Interventional radiology (IR) is a new speciality that is at the forefront of both minimally invasive diagnostic and therapeutic procedures. Advances in equipment have meant that in general IR’s are able to treat many procedurally related complications. For example, if I perform a liver biopsy I know that I have the ability to diagnose and treat a subsequent haemorrhage. This was not the case for lung biopsy.
As both an IR trainee and consultant I had been successfully performing percutaneous lung biopsy for over 5 years and was referring any significant pneumothoraces to the respiratory physicians; inevitably resulting in patient admission and large bore underwater seal chest drainage for a few days. This was what I had been trained to do and was (and still is in most centres) extremely dissatisfying for both patient and me as a practitioner. A consequence of wanting to avoid this complication was either consciously or unconsciously to adopt a conservative approach to biopsy, declining small lesions or declining biopsy in patients with poor lung function. I confess I was missing the opportunity to provide patients with an earlier diagnosis and treatment.
The benefits have not just been confined to lung biopsy alone; [...] we have applied this to treating primary lung cancers and lung metastases by thermal ablation
Dr Sam Hare’s imported technique of treating pneumothoraces by insertion of a narrow (and therefore comfortable) chest drain, placed soon after biopsy if required and attached to a small lightweight Heimlich valve (already freely available from manufacturers) makes perfect sense and is so simple. So much so, that it begs the question “why was I not doing this before?” Not only was I convinced by the science and cost effectiveness but most importantly by the patient response. I saw patients with severe emphysema and small lung cancers being biopsied and their pneumothoraces (if present) being easily managed with no admission, returning the next day for drain removal with minimal discomfort.
This was the lever that made me and my local IR colleagues, change our practices over the last two years. We didn’t really change our biopsy techniques but we gained the confidence to increase the number of biopsy samples, thereby increasing diagnostic accuracy and yielding enough tissue for genetic analysis.
The benefits however have not just been confined to lung biopsy alone and as importantly we have applied this to treating primary lung cancers and lung metastases by thermal ablation. We are currently performing both curative and palliative lung ablation in patients with compromised lung function that precludes surgery. These patients have an increased risk of pneumothoraces and the Heimlich valve technique gives us the confidence to do this, so much so that patients are being treated as day cases, obviating the need for admission altogether.
Innovations such as this, catalyse new models of care, allow patients to be diagnosed and treated earlier with reduced inpatient stay
In a small group of patients with ‘obvious’ lung cancers on CT/CT PET we have offered a ‘one stop’ diagnosis and treatment service performing biopsy and ablation at the same time. This illustrates how far we have come in a short space of time by being open to and embracing new innovation and applying it to maximal patient benefit.
For me, seeing and realising the huge benefits given to patients, has led to a renewed vigour and interest in lung cancer and thoracic intervention as a whole.
The NHS faces huge financial and resource challenges. Innovations such as this, catalyse new models of care, allow patients to be diagnosed and treated earlier with reduced inpatient stay and should be promoted to all, both clinicians and patients.
- Interview with Dr. Sam Hare, A common-sense, practical innovation that improves patient care
- Sam's guest blog about why the ambulatory lung biopsy method should be rolled out across the NHS
- Radiologist Dr. Aniket Tavare gives a trainee's point of view on the practical impact of new lung biopsy methods
Dr. Ash Saini is a consultant interventional radiologist at the Royal Free London NHS Trust.
He studied medicine at The London Hospital Medical School. After training as a surgeon, and gaining membership of the Royal College of Surgeons of England, he underwent specialist training in radiology at Hammersmith and Charing Cross Hospitals. Subsequently, Ash completed an interventional radiology fellowship at Guy’s and St Thomas’ NHS Foundation Trust. He has been a consultant for 7 years and is currently the clinical director for radiology at the Royal Free, London.