LUNG BIOPSY - SURGICAL-INTERVENTIONS

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Lung Biopsy

Generality

Lung biopsy consists of taking and analyzing in the laboratory a small sample of lung tissue from an individual with suspected severe lung disease.

There are 3 different methods of collection: bronchoscopic biopsy, "pulmonary needle biopsy and" open "lung biopsy.
The first two methods are minimally invasive, but unfortunately not very specific, outpatient examinations; the "open" lung biopsy, on the other hand, is a real surgery, the possible complications of which are counterbalanced by a great specificity.

What is lung biopsy?

Lung biopsy is a diagnostic procedure that consists in collecting and analyzing in the laboratory a more or less large sample of lung tissue.
The collection can take place in at least 3 different ways.

The choice of the method used for the collection is up to the attending physician and depends on the patient's general state of health and on the size of the sample to be analyzed. In fact, as will be seen in the next chapters, there are minimally invasive, but not very specific procedural methods, and rather invasive, but very specific and reliable procedural methods from the point of view of results.
Briefly, the 3 techniques for collecting a lung tissue sample are:

Bronchoscopic biopsy
Pulmonary needle biopsy (or pulmonary fine needle aspiration)
"Open" lung biopsy

When you do

Doctors consider it appropriate to perform a lung biopsy when:

Based on physical examination, they suspect the presence of severe lung disease, such as pulmonary fibrosis, interstitial lung disease (or interstitial lung disease), sarcoidosis, or lung cancer.
They need to accurately establish the connotations of severe pneumonia. Pneumonia means an inflammatory process affecting the pulmonary alveoli.
From previous diagnostic procedures, all less invasive than lung biopsy (chest X-ray, etc.), they have not been able to conclude precisely what is the exact origin of the patient's respiratory and lung problems.

Preparation

It is common practice that, a few days before the lung biopsy, the doctor in charge of the biopsy (or a qualified member of his staff) meets the patient, to inform him of the details of the procedure and to question him about:

The clinical history. When we talk about clinical history, we refer to all the pathologies that an individual suffers or has suffered in the past. It is essential to communicate the presence of coagulation diseases (for example haemophilia).
The drugs taken at that time. It is particularly important to tell the doctor about the intake of antiplatelet agents (aspirin or clopidogrel) and / or anticoagulants (warfarin), as these preparations, "diluting the blood", represent a factor favoring bleeding.
Some types of lung biopsy involve one or more surgical incisions and minimal blood loss from these. If an individual does not stop antiplatelet or anticoagulant treatments, this blood loss can be dangerous.
Any allergies to certain medicines, especially anesthetics and sedatives. During the various lung biopsy methods, anesthesia (local or general) and the use of sedatives are used; all this, in the presence of an "allergy or" intolerance, could be very dangerous.

If the sampling method consists of a minor surgery, complete with general anesthesia and short hospitalization ("open" lung biopsy), a blood test, an electrocardiogram and a blood pressure check are also provided. In other words, a check of vital signs is done.
If the patient is a woman and even suspects that she is pregnant, she should report this suspicion to the doctor.

FAST

When general anesthesia is foreseen, as in the occasion of the "open" lung biopsy, the patient, on the day of the examination, is required to report completely fasting for at least 8 hours.
Typically, if the procedure is held in the morning, doctors recommend having the last meal by midnight the previous day.
The only drink allowed, up to a few hours before the intervention, is water.

Bronchoscopic biopsy

Bronchoscopic biopsy (or bronchoscopy) consists in taking lung tissue using an instrument, the bronchoscope (hence the name of bronchoscopic biopsy), which the doctor introduces from the mouth or nose and leads to the level of the lungs.
This procedure requires the administration of a local anesthetic in a spray and can last from a minimum of 30 minutes to a maximum of 60 minutes.

BRONCOSCOPE

The bronchoscope usually used is a very thin, flexible tube equipped with a fiber optic camera. The latter is used by the examining physician to orient himself within the pulmonary airways (in particular the bronchi) and identify the area of abnormal lung tissue, which should be taken.
Once the most indicative area for subsequent analyzes has been identified, the tissue sample is collected.
Sometimes, although increasingly rarely, rigid bronchoscopes are used.

WHO TAKES THE EXAMINATION?

A bronchoscopic biopsy is usually performed by a pulmonologist, that is a doctor specialized in the diagnosis and treatment of diseases affecting the respiratory system, lungs in particular.

AFTER THE PROCEDURE

Bronchoscopic biopsy does not include any hospitalization, but only a short observation period lasting about 1-2 hours.
During this time, the patient is subjected to a chest X-ray to understand / see if the passage of the bronchoscope has damaged the airways.

FEELINGS DURING OR AFTER THE PROCEDURE

At the end of the procedure and for several hours, the patient may experience the following discomfort: sore throat, hoarseness, dry throat and difficulty in swallowing.

ONE VARIATION: BRONCOALVEOLAR WASHING

Sometimes, doctors use the bronchoscope to release a saline solution, which breaks down the lung tissue it comes into contact with.
If properly recovered, this solution contains a sufficient number of cells to be observed in the laboratory.
This alternative practice is also called bronchoalveolar lavage.

Table. Advantages and disadvantages of bronchoscopic biopsy.

Benefits

Disadvantages

It is quick and requires no hospitalization.
Requires local anesthesia.
It is minimally invasive.
It is low risk.

The tissue sample taken contains a limited number of cells, all of which belong only to the airways.

Pulmonary needle biopsy

During a pulmonary needle biopsy, lung cells are taken to be analyzed in the laboratory by means of a long needle inserted into the chest.

SOME DETAILS OF THE PROCEDURE

To find the exact injection site of the needle, doctors use some diagnostic imaging procedures, such as CT scans, ultrasound, or fluoroscopy. In fact, with their execution at the time of the biopsy, it is able to know where the abnormal area of lung tissue resides, which must be taken for laboratory analysis.
When the needle is inserted, the patient is asked to hold his breath and not to move his chest: only in this way, the sampling takes place at the desired point.
The entire procedure is performed under local anesthesia (N.B: the anesthetized area is obviously the chest) and can last between 30 and 60 minutes.

WHO TAKES THE EXAMINATION?

To perform the pulmonary needle biopsy, it can be both a radiologist and a pulmonologist.

AFTER THE PROCEDURE

Like bronchoscopic biopsy, pulmonary needle biopsy also does not require hospitalization, but only an observation period of no more than 2 hours.
During this time, the patient must undergo a chest X-ray to ensure that the needle has not damaged the lungs or other adjacent anatomical structures during penetration.

FEELINGS DURING OR AFTER THE PROCEDURE

During the injection of the anesthetic (N.B: it takes place by means of a syringe), the patient may experience a stinging or burning pain lasting a few seconds.
At the end of the procedure and when the effects of the anesthesia have worn off, it is probable that the point of the chest, where the needle for the biopsy was inserted, is painful.

Table. Advantages and disadvantages of pulmonary needle biopsy.

Benefits

Disadvantages

It is quick and requires no hospitalization.
Requires local anesthesia.
It is minimally invasive.
It is low risk.

The tissue sample taken contains a limited number of cells and all of them come from a well-circumscribed point.

"Open" lung biopsy

The "open" lung biopsy is a full-fledged surgical intervention, which involves making one or more incisions between the ribs and inserting, through the aforementioned incisions, the instrumentation necessary for taking the tissue sample.
As anticipated, the "open" lung biopsy requires general anesthesia. This implies that, at the time of the examination, the patient is completely unconscious.
Due to its delicacy, the "open" lung biopsy is performed only when the less invasive lung biopsies (ie bronchoscopic biopsy and pulmonary needle biopsy) have proved not very exhaustive.

SOME DETAILS OF THE PROCEDURE

The canonical duration of an "open" lung biopsy is approximately one "hour.
At the end of the surgical operations, the operating doctor must perform a pleural drainage for the re-expansion of the lung, from which the tissue sample was taken.
During the operation, in fact, this lung collapses as following a pneumothorax.
Pleural drainage usually lasts a few days.
The incisions are closed with resorbable or non-resorbable sutures. If non-resorbable sutures have been applied, these should be removed after 7-14 days.

AFTER THE PROCEDURE

Generally, after the procedure, the patient must stay in the hospital for at least a couple of days: during this time, the operating surgeon and medical staff periodically monitor his vital signs and how his body responds to the operation.
This is usually a precautionary hospitalization.

POST-OPERATIVE FEELINGS

Upon awakening from anesthesia and for the following 12-24 hours, the patient may feel confused and slowed down in reflexes: these are the normal after-effects of general anesthesia.
As far as the effects of the operation are concerned, the "open" lung biopsy often determines, for at least a few days: fatigue, chest pain during breathing, slight blood loss at the incision point and sore throat (NB: is due to the respirator used for general anesthesia).

ONE VARIATION: THORACOSCOPIC BIOPSY

An alternative surgery to "open" lung biopsy is the so-called thoracoscopic lung biopsy, also known as video-assisted thoracoscopic biopsy (VATS, from Video-Assisted Thoracoscopic Surgery).
Practiced now by an increasing number of hospitals, VATS provides for the use of an instrument called a thoracoscope.

The thoracoscope has, at one end, a light and a fiber optic camera, connected to a monitor; light and a camera allow the operating surgeon to better orientate himself inside the thoracic cavity and identify the sampling area with greater precision.
As far as the procedure is concerned, the operative steps are not very different from those of an "open" lung biopsy: however, "general anesthesia," the execution of some incisions on the chest for the insertion of surgical instruments (including including the thoracoscope) and the realization of the pleural drainage.
To justify its increasingly widespread use are at least a couple of factors:

The small size of surgical incisions. This is possible thanks to the camera, which allows you to see the thoracic cavity from the inside.
The hospitalization period is shorter.

Table. Advantages and disadvantages of "open" lung biopsy.

Benefits

Disadvantages

It is the most exhaustive type of lung biopsy, as the sample taken is of the size necessary for a "complete laboratory analysis

It is invasive and can carry several risks.
Requires hospitalization.
It includes general anesthesia, a practice at risk of complications.

Risks

Currently, lung biopsy is considered a low-risk diagnostic procedure.
However, it should be noted that the occurrence of complications depends very much on the type of lung biopsy performed. In fact, bronchoscopic biopsy and "needle biopsy of the lungs are less dangerous than" open "lung biopsy or its thoracoscopic variant.
After all, the first two are not particularly complex outpatient examinations, while the second two are full-fledged surgeries (and complications can arise during any surgery, even the simplest).

The possible complications of a lung biopsy, performed in a surgical modality.

Pneumothorax
Severe blood loss
Infections, such as pneumonia
Bronchospasm and consequent breathing problems
Arrhythmias
Death. It is a very rare event, which can occur because the surgery severely aggravates the ongoing lung disease or because general anesthesia has triggered an abnormal lethal reaction.