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A Prospective Randomized Controlled Trial Comparing the Efficacy and Safety of Cup vs Alligator Forceps for Performing Transbronchial Lung Biopsy in Patients With Sarcoidosis FREE TO VIEW

Inderpaul Singh Sehgal, MD, DM; Amanjit Bal, MD; Sahajal Dhooria, MD, DM; Parimal Agrawal, MD; Nalini Gupta, MD; Babu Ram, Msc; Ashutosh N. Aggarwal, MD, DM; Digambar Behera, MD; Ritesh Agarwal, MD, DM, FCCP
Author and Funding Information

Drs Sehgal and Bal are joint first authors and contributed equally to this work.

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Ritesh Agarwal, MD, DM, FCCP, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, India. 160012


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(6):1584-1586. doi:10.1016/j.chest.2016.03.025
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Published online

Transbronchial lung biopsy (TBLB) is a common bronchoscopic procedure used in the diagnosis of sarcoidosis. Whether use of alligator forceps would increase the diagnostic yield of TBLB remains unknown. In this prospective, randomized controlled trial, consecutive subjects with clinicoradiologic suspicion of sarcoidosis were randomized 1:1 to undergo TBLB with either cup or alligator forceps. The primary end point was the diagnostic yield of TBLB, defined as demonstration of granulomas in subjects with a final diagnosis of sarcoidosis. The study protocol (e-Table 1) was approved by the Institute Ethics Committee (reference number NK/1995/Res/310), and written informed consent was obtained from all subjects. The trial was registered at ClinicalTrials.gov.

Of the 150 subjects randomized to treatment (mean age, 44.2 years; 50.7% men; 878 TBLB specimens), sarcoidosis was diagnosed in 141 (Fig 1). The baseline characteristics were similar in the two groups (e-Table 2). Granulomas were demonstrated in 88 subjects according to TBLB specimen, and the diagnostic yield was similar in the two groups (cup vs alligator forceps, 64.3% vs 60.6%; P = .76). Of the remaining 53 subjects, 25 had noncaseating granulomas demonstrated elsewhere, and 28 were diagnosed on the basis of clinicoradiologic findings. The secondary outcomes (namely, the number of floating lung biopsies, biopsy specimen size, total number of granulomas, number of alveoli, and crush artifacts) were similar between the two groups (Table 1). A total of 21 (14.9%) complications were observed and were significantly higher with the cup forceps (21.4% vs 8.5%; P = .03). All four pneumothoraces (two requiring intercostal drainage, and two requiring a single aspiration) were encountered with cup forceps.

Figure Jump LinkFigure 1 The Consolidated Standards of Reporting Trials diagram depicting the flow of subjects during the study. cTBNA = conventional transbronchial needle aspiration; EBB = endobronchial biopsy; EBUS = endobronchial ultrasound; NSIP = nonspecific interstitial pneumonia; TBLB = transbronchial lung biopsy.Grahic Jump Location

Table Graphic Jump Location
Table 1 Study Outcomes in Subjects With a Final Diagnosis of Sarcoidosis

Data are given as No. (%) or mean ± SD. Boldface indicates statistical significance (P < .05). TBLB = transbronchial lung biopsy; VAS = visual analog score.

In a previous randomized study, the tissue samples acquired were significantly larger with the use of the alligator forceps. Intuitively, the cup forceps, due to its smaller cup size, may yield smaller biopsy specimens.,, In the present study, the size of the biopsy samples, however, did not differ between the two groups, probably because we obtained at least four moderate-to-large tissue samples in both the study groups. The complication rate was also lower with the alligator forceps, similar to that reported in a previous study. It is likely that the cup forceps cuts through the blood vessels, whereas the alligator forceps crushes the blood vessels, thus leading to higher bleeding with the former method. In addition, the cup forceps has a smaller diameter (4 mm) compared with the alligator forceps (7 mm) in the open position; thus, it possibly reaches the lung segments more distally compared with the alligator forceps, leading to more pneumothoraces.

What are the clinical implications of this study? The addition of TBLB to either conventional or endobronchial ultrasound-guided transbronchial needle aspiration has been shown to increase the diagnostic yield of bronchoscopy.,, The results of the present study suggest that the use of alligator forceps would enhance this incremental yield with a lesser occurrence of significant complications. Because this is a single-center study, our results should be confirmed in a larger, multicenter trial.

National Institutes of Health Clinical Center. A study to evaluate the efficacy and safety of fenestrated cup forceps versus fenestrated alligator forceps for performing transbronchial lung biopsy in patients with sarcoidosis. NCT02405897.ClinicalTrials.gov. Bethesda, MD: National Institutes of Health; 2015.https://clinicaltrials.gov/ct2/show/NCT02405897. Updated October 25, 2015.
 
Jabbardarjani H. .Eslaminejad A. .Mohammadtaheri Z. .Kiani A. .Arab A. .Masjedi M.R. . The effect of cup versus alligator forceps on the results of transbronchial lung biopsy. J Bronchology Interv Pulmonol. 2010;17:117-121 [PubMed]journal. [CrossRef] [PubMed]
 
Wang K.P. .Wise R.A. .Terry P.B. . Comparison of standard and large forceps for transbronchial lung biopsy in the diagnosis of lung infiltrates. Endoscopy. 1980;12:151-154 [PubMed]journal. [CrossRef] [PubMed]
 
Loube D.I. .Johnson J.E. .Wiener D. .Anders G.T. .Blanton H.M. .Hayes J.A. . The effect of forceps size on the adequacy of specimens obtained by transbronchial biopsy. Am Rev Respir Dis. 1993;148:1411-1413 [PubMed]journal. [CrossRef] [PubMed]
 
Smith L.S. .Seaquist M. .Schillaci R.F. . Comparison of forceps used for transbronchial lung biopsy. Bigger may not be better. Chest. 1985;87:574-576 [PubMed]journal. [CrossRef] [PubMed]
 
Gupta D. .Dadhwal D.S. .Agarwal R. .Gupta N. .Bal A. .Aggarwal A.N. . Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146:547-556 [PubMed]journal. [CrossRef] [PubMed]
 
Agarwal R. .Aggarwal A.N. .Gupta D. . Efficacy and safety of conventional transbronchial needle aspiration in sarcoidosis: a systematic review and meta-analysis. Respir Care. 2013;58:683-693 [PubMed]journal. [PubMed]
 
Tremblay A. .Stather D.R. .Maceachern P. .Khalil M. .Field S.K. . A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest. 2009;136:340-346 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 The Consolidated Standards of Reporting Trials diagram depicting the flow of subjects during the study. cTBNA = conventional transbronchial needle aspiration; EBB = endobronchial biopsy; EBUS = endobronchial ultrasound; NSIP = nonspecific interstitial pneumonia; TBLB = transbronchial lung biopsy.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 Study Outcomes in Subjects With a Final Diagnosis of Sarcoidosis

Data are given as No. (%) or mean ± SD. Boldface indicates statistical significance (P < .05). TBLB = transbronchial lung biopsy; VAS = visual analog score.

References

National Institutes of Health Clinical Center. A study to evaluate the efficacy and safety of fenestrated cup forceps versus fenestrated alligator forceps for performing transbronchial lung biopsy in patients with sarcoidosis. NCT02405897.ClinicalTrials.gov. Bethesda, MD: National Institutes of Health; 2015.https://clinicaltrials.gov/ct2/show/NCT02405897. Updated October 25, 2015.
 
Jabbardarjani H. .Eslaminejad A. .Mohammadtaheri Z. .Kiani A. .Arab A. .Masjedi M.R. . The effect of cup versus alligator forceps on the results of transbronchial lung biopsy. J Bronchology Interv Pulmonol. 2010;17:117-121 [PubMed]journal. [CrossRef] [PubMed]
 
Wang K.P. .Wise R.A. .Terry P.B. . Comparison of standard and large forceps for transbronchial lung biopsy in the diagnosis of lung infiltrates. Endoscopy. 1980;12:151-154 [PubMed]journal. [CrossRef] [PubMed]
 
Loube D.I. .Johnson J.E. .Wiener D. .Anders G.T. .Blanton H.M. .Hayes J.A. . The effect of forceps size on the adequacy of specimens obtained by transbronchial biopsy. Am Rev Respir Dis. 1993;148:1411-1413 [PubMed]journal. [CrossRef] [PubMed]
 
Smith L.S. .Seaquist M. .Schillaci R.F. . Comparison of forceps used for transbronchial lung biopsy. Bigger may not be better. Chest. 1985;87:574-576 [PubMed]journal. [CrossRef] [PubMed]
 
Gupta D. .Dadhwal D.S. .Agarwal R. .Gupta N. .Bal A. .Aggarwal A.N. . Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis. Chest. 2014;146:547-556 [PubMed]journal. [CrossRef] [PubMed]
 
Agarwal R. .Aggarwal A.N. .Gupta D. . Efficacy and safety of conventional transbronchial needle aspiration in sarcoidosis: a systematic review and meta-analysis. Respir Care. 2013;58:683-693 [PubMed]journal. [PubMed]
 
Tremblay A. .Stather D.R. .Maceachern P. .Khalil M. .Field S.K. . A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest. 2009;136:340-346 [PubMed]journal. [CrossRef] [PubMed]
 
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