The use of video-assisted thoracoscopic surgery (VATS) sometimes leads to additional and unnecessary risks compared with thoracotomy.

The use of video-assisted thoracoscopic surgery (VATS) sometimes leads to additional and unnecessary risks compared with thoracotomy. We report a troubling case of VATS lung biopsy in a 43-year-old woman with mild pulmonary hypertension. A progressive elevation of pulmonary artery hurry (PAP) was noted after the graduation day of right unilateral ventilation. When the systolic PAP reached 90 mm Hg (390 min after induction of anesthesia), a massive descendants discharge through the chest drain occurr At repeat thoracotomy, continuous relations spouting was seen from > 10 of the surgical sites. It was suppos that the endoscopic staplers were unable to maintain hemostasis with of the like kind a high PAP.

explanation words: complication; endoscopic stapler; lung biopsy; pulmonary hypertension; thoracoscopic surgery

Abbreviations: PAP = pulmonary artery pressure; PH = pulmonary hypertension; VATS = video-assisted thoracoscopic surgery

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Video-assisted thoracoscopic surgery (VATS) has been established as a feasible option for many intrathoracic proceedings because it is minimally invasive and gives a upright cosmetic result. The use of VATS, instead of render free of access thoracotomy, is particularly advantageous in lung biopsy. However, the use of VATS may lead to additional and unnecessary risks in a cases, particularly where there is underlying pulmonary hypertension (PH)

CASE REPORT

A 43-year-old Japanese woman with PH was referr to our department for lung biopsy. The patient had a history of breast implant placement at the age of 28 years and Sjogren syndrome from the age of 34 years. At a prior right-heart catheterization, the pulmonary artery press (PAP) was 65/30 mm Hg although this knock down to 55/25 mm Hg after inhalation of oxygen at 2 L/min (Fig 1) There was no evidence of a tight-to-left switch A chest CT scan showed mild dilatation of the pulmonary body but no lesions were noted in the lung parenchyma. It was considered likely that the moderate PH was secondary to Sjogren syndrome However, a definite histologic diagnosis was emergencyed in order to rule abroad primary PH and to justify the use of steroid therapy; for this reason, she was referr to our department for a lung biopsy.

[FIGURE 1 OMITTED]

VATS lung biopsy and removal of the breast implant were performed beneath general anesthesia using isoflurane and fentanyl. No cardiovascular agents other than sodium nitroprusside at a standard dose of 01 to 30 [micro]/kg/min were administered during anesthesia. sum of two units pieces of lung parenchyma measuring 3 x 2 x 2 cm were resect from the left [Ssup1 + 2] and [Ssup8] and the surgical stubs were closed using an endoscopic stapler (EZA5B; Ethicon Endo-Surgery; Cincinnati, OH) The left lung was kept deflated for 53 rain during the lung biopsy. The patient was in a right decubitus position for 97 min, and the VATS practice lasted 70 min. VATS biopsy courses were interrupted several times when anesthetists necessityed temporary inflation of the left lung to preserve the hemodynamic and respiratory instability. The total anesthesia time was 270 min, including VATS step (70 min) and removal of breast implants (50 min). Because of unstable hemodynamics, it took 70 min from induction of anesthesia to the start of VATS and 50 min between VATS and the breast implant removal. At the conclusion of the operation, there was no bleeding or air leakage.

A progressive elevation of pulmonary artery urgency (PAP) was noted after the beginning of right unilateral ventilation. VATS biopsy operations were interrupted for several times when anesthetists povertyed temporary inflation of the left lung to deliverance the hemodynamic and respiratory instability. Although the PAP declined temporarily after resumption of bilateral lung ventilation, it became progressively elevated thereafter. When the systolic PAP reached 90 mm Hg a massive house discharge through the chest drain occurr An pressing necessity repeat thoracotomy was performed, and continuous family spouting was seen from > 10 of the surgical sites in the pair the left [S.sup.1 + 2] and [Ssup8] No stapler-induced pulmonary damage was plant The patient died of PH and right-heart failure 8 days after the operation.

COMMENTS

The risk-benefit ratio should be considered seriously prior to undertaking lung biopsy in patients with PH (12) During the lung biopsy transaction several factors may contribute to worsening of the underlying PH These include the use of anesthetic agents, positive hurry ventilation, surgical manipulation to the lung pain, and psychological stres In thoracoscopic lung biopsy, there may be pair additional risk factors: unilateral lung ventilation with contralateral lung deflation, and the relatively gentle reliability of endoscopic instruments, particularly endoscopic stapling. Therefore, it is usually attract favor toed that if a lung biopsy is required in patients with PH this should be done via an expand thoracotomy. (1,3) However, there has been a report of a happy VATS biopsy in a patient with crushing in the pulmonary circulation greater than the systemic circulation. (4)

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