Awake thoracoscopic biopsy of interstitial lung disease

Background: Surgical biopsy of interstitial lung disease (ILD) performed through general anesthesia and video-assisted thoracic surgery (VATS) is still associated with not negligible mortality and morbidity rates. We hypothesized feasibility and minimized side-effects of VATS lung biopsy performed by regional anesthesia methods in awake patients. Methods: Thirty patients with clinical and radiologic diagnosis of undetermined ILD underwent awake VATS lung biopsy under thoracic epidural anesthesia (20 patients) or intercostal blocks (10 patients). Primary outcome was technical feasibility scored from 0 (not performed) to 4 (excellent). Cardiorespiratory variables, including the ratio of arterial oxygen to fraction of inspired oxygen (PaO₂/FiO ₂) and arterial carbon dioxide (PaCO₂) were also assessed at fixed time points. Results: Mean age was 62 ± 10 years. No patient needed conversion to general anesthesia. The feasibility score was 3.4 ± 0.7. Feasibility score correlated with percent predicted diffusing capacity of lung for carbon monoxide (R = 0.67, p = 0.0001). Operative time and global in-operating room time (anesthesia time + operative time) was 22 ± 5 minutes and 47 ± 11 minutes, respectively. The average number of biopsies was 1.8 ± 0.4 per patient. There was no operative mortality and 1 minor complication (3.3%). Mean hospital stay was 1.4 ± 0.7 days and procedure-related cost was 2700 ± 472 euros. Both anesthesia methods resulted in optimal feasibility although by intercostal blocks procedure-related cost was lower (2,410 ± 337 vs 2,800 ± 486 euros, p <0.002) than by epidural anesthesia. Precise histopathologic diagnosis was achieved in 29 (97%) patients. Conclusions: Our study has shown that in patients with ILD, awake VATS lung biopsy was easily feasible by regional anesthesia and resulted in low morbidity, excellent diagnostic yield, short hospital stay, and low cost.