT. Follow-up care allows early diagnosis with
a comparably high share of operable tumor stage. Cancer as well as postoperative complications were more
likely after single lung transplantation (SLT). Postoperative morbidity and mortality are higher in this scarce
group of patients and hence, warrants a centered and experienced interdisciplinary approach.
... 34 OLB may also be used when TBBx fails to provide a diagnosis or is contraindicated (high pressure mechanical ventilation, bleeding diathesis, clinically unstable or unlikely to tolerate the TBBx procedure, especially in infants and young children. 34,35 ) AR, ! A2 acute rejection; LB, lymphocytic bronchiolitis; CR, chronic rejection; I, Infection; NS, non-specific; S, Surveillance. ...
Bronchoscopy remains a pivotal diagnostic and therapeutic intervention in pediatric patients undergoing lung transplantation (LTx). Whether performed as part of a surveillance protocol or if clinically indicated, fibre-optic bronchoscopy allows direct visualization of the transplanted allograft, and in particular, an assessment of the patency of the bronchial anastomosis (or tracheal anastomosis following heart-lung transplantation). Additionally, bronchoscopy facilitates differentiation of infective processes from rejection episodes through collection and subsequent assessment of bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) samples. Indeed, the diagnostic criteria for the grading of acute cellular rejection is dependent upon the histopathological assessment of biopsy samples collected at the time of bronchoscopy. Typically, performed in an out-patient setting, bronchoscopy is generally a safe procedure, although complications related to hemorrhage and pneumothorax are occasionally seen. Airway complications, including stenosis, malacia, and dehiscence are diagnosed at bronchoscopy, and subsequent management including balloon dilatation, laser therapy and stent insertion can also be performed bronchoscopically. Finally, bronchoscopy has been and continues to be an important research tool allowing a better understanding of the immuno-biology of the lung allograft through the collection and analysis of collected BAL and TBBx samples. Whilst new investigational tools continue to evolve, the simple visualization and collection of samples within the lung allograft by bronchoscopy remains the gold standard in the evaluation of the lung allograft. This review describes the use and experience of bronchoscopy following lung transplantation in the pediatric setting. Pediatr Pulmonol. © 2015 Wiley Periodicals, Inc.
© 2015 Wiley Periodicals, Inc.
... A research [8] showed that the sensitivity of the spirometry in early diagnosis of the emphysema was about 80%. Histological examination is the most commonly method to observe micro-structure of biological tissues, it can observe the pathological change of early stage emphysema, but this method is invasive and not repeatable [9,10]. In our research, we identified mild emphysema successfully, and located lesion regions with false-color. ...
Background
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide, and emphysema is a common component of COPD. Currently, it is very difficult to detect early stage emphysema using conventional radiographic imaging without contrast agents, because the change in X-ray attenuation is not detectable with absorption-based radiography. Compared with the absorption-based CT, phase contrast imaging has more advantages in soft tissue imaging, because of its high spatial resolution and contrast.
Methods
In this article, we used diffraction enhanced imaging (DEI) method to get the images of early stage emphysematous and healthy samples, then extract X-ray absorption, refraction, and ultra-small-angle X-ray scattering (USAXS) information from DEI images using multiple image radiography (MIR). We combined the absorption image with the USAXS image by a scatter plot. The critical threshold in the scatter plot was calibrated using the linear discriminant function in the pattern recognition.
Results
USAXS image was sensitive to the change of tissue micro-structure, it could show the lesions which were invisible in the absorption image. Combined with the absorption-based image, the USAXS information enabled better discrimination between healthy and emphysematous lung tissue in a mouse model. The false-color images demonstrated that our method was capable of classifying healthy and emphysematous tissues.
Conclusion
Here we present USAXS images of early stage emphysematous and healthy samples, where the dependence of the USAXS signal on micro-structures of biomedical samples leads to improved diagnosis of emphysema in lung radiographs.
Fully rewritten and updated for the cutting-edge sixth edition, Spencer's Pathology of the Lung follows in its predecessors' footsteps as the gold-standard textbook of pulmonary diseases. All recognized diseases of the lungs are discussed and illustrated with extensive, high-quality color images. Each chapter includes practical, clear and concise diagnostic features, including immunohistochemistry, molecular tests and differential diagnoses, while rare entities are discussed and illustrated in detail. This thoroughly reworked edition includes new classification schemes and the latest understanding of the pathophysiology and molecular aspects of a wide range of diseases. Non-neoplastic diseases are presented according to epidemiology, genetics, clinical manifestations, radiographic findings, pathology, cytology, laboratory findings, pathogenesis, differential diagnosis, prognosis and natural history. Neoplasms are discussed according to cell or origin with sections devoted to genetics, molecular findings and clinicopathologic correlations. Downloadable versions of all images are available on a CD-ROM packaged with the print book. Written and edited by leading experts in the field, this is an essential resource for practising and trainee pathologists.
The therapeutic options for patients with advanced pulmonary parenchymal or vascular disorders are currently limited. Lung transplantation remains one of the few viable interventions, but on account of the insufficient donor pool only a minority of these patients actually undergo the procedure each year. Following transplantation there are a number of early and late allograft complications such as primary graft dysfunction, allograft rejection, infection, post-transplant lymphoproliferative disorder and late injury that is now classified as chronic lung allograft dysfunction. The pathologist plays an essential role in the diagnosis and classification of these myriad complications. Although the transplant procedures are performed in selected centers patients typically return to their local centers. When complications arise it is often the responsibility of the local pathologist to evaluate specimens. Therefore familiarity with the pathology of lung transplantation is important.
Fiberoptic bronchoscopy is a valuable diagnostic tool in solid-organ and hematopoietic stem cell transplant recipients presenting with a range of pulmonary complications. This article provides a comprehensive overview of the utility and potential adverse effects of diagnostic bronchoscopy for transplant recipients. Recommendations are offered on the selection of patients, the timing of bronchoscopy, and the samples to be obtained across the spectrum of suspected pulmonary complications of transplantation. Based on review of the literature, the authors recommend early diagnostic bronchoscopy over empiric treatment in transplant recipients with evidence of certain acute, subacute, or chronic pulmonary processes. This approach may be most critical when an underlying infectious etiology is suspected. In the absence of prompt diagnostic information on which to base effective treatment, the risks associated with empiric antimicrobial therapy, including medication side effects and the development of antibiotic resistance, compound the potential harm of delaying targeted management.
A group of 34 heart-lung transplant patients were studied with serial pulmonary function measurements, chest radiographs, and transbronchial biopsies from the time of surgery. These investigations were carried out routinely at 3 and 6 months and then annually after transplantation as well as on clinical suspicion of acute lung rejection or infection. A total of 61 transbronchial biopsies and concurrent lung function and chest radiographs were obtained. Of the biopsies, 30 (49.2%) showed histologic evidence of lung rejection, 12 (19.7%) demonstrated various opportunistic infections, and 19 (31.1%) were normal. Compared to during episodes of normal biopsies, FEV1 decreased significantly with lung rejection (p less than 0.001) and with infection (p less than 0.01). Vital capacity (VC) and DLCO also fell with these acute lung complications. Using histologic diagnosis as a standard, lung function testing had a sensitivity of 86% in detecting lung rejection in the first 3 months postoperation and 75% in the subsequent period. Its sensitivity for detecting lung infection was 75%. Although not distinguishing between these two complications, lung function had a specificity of 84% for detecting occurrence of an acute lung complication. Chest radiographs, although of similar sensitivity in the first 3 months postsurgery, had a sensitivity of only 19% for rejection in subsequent months and 58% for infection. Its specificity was 100%. Lung function testing changes in a predictable fashion with lung rejection and infection, offers an improvement over chest radiographs, and provides a quantitative measurement to aid the decision of when to undertake transbronchial lung biopsy.
Lung transplantation is an important option to treat patients with advanced cystic fibrosis (CF) lung disease. The outcomes of a large UK cohort of CF lung transplantation recipients is reported.
Retrospective review of case notes and transplantation databases.
176 patients with CF underwent lung transplantation at our centre. The majority (168) had bilateral sequential lung transplantation. Median age at transplantation was 26 years. Diabetes was common pretransplantation (40%). Polymicrobial infection was common in individual recipients. A diverse range of pathogens were encountered, including the Burkholderia cepacia complex (BCC). The bronchial anastomotic complication rate was 2%. Pulmonary function (forced expiratory volume in 1 s % predicted) improved from a pretransplantation median of 0.8 l (21% predicted) to 2.95 l (78% predicted) at 1 year following transplantation. We noted an acute rejection rate of 41% within the first month. Our survival values were 82% survival at 1 year, 70% at 3 years, 62% at 5 years and 51% at 10 years. Patients with BCC infection had poorer outcomes and represented the majority of those who had a septic death. Data are presented on those free from these infections. Bronchiolitis obliterans syndrome (BOS) and sepsis were common causes of death. Freedom from BOS was 74% at 5 years and 38% at 10 years. Biochemical evidence of renal dysfunction was common although renal replacement was infrequently required (<5%).
Lung transplantation is an important therapeutic option in patients with CF even in those with more complex microbiology. Good functional outcomes are noted although transplantation associated morbidities accrue with time.
The adult respiratory distress syndrome, bacterial pneumonia, cytomegalovirus pneumonitis, acute rejection, or a combination thereof were the primary causes of radiographic infiltrates or gas exchange abnormalities that occurred early after lung transplantation. The time of occurrence after transplantation, standard measures of clinical assessment as for nontransplant patients (i.e., vital signs, weight, white blood cell count, sputum, and cultures, etc.), bronchoalveolar lavage, and transbronchial lung biopsy were the primary tools used to analyze these situations. Bacterial pneumonia always occurred after postoperative day 2, acute rejection after postoperative day 5, and cytomegalovirus pneumonitis after postoperative day 16. Although cultures of bronchoalveolar lavage fluid were useful to detect pneumonia caused by bacteria, virus, and fungus, the types of cells recovered by bronchoalveolar lavage were not diagnostic of any type of disorder. Transbronchial lung biopsy was necessary to detect acute rejection and cytomegalovirus pneumonitis. Thus the cause of an early radiographic infiltrate or impairment of gas exchange was almost always reliably determined by using standard tools of clinical assessment, knowledge of the usual temporal sequence of the complications, and judicious use of bronchoalveolar lavage and transbronchial lung biopsy.
Long-term success of human lung transplantation has been hindered by the lack of an effective and repeatable method of obtained tissue from the transplanted lung for histology. Management of patients is complicated by the difficulty in distinguishing clinically between opportunistic infection of the lung and rejection. As a result, a large number of patients in recent reports develop chronic disabling obliterative bronchiolitis, believed to be the consequence of "chronic" rejection. Twenty-one patients have undergone heart-lung transplantation in our institute since 1984. During fiberoptic bronchoscopy, 43 transbronchial lung biopsies were performed in 15 patients. Twenty episodes of rejection occurred in 11 patients, from whom 16 sets of biopsies showed the typical changes of perivascular infiltrate and mucosal inflammation. Three biopsies were falsely negative; six routine biopsies performed when patients were well were all normal. Overall sensitivity was 84% and specificity 100%. By contrast, the sensitivity of the chest radiograph was only 40%. Opportunistic lung infection in 8 patients was diagnosed by transbronchial biopsy with a sensitivity of 38% and specificity of 100%. In no patient with opportunistic infection were the histologic features of rejection seen. Transbronchial lung biopsy offers a safe and repeatable method to obtain tissue from heart-lung transplants for histology. It has enabled the management of the lung transplant patient to be equivalent to that of the kidney, liver, and heart transplant patient.
Twenty consecutive patients with pulmonary infiltrates undiagnosed by routine, noninvasive methods were entered into a prospective study designed to evaluate the diagnostic yield of four methods of lung biopsy. Percutaneous aspiration needle, cutting needle, transbronchial, and open (anterior thoracotomy) biopsy were performed synchronously on all patients. Specimens were evaluated by microbiological, virological, and pathological methods. The diagnostic yields of the four methods were as follows: aspiration needle, 29%; cutting needle, 53%; transbronchial, 59%; and open lung biopsy, 94%. Open lung biopsy was significantly better in yielding a diagnosis than aspiration needle (p less than 0.001), cutting needle (p less than 0.001), and transbronchial biopsy (p less than 0.04).
Between November 1983 and August 1993, The Toronto Lung Transplant Program performed 153 transplantations in 144 recipients: 53 single-lung transplantations (SLT) and 100 double-lung transplantations (DLT). Thirty-eight open lung biopsies (OLBs) were done in 32 (22% of all recipients): 19 in SLT (36% of SLT) 12 in DLT (12% of DLT), and 1 in a patient who had a SLT and then a double retransplantation. Six recipients underwent OLB twice: 1 DLT, 3 SLT, and 2 who had OLB both before and after retransplantation. Indication for 11 early OLBs (< or = 45 days postoperative) was persistent parenchymal infiltrates. Indications for 27 late OLBs (> 45 days postoperative) included progressive radiologic disease with clinical findings or progressive loss of pulmonary function (18), persistent poor graft function (3), mass or nodules (3), persistent infiltrates without functional loss (2), and persistent lymphocytosis in bronchoalveolar lavage (1). Open lung biopsy confirmed a previous clinical or pathologic diagnosis in 11, suggested a diagnosis in 2, yielded nonspecific information in 16, and provided different diagnosis in 9. New diagnosis that changed therapy was made in 1 of 11 early OLBs and in 8 of 27 late OLBs. These 9 diagnoses included in SLTs: bronchiolitis obliterans (2), bronchiolitis obliterans organizing pneumonia (1), malignant lymphoma (1), and chronic vascular rejection (1) in SLT, and bronchiolitis obliterans organizing pneumonia (3) and Burkholderia cepacia infection (1) in DLT. We conclude that OLB is of little value in the perioperative period but yields useful information in approximately 30% of patients when performed late.
Video assisted thoracoscopic lung biopsies were compared with historical controls undergoing open lung biopsy to determine the diagnostic accuracy, effect on length of postoperative stay, and cost effectiveness of the new thoracoscopic technique.
The first 25 video assisted thoracoscopic lung biopsies performed in the Edinburgh Thoracic Unit were compared with 25 historical controls for complications, diagnostic accuracy, and length of postoperative stay.
Statistical comparison showed equal diagnostic accuracy in both groups (96% v 92%), but mean (SD) inpatient stay was reduced in the video assisted thoracoscopic group (1.4 (0.7) days) compared with those undergoing open lung biopsy (3.1 (1.8) days). No postoperative complications were reported in the group which underwent video assisted thoracoscopic lung biopsies but three patients had postoperative complications in the open lung biopsy group.
Video assisted thoracoscopic lung biopsy is as effective in providing histological diagnosis as is open lung biopsy. All postoperative complications were related to post thoracotomy pain and occurred only in patients undergoing open lung biopsy. Reduced postoperative disability in the video assisted thoracoscopic group decreased hospital stay, offsetting the increased cost in disposables. The overall cost of video assisted thoracoscopic and open lung biopsy was 712 pounds and 1114 pounds, respectively.
A total of 125 transplant procedures involving the lung have been performed at Loyola University of Chicago in 120 patients. There were 67 single (40 right, 27 left), 44 bilateral single, 2 double lung, and 12 heart-lungs (HL) transplant procedures. This paper summarizes the pathologic findings in 565 transbronchial, 102 endobronchial, 20 open lung, and 92 endomyocardial biopsies and compares them with the recommendations in the published literature. The lung biopsies were evaluated according to the Working Formulation, Lung Rejection Study Group, International Society of Heart Transplantation. In transbronchial biopsies, all of which were from the transplanted lungs, the number of alveolated lung fragments ranged from 0 to 14 (mean, 5). Two hundred twelve biopsies showed no rejection, 113 had minimal rejection, 133 had mild rejection, 34 had moderate rejection, and 1 had severe acute rejection. Active airway damage (Grade B) was seen in 48 biopsies, which were graded from minimal to severe based on the amount of inflammation. Chronic rejection (Grade C) was diagnosed in 23, chronic vascular rejection (Grade D) in 8, and acute vasculitis (Grade E) in 9 biopsies. Routine trichrome and elastic van Gieson stains did not add to the diagnosis. All biopsies were routinely stained with immunoperoxidase for cytomegalovirus. Cytomegalovirus was diagnosed in 84 biopsies, 54 by both H&E and immunoperoxidase, 23 by immunoperoxidase alone, and 5 by H&E alone. The endobronchial biopsy of the anastomotic site had nonspecific inflammation in 46 biopsies. Twenty-nine had infection with a specific organism, Aspergillus and Candida in each of 8 biopsies by Gomori's methenamine silver stain, cytomegalovirus in 7 (4 by H&E and immunoperoxidase; 3 by immunoperoxidase), bacteria in 4, and fungal hyphae in 2 biopsies. In the 12 patients with heart-lung transplants, a total of 92 endomyocardial, 35 transbronchial, and 1 endobronchial biopsies were obtained. Acute rejection was seen only in 2 endomyocardial biopsies, whereas the transbronchial biopsy showed acute mild or moderate rejection in 10, chronic rejection in 1, and cytomegalovirus infection in six biopsies. We conclude that: (a) all biopsies with alveolated lung parenchyma can be evaluated for rejection and infection yielding clinically significant diagnoses; (b) sections from three levels stained by H&E are essential for evaluation; (c) routine Gomori's methenamine silver, elastic van Gieson, and trichrome stains are not required for transbronchial biopsy, however, routine Gomori's methenamine stain is recommended for all anastomotic site biopsies; (d) routine immunoperoxidase for cytomegalovirus is extremely helpful; (e) Grade B rejection should be further graded; and (f) endomyocardial biopsy played no significant role in the management of heart-lung recipients.
Most pulmonary complications associated with lung transplantation have non-specific clinical characteristics. Furthermore, common diagnostic modalities, including bronchoscopy with transbronchial biopsy (TBB), often do not render a definitive diagnosis. In this study, we reviewed our experience with open lung biopsy (OLB) following lung transplantation, specifically regarding its ability to safely provide clinically relevant information that affects therapeutic decisions.
From October 1989 to March 2000, 202 patients underwent lung transplantation at our institution. We reviewed the clinical course of the 42 patients who received 48 OLBs. Of these patients, we determined the pre-operative clinical condition, preceding TBB histologic information, OLB histology, treatment changes, and procedural complications as a result of the OLB.
A new, clinically unsuspected diagnosis was made in 14 biopsies (29% of all OLB), and all of these resulted in therapy changes. Thirty-two biopsies (67% of all OLB) confirmed our clinical suspicions, and new therapy was initiated in 30 of these patients. Two patients (4% of all OLB) had non-diagnostic OLB. Four biopsies (8% of all OLB), including the 2 non-diagnostic OLBs, did not result in any therapy changes or initiation of new therapy. Complications occurred in 3 patients, all of whom had an air leak for >7 days.
Open lung biopsy in lung transplant patients renders a new, unsuspected diagnosis in nearly one third of patients and leads to specific, directed therapy in the vast majority of patients. Open-lung biopsy can be performed safely and should be considered when diagnosis is uncertain in clinically deteriorating patients.
Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done.
Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected.
A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups (p = 0.397). Total morphine dose was 50.8 +/- 27.3 mg in the thoracoscopy group and 52.5 +/- 25.6 mg in the thoracotomy group (p = 0.86). Spirometry (FEV1) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 (p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 +/- 30 minutes, thoracotomy 37 +/- 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 +/- 28 hours, thoracotomy 31 +/- 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 +/- 82 hours, thoracotomy 69 +/- 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients.
There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.
There are few data in the literature regarding the utility of open lung biopsy for the assessment of graft dysfunction after pediatric lung transplantation. The aim of this study is to review our experience with diagnostic open lung biopsy in lung transplant recipients in a children's hospital.
Records of lung transplant recipients from January 1990 through December 2002 were reviewed to identify the indications, outcomes, and complications of open lung biopsy.
Two hundred twenty-four patients (mean age, 9.9 +/- 6.2 years; median age, 11 years; age range, 0.01-19.6 years) underwent 249 lung transplantations: 231 bilateral, 8 single, and 10 heart-lung transplantations. Mean follow-up was 3.4 years. One hundred three open lung biopsies were performed in 89 (40% of all recipients) patients. Thirteen recipients underwent open lung biopsy twice, and 1 recipient had 3 open lung biopsies. The indications for open lung biopsy were suspicion of bronchiolitis obliterans (n = 70), posttransplantation lymphoproliferative disorder (n = 15), infection (n = 8), and unexplained respiratory failure (n = 10). A new diagnosis was made in 49 biopsies (48%), 50 biopsies (49%) confirmed the preoperative clinical diagnosis, and 4 biopsies (3%) were nondiagnostic. Bronchiolitis obliterans was confirmed in 40 (57%) of 70 open lung biopsies, posttransplantation lymphoproliferative disorder was confirmed in 4 (27%) of 15 open lung biopsies, and infection was confirmed in 6 (75%) of 8 open lung biopsies. A change in therapy occurred in 69% of the cases as a result of the diagnosis made from open lung biopsy. There was no mortality as a direct result of open lung biopsy. Eleven major complications and 22 minor complications occurred in 103 procedures.
Open lung biopsy can be performed safely, and established or confirmed a diagnosis in 97% of the cases. A change in therapy occurred in 69% of the cases as a result of the diagnosis made from open lung biopsy. In our experience open lung biopsy appears to be a useful tool.
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Abstract: Thoracoscopy in the evaluation and treatment of lung transplant recipients
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