Thoracoscopy in the diagnosis of pleural effusion

Medical thoracoscopy: Analysis on diagnostic yield through 30 years of experience

BACKGROUND:

Medical thoracoscopy (MT) or pleuroscopy is a procedure performed to diagnose and treat malignant and benign pleural diseases. Totally 2752 pleuroscopies executed in 1984–2013 in our center were considered in this study.

METHODS:

A retrospective observational study was performed. Observational time was divided into six series of 5 years. We calculated MT diagnostic yield and analyzed trends of main diseases diagnosed along the time.

RESULTS:

Along the 30 years population became progressively older. Number of pleuroscopies firstly increased, then stabilized and decreased in the last 5 years. The overall diagnostic yield of MT was 71%, increasing from 57% to 79%. The diagnostic yield was significantly higher in the presence of monolateral pleural effusion. Cancer represented more than half of diagnosis; tuberculosis was the most common nonneoplastic disease. The frequency of all cancers, mesothelioma, and lung cancer increased through the time; tuberculosis first decreased and then increased. All specimens resulted appropriate during the last 25 years.

CONCLUSION:

MT has a great diagnostic yield that can be improved by practice, permitting to achieve a specific histological diagnosis in about 80% of patients. Our experience demonstrates that the accurate selection of the patients undergoing to MT is very important to reach these results.

Effectiveness of medical thoracoscopy and thoracoscopic talc poudrage in patients with exudative pleural effusion

INTRODUCTION

This study aimed to assess the effectiveness of medical thoracoscopy (MT) and thoracoscopic talc poudrage (TTP) in patients with exudative pleural effusion.

METHODS

We evaluated the diagnostic yields, complications and outcomes of MT and TTP in 41 consecutive patients with symptomatic pleural effusions who were planned to undergo both procedures from 1 December 2011 to 30 November 2012. Data was reviewed retrospectively and prospectively up to March 2013.

RESULTS

Among the 41 patients, 36 underwent MT with the intent of biopsy and talc pleurodesis, 2 underwent MT for pleurodesis only and 3 had failed MT. Aetiologies of pleural effusion included lung cancer (n = 14), tuberculosis (n = 9), breast cancer (n = 7), ovarian cancer (n = 2), malignant mesothelioma (n = 1), congestive cardiac failure (n = 1), peritoneal dialysis (n = 1) and hepatic hydrothorax (n = 1); pleural effusion was undiagnosed in five patients. The overall diagnostic yield of MT, and the yield in tubercular and malignant pleural effusions were 77.8%, 100.0% and 82.6%, respectively; it was inconclusive in 22.2%. Complications that occurred were self-limiting, with no procedure-related mortality. The 30-day mortality rate was 17.1%. A total of 15 patients underwent TTP. The 30-, 60- and 90-day success rates were 77.8%, 80.0% and 80.0%, respectively, with one patient having complications (i.e. empyema). The 30-day mortality was 40.0%.

CONCLUSION

MT is a safe procedure with high diagnostic yields in undiagnosed pleural effusions. TTP is an effective method to stop recurrence of pleural effusions.

Pleural effusion: Role of pleural fluid cytology, adenosine deaminase level, and pleural biopsy in diagnosis

Objective:

The present study is designed to evaluate the role of pleural fluid analysis in diagnosing pleural diseases and to study the advantages and disadvantages of thoracocentasis and pleural biopsy.

Materials and Methods:

We prospectively included 66 consecutive indoor patients over a duration of 1 year. Pleural fluid was collected and cytological smears were made from the fluid. Plural biopsy was done in the same patient by Cope needle. Adequate pleural biopsy tissue yielding specific diagnosis was obtained in 47 (71.2%) cases.

Results:

Tuberculosis was the commonest nonneoplastic lesion followed by chronic nonspecific pleuritis comprising 60% and 33.3% of the nonneoplastic cases respectively and tuberculosis was predominantly diagnosed in the younger age group. Majority (70.8%) of malignancy cases were in the age group of >50-70. Adenocarcinoma was found to be the commonest (66.7%) malignant neoplasm in the pleurae followed by small-cell carcinoma (20.8%).

Conclusion:

Pleural biopsy is a useful and minimally invasive procedure. It is more sensitive and specific than pleural fluid smears.

Efficacy and safety of diagnostic thoracoscopy in undiagnosed pleural effusions

BACKGROUND

The differential diagnosis of pleural effusions can present a considerable challenge, and the etiology of pleural effusions varies depending on the population studied.

OBJECTIVE

This study aimed to assess the efficacy and safety of medical thoracoscopy in the diagnosis of patients with undiagnosed pleural effusions in a Chinese population.

METHODS

Between July 2005 and June 2014, medical thoracoscopy (MT) using the semirigid instrument was performed in 833 patients with pleural effusions of unknown etiology in our Institute, where diagnostic thoracocentesis or/and blind pleural biopsy had failed to yield an answer. Demographic, radiographic, procedural, and histological data were recorded and analyzed.

RESULTS

During this 9-year study, satisfactory pleural biopsy samples were obtained in 833 patients, and MT revealed malignant pleural effusion in 342 (41.1%) patients, benign pleural effusion in 429 (51.5%) patients, and 62 (7.4%) patients could not get definite diagnoses. The overall diagnostic efficiency of MT was 92.6% (771/833). After MT, the only severe complication was empyema, seen in 3 patients (0.4%). The most common minor complication was transient chest pain (44.1%) from the indwelling chest tube.

CONCLUSIONS

MT is an effective and safe procedure for diagnosing pleural effusions of undetermined causes. In areas with high tuberculosis prevalence, MT should be particularly helpful in the differential diagnosis of tuberculous pleural effusion.

Utility of semi-rigid thoracoscopy in undiagnosed exudative pleural effusion

Background:

Semi-rigid thoracoscopy is a safe and efficacious procedure in patients with undiagnosed pleural effusion. Literature on its utility from developing countries is limited. We herein describe our initial experience on the utility of semi-rigid thoracoscopy from a tertiary care teaching and referral center in north India. We also perform a systematic review of studies reporting the utility of semi-rigid thoracoscopy from India.

Patients and Methods:

The primary objective was to evaluate the diagnostic utility of semi-rigid thoracoscopy in patients with undiagnosed exudative pleural effusion. Semi-rigid thoracoscopy was performed under local anesthesia and conscious sedation in the bronchoscopy suite.

Results:

A total of 48 patients underwent semi-rigid thoracoscopy between August 2012 and December 2013 for undiagnosed pleural effusion. Mean age was 50.9 ± 14.1 years (range: 17–78 years). Pre-procedure clinico-radiological diagnoses were malignant pleural effusion [36 patients (75%)], tuberculosis (TB) [10 (20.83%) patients], and empyema [2 patients (4.17%)]. Patients with empyema underwent the procedure for pleural biopsy, optimal placement of intercostal tube and adhesiolysis. Thoracoscopic pleural biopsy diagnosed pleural malignancy in 30 (62.5%) patients and TB in 2 (4.17%) patients. Fourteen (29.17%) patients were diagnosed with non-specific pleuritis and normal pleura was diagnosed on a pleural biopsy in 2 (4.17%) patients. Overall, a definitive diagnosis of either pleural malignancy or TB was obtained in 32 (66.7%) patients. Combined overall sensitivity, specificity, positive predictive value and negative predictive value of thoracoscopic pleural biopsy for malignant pleural effusion were 96.77%, 100%, 100% and 66.67%, respectively. There was no procedure-related mortality. On performing a systematic review of literature, four studies on semi-rigid thoracoscopy from India were identified.

Conclusion:

Semi-rigid thoracoscopy is a safe and efficacious procedure in patients with undiagnosed exudative pleural effusions.

Is There a Role for a Needle Thoracoscopic Pleural Biopsy under Local Anesthesia for Pleural Effusions?

Background

A closed pleural biopsy is commonly performed for diagnosing patients exhibiting pleural effusion if prior thoracentesis is not diagnostic. However, the diagnostic yield of such biopsies is unsatisfactory. Instead, a thoracoscopic pleural biopsy is more useful and less painful.

Methods

We compared the diagnostic yield of needle thoracoscopic pleural biopsy performed under local anesthesia with that of closed pleural biopsy. Sixty-seven patients with pleural effusion were randomized into groups A and B. Group A patients were subjected to closed pleural biopsies, and group B patients were subjected to pleural biopsies performed using needle thoracoscopy under local anesthesia.

Results

The diagnostic yields and complication rates of the two groups were compared. The diagnostic yield was 55.6% in group A and 93.5% in group B (p<0.05). Procedure-related complications developed in seven group A patients but not in any group B patients. Of the seven complications, five were pneumothorax and two were vasovagal syncope.

Conclusion

Needle thoracoscopic pleural biopsy under local anesthesia is a simple and safe procedure that has a high diagnostic yield. This procedure is recommended as a useful diagnostic modality if prior thoracentesis is non-diagnostic.

Video assisted rigid thoracoscopy in the diagnosis of unexplained exudative pleural effusion

INTRODUCTION

An undiagnosed exudative pleural effusion is often a difficult diagnostic dilemma that needs further histological study for a definitive etiological diagnosis. Video assisted rigid thoracoscopy is a minimally invasive procedure with a minor morbidity and mortality risk that could resolve this problem.

METHODS

Between January 2010 and December 2011, we performed thoracoscopy in 26 patients for diagnosis of undiagnosed exudative pleural effusion. Clinical and paraclinical data of patients were collected prospectively and analyzed.

RESULTS

Sole pleural effusion was the most common CT scan finding seen in 17 (65.4%) patients. Thoracoscopy was diagnostic in 24 patients (92.3%). The pathologic findings were carcinoma (46.2%), tuberculosis (30.8%) and chronic inflammation without a definitive microbiologic culture (15.4%). Surprisingly mean ADA level in the tuberculosis group was in normal range. No mortality or complication related to our operation was observed.

CONCLUSION

Video assisted thoracoscopy is a minimally invasive procedure with a high definitive diagnostic accuracy in the evaluation of tuberculosis and malignant pleural effusions. Pulmonologist should refer these patients sooner to decrease the waiting period of diagnosis and treatment of such conditions.

Medical thoracoscopy performed under local anesthesia is useful for diagnosing pleural metastasis of renal cell carcinoma

A patient with a past history of renal cell carcinoma (RCC) presented to us with an exudative pleural effusion. Because pleural effusion cytology was inconclusive, we performed medical thoracoscopy under local anesthesia. Multiple white tumors measuring approximately 2 cm in diameter were observed on the parietal pleura. Metastatic carcinoma from RCC was diagnosed histologically. Although malignant effusions are rare in cases of RCC metastasis, clinicians should be aware of this possibility. When pleural effusion cytology is inconclusive in a patient with a past history of RCC, medical thoracoscopy can be useful for making the diagnosis of pleural metastasis.

Clinical-therapeutic management of thoracoscopy in pleural effusion: a groundbreaking technique in the twenty-first century

INTRODUCTION

The aim of this study was to investigate the effectiveness of thoracoscopy in the diagnosis of non-affiliated pleural effusions (PE).

MATERIAL AND METHODS

A five-year prospective study including data from 110 patients that were clinically diagnosed as benign (14.5%), malign (34.5%) and non-affiliated (50.9%). PE in patents without oncology disease and negative biopsy or cytology were considered as benign. Malignant diagnosis was established according to a pleural biopsy, compatible cytology and/or clinical features. Remaining cases were considered as non-affiliated. Thoracoscopy was done under local anaesthesia and sedation.

RESULTS

Thoracoscopy confirmed previous clinical diagnosis of benignity and malignity. Regarding non-affiliated patients, 30.35% were diagnosed after thoracoscopy as unspecific pleuritis, 17.86% mesothelioma and 1.79% pleural tuberculosis (TBC). The other 48.21% of patients reported as non-affiliated were diagnosed with pleural carcinoma. Statistical analysis did not reveal differences between frequencies analysed.

CONCLUSIONS

Our results indicate that thoracoscopy is a cost-effective and reliable technique for obtaining histological diagnosis in PE and also allows a directed pleurodesis if indicated.

Medical thoracoscopy

PURPOSE OF REVIEW

The technique and clinical applications of medical thoracoscopy have substantially evolved in the last few decades. The recent development of a semirigid thoracoscope, which is handled similarly to a bronchoscope, has made this procedure more attractive to pulmonologists. We will review the latest data on clinical applications, recently developed techniques, and safety of medical thoracoscopy, focusing mainly on its role in thoracic malignancies.

RECENT FINDINGS

Recent data confirm the high diagnostic yield of medical thoracoscopy - both with rigid and semirigid instruments - in detecting pleural metastases and determining the origin of pleural effusions. The degree of pleural adhesions found during thoracoscopy has been proposed by some authors as a prognostic factor for survival in patients with malignant pleural effusion. A large prospective multicenter study has established the safety of talc poudrage with large-particle talc, showing no cases of acute respiratory distress syndrome.

SUMMARY

Medical thoracoscopy is an excellent tool to establish diagnosis in patients with exudative pleural effusion of unclear origin. It is highly valuable in clarifying the origin of pleural effusions in patients with lung cancer, as the presence of a malignant pleural effusion is associated with poor survival and precludes the possibility of treatment with curative intention. Pleurodesis with talc poudrage is efficacious and well tolerated, especially with the use of large-particle talc.

The evolving role of interventional pulmonary in the interdisciplinary approach to the staging and management of lung cancer. Part III: diagnosis and management of malignant pleural effusions

The diagnosis and management of a malignant pleural effusion can be one of the most vexing problems faced by physicians and their patients. Lung cancer is the most common primary tumor of origin with a prognosis that is limited, but variable and correlated with performance status (PS). Therefore, with a poor PS and known advanced lung cancer, establishing whether or not an effusion is malignant might not be necessary. Conversely, identifiable subsets of patients will have a much better survival, and establishing a definitive diagnosis could be of critical importance. In the great majority of cases, a diagnosis can be determined by serial thoracenteses with or without closed pleural biopsy. However, thoracoscopy is increasingly being utilized and can expedite the workup by obviating the need for repeated thoracenteses and/or closed pleural biopsy, while in the same setting providing definitive palliative treatment. Although studies comparing diagnostic and treatment strategies are limited, we will present the available data with the intention of providing the practicing oncologist with a practical strategy for the diagnosis and management of malignant pleural effusions due to lung cancer. The interventional pulmonologist can play an important role from diagnosis to palliation, greatly facilitating the care of patients with malignant pleural effusions.

[The indications for and results of video thoracoscopic surgery. Reflections on 152 procedures]

Since thoracoscopy was first described in 1910, its application has been confined mainly to diagnosis and symptomatic treatment of pleural diseases. Recent technological advances in endoscopy and the refinement of surgical technique have brought wider applications, giving rise to video-assisted thoracoscopy (VAT). VAT surgery allows us to view, access and act upon internal thoracic organs without recourse to thoracotomy, thus circumventing inherent risk. We have reviewed our experience from April 1994 through November 1998 in 152 procedures with 141 consecutive patients. Diagnoses were pneumothorax in 94 cases, sympathetic nervous system alteration in 10, diffuse lung disease in 10, lung tumors in 9, pulmonary metastasis in 4, pleural tumors in 5, mediastinal tumors in 2, pericardial effusion in 2, spinal disease in 2 and chronic pancreatitis in 1. No deaths associated with the procedure occurred. The incidence of non-fatal postoperative complication was 11%. The most common complications were prolonged air leak (5%) and bloody pleural effusion (3.5%). The mean length of postoperative hospital care was 3.8 days (range 1 to 18 days). Our experience indicates that VAT is increasingly used to diagnose and treat a variety of chest lesions. Complications are fewer than in procedures in which thoracotomy is needed. Prolonged air leakage does not occur significantly more often with VAT than with thoracotomy. VAT is apparently safe and is particularly useful in some situations, as postoperative morbidity is low and clinical tolerance good.

Medical thoracoscopy in the diagnosis of unexplained pleural effusion

Approximately 20% of pleural effusions remain without an established aetiology after evaluation. Thoracoscopy has a very high sensitivity for the diagnosis of both benign and malignant diseases and greatly increases the diagnostic yield for pleural effusion. We sought to evaluate the diagnostic yield and safety of medical thoracoscopy at this institution. The records of all patients undergoing medical thoracoscopy for the evaluation of undiagnosed pleural effusion between 1990 and 1996 were reviewed. The procedure was performed under local anaesthesia with sedation using a Stortz rigid thoracoscope. Fifty-eight patients had thoracoscopy, most having had two (range: 1-6) non-diagnostic pleural aspirations and biopsies of the pleura. Nineteen patients were found to have mesothelioma and nine metastatic malignancy. Three patients were considered likely to have tuberculous pleural disease, six had asbestos related benign pleural fibrosis and three post-cardiotomy syndrome. There was one chylous effusion of uncertain aetiology, one posttraumatic and two other benign effusions, both of which resolved without clear aetiology. On seven occasions the pleural space could not be adequately accessed, but none of these patients had prior computerized tomography (CT) or ultrasound of the pleural space. There were five false negative diagnoses of malignancy, but no false positives. The diagnostic sensitivity for pleural malignancy was 85% and specificity 100%. There were no major complications, but four patients had late tumour seeding at the thoracoscopy site. Medical thoracoscopy is a safe procedure with a high diagnostic yield. Pre-operative evaluation of the pleural collection using ultrasound or CT increases the likelihood of successful access to the pleural space and may increase diagnostic yield.

Diagnostic thoracoscopy

Thoracoscopy provides diagnosis of pleural diseases with a high degree of accuracy. Moreover, this procedure allows a careful pleural staging of the disease, in particular for pleural cancer, which is important for the prognosis and therapeutic decision. This article focuses on the technique, indications, and results of medical thoracoscopy.

Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax

We performed thoracoscopic wedge resections of blebs with a stapling device under local anesthesia with sedation in 34 consecutive patients who presented with spontaneous pneumothoraces. The indications for surgery included the absence of parietal pleural adhesions and knowledge of the precise bleb location prior to the procedure. Prior to surgery, 0.5% lidocaine was administered into the pleural space, and IV butorphanol tartrate and diazepam were administered to reduce pain and anxiety during the procedure. In our series, the thoracoscopic procedure resulted in favorable outcomes in all but two patients. There was no evidence of hemodynamic instability or arterial blood gas abnormalities encountered during the procedure. Minor postoperative complications were seen in only three patients (two with air leakage and one with transient atelectasis). One patient had a recurrence of his spontaneous pneumothorax 3 months following the procedure. Therefore, the overall success rate was 91%. We compared the results of this therapeutic modality (group 1) with those of 38 patients who underwent the procedure under general anesthesia (group 2) during the same period. The length of hospital stay was shorter in group 1 than in group 2 (4.5 +/- 1.3 vs 5.8 +/- 1.1 days; p < 0.01). Thoracoscopic wedge resections under local anesthesia are safe and offer the benefit of shorter hospital stays. We believe that this thoracoscopic technique will further simplify the surgical treatment of pneumothoraces without incremental risks.

[The so-called malignant pleural effusion: a new review of direct data obtained with diagnostic pleuroscopy]

We analyze a series of 896 thoracoscopies for pleural effusion, of which 78% (662/896) were due to pleural carcinomatosis, primary or metastatic. Pleural malignancy was observed mainly, in the right hemithorax (65%), arising from tumors within the diaphragm. The likelihood of finding pleural metastasis in lung cancer was 77%. When the pleural effusion is slight (less than 500 ml) the likelihood falls to 22%. We therefore advise thoracoscopy in the former and thoracotomy in the latter. Blood-stained effusion continues to have the worst prognosis (84% stemming from metastasis) and signifies an advanced stage of pleural metastasis. The pleura parietal is involved in 69% of pleural carcinomatosis cases, and in 80% when the lower hemithorax or the area around breast or lung tumors are involved. The cytology yield was 45.9%, though always depending on extent of metastasis. When metastasis was slight, the likelihood of positive cytology was less (19%) and when metastasis was generalized throughout the entire pleura the likelihood increased to 73%. We found no reason to think that the cells in most pleural liquids are able to nest and form tumoral niches. The origin of such cell nests was rather found to be in shedding from the metastases themselves, from lung tumors or from carcinomatous lymphangitis by lymphatic obstruction. The diagnostic yield of thoracoscopy once again proved to be superior to that of pleural biopsy.

[Videothoracoscopy in the surgical treatment of pneumothorax: report of 46 cases]

We report our 3-years experience with video-thoracoscopy for pneumothorax. Forty-six endoscopies (34 men, 12 women; mean age 27 +/- 9 years) were performed. Patients were under general anesthesia and intubation was selective. The conventional approach was used, with 3 incisions through which the camera and endoscopic instruments were inserted. Results were good in 39 (84.7%) patients. Pneumothorax recurred in 4 (8.7%) patients during the 3 years of follow-up. Thoracotomy was performed in 3 patients, because of lack of lung expansion in 1, persistent leak in another and encapsulated empyema in the third. Mean hospital stay after surgery was 7.3 days. Video-thoracoscopy can be considered a good therapeutic alternative to thoracotomy in the surgical treatment of patients with pneumothorax.

Pleuroscopy: therapeutic applications

Pleuroscopy is mostly regarded as a diagnostic procedure. Although therapeutic uses of pleuroscopy were popular when pulmonary tuberculosis was common, they are less well known today. This review of modern therapeutic pleuroscopy is based on both personal experience and previous reports. We have grouped the purposes of therapeutic pleuroscopy as 1) to provoke formation of pleural adhesions in the management of pleural effusion, recurrent pneumothorax, chylothorax or (in selected cases) empyema, 2) to divide adhesions in persistent pneumothorax, 3) to perform pleural toilet in the fibrinopurulent stage of empyema, 4) to retrieve foreign bodies, and 5) to achieve haemostasis and removal of clotted blood following operation or trauma. These applications of pleuroscopy should be studied and popularized so that the method can attain recognition as a revived therapeutic procedure.

[Correlation between sensitivity of the cytogenetic and cytological analysis and thoracoscopic findings in the study of malignant pleural effusions]

We studied 104 patients with pleural effusion. All underwent thoracoscopic exploration to allow direct examination of any pleural lesions present. At the same time pleural biopsies for histopathologic study and samples of pleural fluid for cytopathologic and cytogenetic study were taken. The volume of fluid in pleural cavity was also measured. The aims of the study were: a) to evaluate the sensitivity of cytogenetic analysis and cytopathology, both separately and together, and b) to look for a correlation between the sensitivity of these cell studies and the following thoracoscopic findings: tissue biopsy of pleural neoplasms, volume of pleural effusion and extension of neoplastic lesions in the pleural cavity. Seventeen of the pleural liquids studied were benign and 87 were neoplastic. Cytopathology was sensitive in 55% of the neoplastic cases and cytogenetic study was sensitive in 49%. Sensitivity rose to 74% when both techniques were applied. Cytogenetic study yielded a higher percentage of correct diagnoses in the group with hematologic neoplasia, whereas cytopathology was correct more often in cases of solid tumors, though these differences were not statistically significant. Use of both techniques resulted in correct diagnosis in 92% of patients with mesotheliomas. The number or correct diagnoses achieved with cytopathology tended to increase with size of macroscopic pleural lesion whereas cytogenetic study was more sensitive in patients with minimal or incipient pleural involvement. There were no statistically significant differences in sensitivity of cytopathology and cytogenetic analysis with regard to volume of pleural effusion.

The impact of thoracoscopy on the management of pleural disease

STUDY OBJECTIVE

To describe the diagnostic efficacy, morbidity, and patient outcome of thoracoscopy; to quantify the direct impact of thoracoscopy on clinical management; and to determine preoperative variables associated with finding malignancy at thoracoscopy to aid patient selection.

DESIGN

Retrospective chart review of consecutive cases of thoracoscopy for pleural disease.

SETTING

Single tertiary medical center.

PATIENTS

One hundred eighty-two consecutive patients who underwent thoracoscopy for pleural disease over a 5-year period (from 1987 through 1992).

MEASUREMENTS AND RESULTS

Final diagnoses were 98 (54%) malignant, 58 (32%) benign, and 26 (14%) idiopathic. Thoracoscopy had a diagnostic sensitivity of 95% for malignancy and 100% for benign disease. Malignancy was shown by thoracoscopy in 27 of 41 (66%) patients who had a preoperative nondiagnostic closed pleural biopsy, and in 24 of 35 (69%) patients who had at least 2 preoperative negative pleural cytologic specimens. Chart review by preestablished criteria showed information obtained from thoracoscopy directly influenced treatment in 155 (85%) patients. Thirty-seven (20%) patients, however, had at least one perioperative complication (15% major, 8% minor). Ten (6%) patients died during the same hospitalization in which a thoracoscopy was performed, although none died within 48 h. There was one thoracoscopy-related death. Sixty-two (34%) patients died within 6 months of thoracoscopy (death by all causes). Forty-seven (48%) patients who had intrathoracic malignancy present at thoracoscopy died within 6 months. Patients found to have malignant pleural disease by thoracoscopy were more likely to have a preoperative history of a malignancy (p = 0.001). Age more than 50 years was associated with finding malignancy at thoracoscopy (p = 0.04). A combined lymphocytic and hemorrhagic effusion was associated with malignancy (p = 0.004). Preoperative pleural data showed that idiopathic effusions had a significantly lower median lactate dehydrogenase (LDH) value (192, which was normal) compared with malignant or benign effusions.

CONCLUSIONS

(1) Thoracoscopy increases yield for malignant and benign disease when thoracentesis and closed pleural biopsy are nondiagnostic. (2) Thoracoscopy directly affects clinical management in 85% of patients. (3) Significant complications can occur in patients receiving tertiary care. (4) For the evaluation of suspected malignant pleural disease, thoracoscopy has its greatest diagnostic yield in older patients who have a history of malignancy and who present with a lymphocytic, hemorrhagic, high LDH effusion.

Contribution of videothoracoscopy to the management of the cancer patient

BACKGROUND

Videothoracoscopy has rapidly become a popular procedure, but its technical feasibility has been emphasized without critically evaluating its role in the management of thoracic disease. To assess the value of videothoracoscopy in the diagnosis and staging of the cancer patient and to determine if it has added to our previous standard approach of thoracoscopy performed with a mediastinoscope without video, we established a prospective database when we initiated videothoracoscopy in January 1992.

METHODS

Patients were offered videothoracoscopy as an alternative to thoracotomy only if other standard approaches (e.g., needle biopsy, mediastinoscopy) were inadequate to diagnose or stage cancer or to restage patients after therapy. Parameters entered and analyzed in a prospective database were patient name; age; sex; past history; indications for videothoracoscopy; procedure type; surgical technique; whether conversion to thoracotomy was necessary, and if so, why; complications; and pathology. A complete case list of thoracoscopies performed in 1991 before videothoracoscopy was available provided historical comparison.

RESULTS

From January 1 to December 31, 1991, 82 patients underwent thoracoscopy using a mediastinoscope for diagnosis and therapy of pleural disease. From January 1 to July 31, 1992, 160 patients (male:female = 81:79; mean age 56 years) had videothoracoscopy; 72 of 160 patients (44%) had procedures that previously would have required thoracotomy: 69 lung wedge resections, one pericardial window, one pleurectomy, one mediastinal node sampling. No major resectional procedures (e.g., lobectomy, esophagectomy) were performed by videothoracoscopy. Twenty-two percent of all patients (35 of 160), and 23% of wedge resection patients (16 of 69) required conversion to thoracotomy because videothoracoscopy was inadequate for diagnosis or staging. Reasons for conversion (multiple reasons in five patients) included further resection required in 23 patients; inability to evaluate lesion in 11; adhesions in five; and inability to tolerate one lung ventilation in two. The chest tube was in place postoperatively for a mean of 2.3 days. Thirty-day postoperative complications included ventilation for > 48 h in one patient; prolonged air leak in one; pneumonia in one; arrhythmia in one; and death from progressive disease in two.

CONCLUSIONS

Although the role of videothoracoscopy in the treatment of primary thoracic malignancies and pulmonary metastases is still undefined, this early experience indicates that videothoracoscopy often enhances the ability to diagnose and stage patients by obviating thoracotomy.

Diagnostic and therapeutic thoracoscopy: techniques and indications in pulmonary medicine

Recently thoracoscopy has been used with increasing frequency for the diagnosis and treatment of pleuropulmonary diseases.

METHODS

The main requirements for thoracoscopy are rigid telescopes, forceps, scissors, stapler and a video recorder. The procedure can be performed either under general anaesthesia with or without double lumen intubation or under neuroleptanalgesia after inducing an artificial pneumothorax. At the end of the procedure a chest tube should always be inserted even if it is only for a few minutes until the lung re-expands after diagnostic thoracoscopy. Complications are exceptional and mortality is less than 0.017%.

INDICATIONS AND RESULTS

Thoracoscopy is useful for diagnosis of a number of lung diseases. For pleural effusion, the sensitivity of thoracoscopy is 92-97% and its specificity is 99%. This is much better than needle pleural biopsy and/or fluid cytology. In malignant mesothelioma, thoracoscopy allows accurate staging. Similarly in spontaneous pneumothorax, classification based on the endoscopic aspects of the lung according to the classification of Vanderschueren allows a better selection of therapeutic alternatives. For diffuse pulmonary diseases, thoracoscopic lung biopsy has a sensitivity ranging from 60-98% depending on whether the underlying disease is sarcoidosis, idiopathic fibrosis, collagenous diseases or other rare diseases. Interventional thoracoscopy is a rapidly expanding domain. In this review the most widespread techniques are summarized. Thoracoscopic pleurodesis is performed for pleural effusion. It can be achieved by talc poudrage but other methods are available. For spontaneous pneumothorax, pleurodesis must be associated with treatment of the causal lesions. The other therapeutic procedures described here are sympathectomy for palmar hyperhidrosis, pulmonary biopsy using an endo-GIA stapler and pericardial biopsy.

Percutaneous visceral pleural biopsy with fenestrated cup biopsy forceps

When there is an exudative pleural effusion often both the parietal and the visceral pleura are affected, but the usual practice is to perform a percutaneous parietal pleural biopsy alone for diagnosis. Percutaneous visceral pleural biopsy was carried out in 20 patients with exudative pleural effusions with fenestrated cup biopsy forceps. In all 20 biopsies pleural tissue was obtained and it was diagnostic in 19 cases. The procedure is painless and appears safe.

Thoracoscopy in the diagnosis and management of recurrent pleural effusions

Between April 1984 and July 1988, 102 patients with persistent or recurrent pleural effusions investigated by conventional methods in whom a diagnosis had not been achieved were submitted to thoracoscopy under general anesthesia. A positive diagnosis was obtained in 80.3% of the patients. The procedure was well tolerated, and although some of these were seriously ill patients, there were no procedure-related deaths.