Diagnostic yield of medical thoracoscopy in cases of undiagnosed pleural effusion in Kobri El-Kobba Military Hospital

The role of medical thoracoscopy in the diagnosis of exudative lymphocytic pleural effusions: an observational study

Diagnosis of pleural effusion remains challenging despite extensive microbiological and radiological investigations. Pleural histopathological examination (HPE) is often needed to ascertain the etiology. Medical thoracoscopy (MT) is surpassing the other modalities of pleural biopsy on account of its high diagnostic yield. We aim to estimate the yield of MT in undiagnosed exudative lymphocytic pleural effusion and also intend to correlate gross thoracoscopy findings with HPE results. This retrospective observational study was conducted in a tertiary respiratory care center. Medical records of undiagnosed exudative lymphocytic predominant pleural effusion patients who underwent MT during the study period of 24 months were retrieved from the Medical Records Department. The clinico-demographic profile, radiological images, gross thoracoscopy findings, HPE reports, and post-procedure complications were recorded and analyzed using analysis of variance and chi-square test. The study comprised 62 patients with a mean age of 52 years at presentation. HPE of MT-guided biopsy confirmed tuberculosis in 22 (35.3%), malignancy in 18 (29%) cases, and 22 (35.5%) cases had chronic nonspecific inflammation. The most commonly observed MT finding in malignancy was pleural nodules (14.70%), followed by thickened pleura (10.50%) and growth (2.10%). In tuberculosis, the most common MT finding was adhesions in all, followed by nodules (5.28%). We also diagnosed a case of pleural amoebiasis and ependymoma, which are rare. Macroscopic findings had a significant correlation with the final histopathologic diagnosis, with a diagnostic yield of 66.1%. Gross thoracoscopic findings correlate well with the histopathological diagnosis of pleural effusion etiology, with a correlation coefficient of 0.73. Pleural nodules were the most common finding in malignancy, while adhesions were common in benign pathology like tuberculosis. A good diagnostic yield underscores the utility of MT in undiagnosed exudative lymphocytic pleural effusions.

Local Anesthetic Thoracoscopy: A Focus on Indications, Techniques and Complications

The main purpose of this narrative review is to educate general practitioners about a crucial pleural procedure, namely local anesthetic thoracoscopy (LAT), and to provide established respiratory physicians with an expert opinion-based summary of the literature. This narrative review focuses on the indications, technical aspects and complications of LAT, highlighting its safety and high degree of diagnostic sensitivity for patients who present with an unexplained pleural effusion and have a high pre-test probability of cancer.

Validity of Pleuroscopy in Evaluating Pleural Effusions of Uncertain Etiology at the Cardiothoracic Unit of Minia University Hospital, Egypt

INTRODUCTION

Pleural effusion is a medical condition where an excessive amount of fluid accumulates in the pleural space. This can be caused by inflammation or malignant growth in the body. Doctors use medical thoracoscopy for both diagnostic and therapeutic purposes. This technique allows them to view the internal pleural surfaces and take biopsies of any abnormal lesions within the pleural cavity.

OBJECTIVE

This work aimed to evaluate the diagnostic value of pleuroscopy in patients with undiagnosed exudative pleural effusion.

PATIENTS AND METHODS

A study was conducted on 61 patients who had undiagnosed exudative pleural effusion and were admitted to the chest department at the cardiothoracic unit of the Minia University Hospital. All patients provided written consent and underwent a complete history and clinical examination. Standard laboratory tests, including routine liver and kidney function tests, a complete blood count, and a coagulation profile, were conducted on all patients, along with chest X-rays. If necessary, a chest CT scan was also performed. Diagnostic thoracentesis was done, and the pleural fluid was analyzed for sugar, protein, and lactate dehydrogenase and sent for bacteriological analysis (Gram stain, culture, and acid-fast bacilli smear) and cytopathological examination. Medical thoracoscopy was performed in cases where an etiological diagnosis was not established.

RESULTS

A total of 61 patients with undiagnosed exudative pleural effusions were included. A definitive etiological diagnosis was reached in 58 (95%) patients. In 47 (77%) of the studied group, malignant etiology was confirmed; nine (14.8%) had tuberculous pleurisy, one (1.6%) had empyema, and one (1.6%) had inflammatory/autoimmune pleurisy. A definite diagnosis was not reached in three (5%) patients. The malignant pathology was caused by bronchogenic carcinoma in 20 (42.5%) cases, malignant mesothelioma in 10 (21.3%) cases, metastatic malignant deposits from other organs in six (12.7%) cases, and lymphoma in three (6.5%) cases. No serious adverse events related to the procedure were recorded. The most common minor complications were transient chest pain in 34 (55.7%) patients, followed by surgical emphysema in 10 (16.4%) patients.

CONCLUSION

Pleuroscopy is an effective diagnostic tool for identifying the cause of pleural effusion when it is unclear. It is a minimally invasive and straightforward procedure associated with high diagnostic accuracy and low complication rates.

Unveiling Insights: A Comprehensive Review of the Role of Medical Thoracoscopy in Pleural Effusion Assessment

Pleural effusion, characterized by abnormal fluid accumulation in the pleural cavity, poses diagnostic and therapeutic challenges across various medical conditions. This comprehensive review explores the role of medical thoracoscopy in assessing pleural effusions, providing insights into its historical context, procedural intricacies, diagnostic performance, safety considerations, and clinical applications. Medical thoracoscopy, a minimally invasive endoscopic procedure, offers advantages such as high diagnostic yield, therapeutic interventions, real-time assessment, and a minimally invasive nature. The review critically analyzes the procedure's advantages and disadvantages, including technical expertise, risk of complications, resource intensity, and patient selection criteria. Comparative analyses with alternative diagnostic modalities highlight the unique benefits of medical thoracoscopy in specific clinical scenarios. The diagnostic yield of medical thoracoscopy is examined, considering sensitivity and specificity in various contexts. Patient selection criteria, complications, and safety measures are discussed, emphasizing the importance of careful consideration in integrating thoracoscopy into clinical practice. The review further explores its clinical applications, including differentiating exudative and transudative effusions, identifying specific etiologies, and its role in treatment planning. In conclusion, medical thoracoscopy emerges as a valuable tool in the comprehensive management of pleural effusions, offering a nuanced approach to diagnosis and treatment. The evolving landscape of diagnostic modalities underscores the continued significance of medical thoracoscopy and potential advancements in the field.

Visual Diagnosis of Pleural Tuberculosis and its Association with Tissue Biopsy, Culture and Xpert Assay

INTRODUCTION

 The diagnosis of pleural tuberculosis remains a clinical challenge due to the paucibacillary nature of disease. Medical thoracoscopy remains the gold standard in diagnosing tuberculous pleuritis.

OBJECTIVE

 To establish the diagnostic yield of sago-seed thoracoscopic appearance of pleura in tuberculosis and its correlation with histopathology, tissue AFB culture and tissue Xpert MTB/Rif assay.

METHODS

 All consecutive patients with lymphocytic exudative pleural effusion, who fulfilled inclusion criteria of the study underwent medical thoracoscopy under local anesthesia and pleural tissue was sent for histopathology, AFB culture and Xpert MTB/Rif assay. Chronic granulomatous inflammation on histopathology and response to anti-tuberculous treatment was taken as reference standard for diagnosis of tuberculous pleurisy.

RESULTS

 A total of 249 patients were included in the study, out of which 168 had effusion secondary to tuberculosis. Sago-like nodules visualized on thoracoscopy had a sensitivity of 58.9 %, specificity of 92.6 % and diagnostic accuracy of 69.88 % for pleural tuberculosis. There is a strong association between the presence of sago-like nodules and detection of mycobacterium tuberculosis on Xpert MTB/Rif assay and AFB culture of pleura (p-value 0.007).

CONCLUSION

 Sago seed nodules on pleura have a high positive predictive value for tuberculous pleurisy. In high endemic countries patients with this finding on thoracoscopy can be commenced on anti-tuberculous treatment before histopathology or culture results are available.

Diagnostic accuracy of semirigid thoracoscopy in exudative pleural effusions and relationship of thoracoscopic findings with probability of malignant diagnosis

Semirigid thoracoscopy is increasingly becoming the procedure of choice for evaluation of undiagnosed exudative pleural effusions. Few studies have reported relationship of thoracoscopic appearances of pleural abnormalities and etiological diagnoses. We aimed our study to assess the diagnostic utility and safety of semirigid thoracoscopy for evaluation of patients with undiagnosed exudative pleural effusion. Further, we also pursued to find any relation of various thoracoscopic findings with the final diagnosis. We prospectively enrolled hospitalized patients with undiagnosed exudative pleural effusion who underwent semirigid thoracoscopy. Demographic, clinical and laboratory data along with data on thoracoscopic appearance of various pleural abnormalities and histopathological diagnosis of pleural biopsy specimens were collected and analysed. Semirigid thoracoscopy was diagnostic in 46 (N=55) patients (83.64%). Malignancy was diagnosed in 31 patients (56.36%), of which adenocarcinoma was the most common histopathological diagnosis (45.16%).  Sensitivity, specificity, PPV, NPV LR+ and LR- of thoracoscopy were 93.87%, 100%, 100%, 66.67%, 40.30 and 0.06, respectively. Pleural nodules, masses and hemorrhagic pleural fluid significantly increased the diagnosis yield of malignancy [OR= 37.16 (95%CI = 3.61-382.65),  =0.002]. The procedure related complications were mild and transient. Post- procedural pain (20%) was most commonly reported followed by dry cough (18.18%), sub-cutaneous emphysema (7.27%) and anaesthesia related complication (1.82%). Semirigid thoracoscopy is simple, safe and effective procedure in diagnosing exudative pleural effusion of unknown etiology with high diagnostic accuracy and minor procedure related complications. The likelihood of diagnosing malignancy is high if combination of pleural nodules, masses and hemorrhagic pleural fluid is present.

Minithoracoscope versus Conventional Medical Thoracoscope in Patients with Exudative Pleural Effusion

Background

Thoracoscopy allows visualization of the pleural cavity including diaphragm, visceral pleura, and lungs. It provides the physician with information about the disease extent and it has the ability to get a biopsy from these lesions to differentiate between tumors and fibrotic reactions. This study aims to compare minithoracoscopy and medical thoracoscope in patients with exudative pleural effusion as regards the diagnostic yield, safety, complications, and duration of hospital stay.

Patients and methods

Sixty patients were diagnosed with exudative pleural effusion and were randomly divided into 2 equal groups: Group (1): included 30 patients who underwent minithoracoscopy and Group (2): included the remaining 30 cases who underwent the standard thoracoscope.

Results

Pathological examination of the sample revealed that biopsy size was 2.02 and 1.25 in group 1 and group 2 was respectively with highly statistically significant between both groups (P < .001). Group 1 revealed TB, malignant, chronic nonspecific pleurisy, Staph aureus, Klebsiella, and Pseudomonas in 30% (9), 30% (9), 33.3% (10), 69% (9), 15% (2), and 15% (2) of cases respectively. While group 2 reveled TB, malignancy, chronic nonspecific pleurisy, Staph aureus, Klebsiella, Pseudomonas, and other causes in 40% (12), 23.3% (7), 23.3% (7), 67% (8), 8% (1), 8% (1), and 16% (2) respectively with no statistically significant differences between both groups (P > .05).

Conclusion

Minithoracoscopy is well tolerated by patients as minimal pain and early hospital discharge could be achieved by that approach.