Tag Archives: Lung biopsy

Videotoracoscopía uniportal

Si bien la videotoracoscopía lleva muchos años entre nosotros, no ha sido hasta hace pocos años que la videotoracoscopía uniportal se ha convertido en un acceso al tórax para realizar casi cualquier tipo de cirugía en el tórax. A quien primero escuché hablar del videotoracoscopía uniportal, fue al Dr Gaetano Rocco. En su paper del 2004 , Gaetano describe en la sección “How to do it” del Annals of Thoracic Surgery, la técnica para realizar resecciones segmentarias pulmonares mediante un único acceso al tórax. Recuerdo haberle escrito a Gaetano para que nos describa su técnica en un newsletter que hacíamos desde nuestro servicio en el año 2011.

Sin embargo, la videotoracoscopía uniportal tomó un nuevo impulso cuando el Dr. Diego Gonzalez Rivas comenzó a realizar lobectomías mediante el acceso uniportal. Diego ha popularizado, mostrado y  enseñado la videotoracoscopía uniportal en muchísimos lugares del mundo. En su canal de youtube pueden ver muchos de estos videos. Es impactante ver cómo con este abordaje, Diego ha mostrado hacer todo tipo de cirugía pulmonares, incluyendo resecciones muy complejas que muchos de nosotros hacemos por toracotomía.

Tengo que decir que yo tenía algunas reservas con respecto a realizar resecciones pulmonar con un único puerto. Tenemos tan reglada la videotoracoscopía con tres puertos, que me resultaba difícil pensar en hacerlo de otra manera. Pero habiéndolo realizado, el abordaje con un puerto ha superado ampliamente nuestras expectativas. Por esto, les comparto un video en el que por videotoracoscopía uniportal, resecamos un nódulo pulmonar del segmento basal posterior del lóbulo inferior izquierdo. Tal vez el tip más importante sea dónde realizar la incisión. En este caso, ya que se trataba de un nódulo basal y posterior, la realizamos sobre lo que palpamos como la 7º costilla en la región medio axilar. Como verán el acceso quedó justo por delante de la región que buscábamos biopsiar.

 

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Nódulos pulmonares en el paciente de alto riesgo

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Cada vez es más frecuente ver nódulos pulmonares en pacientes de alto riesgo quirúrgico. El uso de la tomografía computada (TC) nos ha hecho encontrar cada vez más de estos nódulos, a veces muy pequeños, que nos hacen preguntarnos qué debemos hacer con ellos. Estas TCs se hacen en pacientes fumadores, muchas veces con daño significativo en el parénquima pulmonar y funcional respiratorio muy en el límite para intentar cualquier tipo de resección. El problema es que los nódulos pequeños ni siquiera son punzables en muchas ocasiones y la fibrobroncoscopía tampoco resulta de utilidad diagnóstica. Miren el caso de la figura (es la misma TC del post anterior), paciente de 55 años de edad, fumadora de 30 cigarrillos por día por 40 años, nódulo pulmonar en el lóbulo inferior izquierdo y un FEV1 de 0.9 litros. Si bien el nódulo está suficientemente cerca de la superficie, está dentro de una zona de severo enfisema, que la mínima aguja que pongamos para biopsiarlo le causará un neumotórax, y recordemos que tiene 0.9 litros de FEV1.

Estos pacientes son todo un desafío en lo que respecta a cómo diagnosticarlos. Si se sabe que el nódulo es tumoral, es sólo una decisión de qué método usar para tratarlo entre los que tengan experiencia, pero el hecho de cómo encontrar qué tiene este nódulo me parece lo más complejo. ¿Creen que sería adecuado tratar a esta paciente con radioterapia o RFA sin tener una biospia? ¿Harían la biospia en el mismo momento que intentaría la RFA? ¿O intentarían sacarlo con una cuña por VATS? No me parece que ninguna de estas opciones sea incorrecta. Estaría bueno saber qué hacen con casos como este.

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Small Central Ground Glass Opacity: how do you proceed?

What do you do with a case like this? It’s a 65 year, smoking history of 20 cigarettes a day for 30 years, that got a CT scan for other reason and a GGO spot was found in the left upper lobe. The nodule was sized in 1 cm and the doctor that saw the patient ordered a PET-CT that showed SUV of 5. Nothing lighted up in the mediastinum or elsewhere. Bronchoscopy was normal. FEV1 is 1.35 liters (50%) and DLCO 65%. He hasn’t any other significant health issue. The patient is not very anxious about this finding and he wants to know your suggestion. What are the options?

I guess you might try to stick a needle on it, but your radiologist should be very skilful to target this tiny spot in the middle of the lung, especially in a patient with emphysema. The risk of pneumothorax is significant.

What other options? Well, I don’t have any experience with navigational bronchoscopy, but if any has, it’ll be great to hear any input. The two other options I can think of are surgery or just wait. I’m not very keen on waiting in a case like this, but I accept somebody may have this as a suggestion. Surgery will take a lobectomy, as the spot is in the middle of the upper lobe and very close to a PA branch.

What do you think is the best option? Do you think you can take it out with a lesser resection than lobectomy?

 

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Surgical Lung Biopsy for Diffuse Lung Disease

When I started training I found out that some patients that had lung biopsy for diffuse lung disease had a complicated postoperative course and there was even some mortality associated with the procedure. The ATS/ERS guidelines recommend doing surgical lung biopsy when the clinical picture and high resolution CT scan are not characteristic of idiopathic pulmonary fibrosis. I wondered how useful was the lung biopsy affecting treatment, prognosis and survival. To answer some of these questions, we did a retrospective revision of the surgical lung biopsies we did at my Institution and try to figure out how many times we found results that changed the treatment of the patient or improve outcome. As a significant part of the practice at my Institution is transplant surgery, among these patients there was a significant number with transplants. We thought it was going to be interesting to compare patients with and without transplants having diffuse lung disease that had lung biopsies. As it is usual to find weird causes of diffuse lung disease in transplant patients, we expected to find out that lung biopsies were very useful in this group. We presented our work at the STS annual meeting and latter published in the Annals of Thoracic Surgery. We found among 60 patients that lung biopsy affected the treatment in 33 of them, and to our surprise we found no significant differences between the ones that had transplant and those without transplants.

We found that patients on the ventilator at the time of the biopsy and especially if transplant had an important in-hospital mortality. The probability of affecting the treatment was higher when biopsing a lung with nodules. Biopsing a consolidation was associated with increased mortality. On multivariate analysis, being on the vent, having a solid organ transplant and a diagnosis of cancer from the biopsy were associated with mortality.

Diffuse lung disease requiring surgical lung biopsy for diagnosis is a very serious condition just by itself. I try to make sure that all other less invasive methods of having lung tissue for diagnosis have been tried (bronchoscopy), before taking a patient to the OR for surgical lung biopsy. However, there are times that the patient is deteriorating fast and there is no time for multiple procedures; in this situation, the procedure that you believe will give you the best chance of finding out what going on is the one that should be done first. This method is a surgical biopsy most of the times. It should always be clear about what are the possibilities of finding something useful in the lung biopsy. This is especially true when taking with the patient and family. Despite surgery is probably the most accurate method, many times is not useful for affecting treatment (in our experience change treatment 30% of the times) and has a considerable risk of complications and even mortality, especially in the sicker patients.

It’d be great to hear your thoughts,

Sebastian

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