- Hemothorax:
Accidental injury to the neurovascular bundle may result in arterial bleeding which would
require a thoracotomy to correct. It was stressed throughout the procedure never to direct
the biopsy hook upwards along the inferior margin of the rib.Of course,
a pleural biopsy is contraindicated when there is a coagulation defect either secondary to
disease process or use of anticoagulants. The granulation tissue tends to bleed and I
strongly advise against pleural biopsy in patients with empyema. I am also very scared of
uremic patients. They tend to bleed in spite of normal PT, PTT and platelet counts. This
may possibly be due to platelet function impairment.
If proper care is taken in avoiding patients with an increased risk of bleeding,
this complication is rare. I have encountered this complication twice. Once in an uremic
patient and once in a patient with myelofibrosis and empyema.
- Empyema:
Empyema could complicate the procedure. I have not come across this complication yet. If
you follow strict sterile surgical techniques, this complication should not occur.
- Pneumothorax:
A pneumothorax can complicate the procedure. Two types of pneumothorax can occur in this
situation:
- Due to a lung puncture:
If an accidental puncture to the lung occurs during anesthesia, a pneumothorax may occur.
The Cope needle is blunt and, in the presence of sufficient fluid, this complication
should not occur. However, it can occur if the amount of effusion is small or there were
adhesions present. Usually, it resolves spontaneously and would not require chest tube
drainage.
- Due to introduction of air during stylet changes:
The second benign form of pneumothorax is due to the accidental suction of air into the
chest during stylet changes. If you change the stylet only during expiration, this will
not occur. I instruct the patient to make an "ooooh" sound to ensure expiration.
This enables me to change the stylet.I am sure you are familiar with
the hissing noise with which air can enter the chest during inspiration. Unfortunately,
this frequently occurs and is not too serious. Nothing has to be done, as it will reabsorb
itself.
- Seeding of Tumor:
Tumor seeding at the site of the biopsy has been reported. Fortunately, it is rare and
inconsequential. Since we are dealing with a patient with metastatic disease to start
with, this complication would not alter the outcome. However, this complication occurs
frequently in patients with mesothelioma and they are distressing to the patient.Unfortunately,
the diagnosis by pleural biopsy is difficult in patients with mesothelioma. This results
in multiple biopsy attempts. I have seen this complication twice and the tumor growth
along the track of biopsy were massive, disfiguring and painful.
Due to the inability of making a definite diagnosis of mesothelioma by pleural
biopsy and this distressing complication, I resort to performing an open or thoracoscopic
biopsy whenever my working diagnosis is mesothelioma.
- Extravasation:
Extravasation of pleural fluid can occur along tissue planes and the patient can develop
massive swelling of the back, abdominal wall and genitals. This complication occurs in
patients with massive effusion under significant pressure.You can avoid
this complication by evacuating some of the fluid following the biopsy and applying a
pressure bandage. The fluid will be absorbed spontaneously. The problem is mainly
cosmetic. The bandage can soak through and soil the patient's clothing. You may have to
repeatedly change the dressing. Remember that the biopsy process leaves a sizeable hole in
the pleura.