Tubeless And Uniportal VATS Lung Biopsy For Diffuse Lung Disease

Objective:Diffuse lung disease(DLD)is also known as diffuse parenchymal lung diseases(DPLD),interstitial lung disease(ILD),mainly involved the lung interstitial,alveolar wall and alveolar space.The major pathological changes are the inflammation of the diffuse lung parenchymal and alveolar,besides the interstitial pulmonary fibrosis.There are more than 300 kinds of diseases in DLD with similar clinical symptoms and difficulties to achieve accurate diagnosis.The diagnosis of DLD requires multi-disciplinary participation.Some typical patients with interstitial lung disease can be diagnosed by history,laboratory tests and high-resolution CT(HRCT),but 1/3 patients with DLD still have no accurate diagnosis and lung biopsy are needed to confirm the diagnosis.The lung biopsy is invasive,including fiberoptic bronchoscopy,CT-guided percutaneous lung biopsy and surgical lung biopsy.The current guidelines still emphasize on the significant role of video-assisted thoracic surgical lung biopsy(VATS-LB).Recently,spontaneous ventilation anesthesia and uniportal approaches have become remarkable evolutionary steps in VATS.Encouraging results have been achieved from systemic applications for both,spontaneous ventilation VATS and uniportal VATS.However,a combination of these two techniques of VATS has only been reported in a handful of thoracic surgery centers.We have previously performed both traditional VATS biopsy and spontaneous ventilation VATS for DLD.In light of the satisfying outcomes,we have conducted spontaneous ventilation and uniportal VATS-LB for selected DLD patients in this study.Furthermore,these cases need no postoperative chest tube drainage,which may obviously contribute to postoperative discomfort.We name this technique as tubeless and uniportal VATS lung biopsy(TU-VATS-LB).The objectives of this study are the report of surgical techniques and clinical outcomes.Methods:From July 2015 to Oct 2017,108 DLD patients who were transfered for TU-VATS-LB were included in the study in The First Affiliated Hospital of Guangzhou Medical College,including 63 males and 45 females.The average age is 50 years ranged from 21 to 67 years.The preoperative diagnosis procedure included interactive team work among pulmonologists,radiologists and pathologists with detailed clinical information,complete laboratory tests,pulmonary function tests,chest high resolution computerized tomography(HRCT)and transbronchial LB(TBLB)examinations.Suitable sites for lung biopsy were also identified after the same interactive team work.After the surgery,Tissue samples from 108 patients were transfered to the pathologist for histopathologic examination.Among them,35 casests during the June 2017 to Oct 2017,including 19 males and 16 females,accepted post-operative pain evaluation using a digital rating scale(NRS)table Clinical information was collected,along with age,sex,disease history,medication,analysis of blood gas,pulmonary function,histological results after VATS,post-operative complications,30-day mortality rate,etc.Results:1.The hospitalization time of 108 patients was 9-19 days,and the time of postoperative hospitalization was 3-12 days,the average time of hospitalization was 13±2days,and theaverage time of postoperative hospitalization was 6±2 days.There was no 30-day mortality.None of the patients required postoperative mechanical ventilation or admission to the intensive care unit(ICU).They also have no intra-operative transfer to intubated ventilation.Of all the cases,91 patients successfully fulfilled TU-VATS-LB with a 2.4cm incision,while 17 patients needed an additional 5mm incision.The average surgical duration is 43 minutes,35 minutes for hand-sewing group and 62 minutes for staple group respectively.The average blood lost for allthecases is 7 ml.2.17 patients suffered postoperative complications,including 1 case of pneumonia,7 cases of small pleural effusion,6 cases of subcutaneous emphysema and 3 cases of pneumothorax.Of the 3 cases of postoperative pneumothorax,chest tube insertion was indicated in 1 patient.3.Of all patients,target lesion were successfully harvested and definite diagnosis were achieved.The associated diagnosis included 9 cases of allergic pneumonia,4 case of opportunistic pneumonia,20 cases of autoimmune-related interstitial pneumonia,17 cases of connective tissue-associated interstitial pneumonia,1 case of lung ossification,28 cases of idiopathic interstitial pneumonia,4 cases of smoking-related interstitial pneumonia,2 cases of dermatomyositis-associated interstitial pneumonia,10 case of idiopathic pulmonary fibrosis,3 case of pulmonary alveolar proteinosis,1 case of pulmonary infiltrating adenocarcinoma,6 case of pulmonary capillary hemangiomatosis,2 case of interstitial pneumonia associated with Sjogren's syndrome,and 1 case of follicular bronchiolitis.4.Of the patients listed in postoperative pain evaluation,11 cases suffered medium pain and 24 case suffered minor pain on postoperative day 1.On postoperative day 2,the situation is 3 cases of medium pain,14 cases of minor pain and 18 cases of zero pain,respectively.On postoperative day 3,only 4 cases remained minor pain,while the rest cases were free of pain.5.For all the patients,the average cost of operation was RMB 9313,ranged from 5111 to 17885.86 cases performed hand sewing with the average cost of operation of RMB 6212,while 22 cases needed staples with the average cost of operation of RMB 16389.Conclusions:1.TU-VATS-LB has the characteristics of less trauma,fewer complications,high diagnostic rate and easy operating.2.TU-VATS-LB for DLD had less pain.3.TU-VATS-LB has acceptable operative cost.4.Surgeon-physician dual management model work well for postoperative DLD patients.