A realist (re)view on surgical lung biopsy in interstitial lung disease: who, how, when and at what risk?

Abstract

Interstitial lung disease (ILD) is a heterogenous group of conditions which cause scarring of lung parenchyma. It poses a diagnostic challenge for clinicians, especially if radiological and pathophysiological features are indeterminate. Surgical lung biopsy (SLB) may be offered in the diagnostic workup for patients with suspected ILD; however, the delicate balance between risk and benefit in these patients remains a challenge. We reviewed key recommendations from international societies and further explored the evidence using snowball sampling. We then used the realist review method to build a best-fit approach to risk-benefit considerations for patients undergoing SLB. SLB allows for diagnostic certainty which informs prognosis.It allows quicker treatment and reduces diagnostic uncertainty. However, mortality and morbidity vary significantly between centres and patient cohorts. Recent studies suggest outcomes are markedly more favourable for elective SLB compared to non-elective SLB. Comprehensive risk-benefit assessment and discussion, as well as patient evaluation in the context of a dedicated multi-disciplinary team are crucial to achieve the best outcomes for this complex patient group. The complex balance between patient selection, urgency of surgery, volume of work, training needs and outcomes continues to evade equilibrium. Going forward, further research, continued monitoring, robust patient selection processes and multidisciplinary shared decision-making are some ways to optimise outcomes whilst minimizing risk. Novel surgical approaches as well as advances in interventional techniques might offer further benefit in future.