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Fantin A, Castaldo N, Crisafulli E, Sartori G, Aujayeb A, Vailati P, Morana G, Patrucco F, de Martino M, Isola M, Patruno V. The Role of Medical Thoracoscopy with Talc Poudrage in Spontaneous, Iatrogenic, and Traumatic Pneumothorax: A Prolonged Experience of a Tertiary Care Center. Pulm Ther 2024:10.1007/s41030-024-00268-w. [PMID: 39126456 DOI: 10.1007/s41030-024-00268-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION Medical thoracoscopy is a minimally invasive and safe procedure mostly performed for unexplained exudative pleural effusions but may be considered for pneumothorax (PNX). METHODS This retrospective study included participants affected by PNX who underwent medical thoracoscopy with talc poudrage at a single academic hospital from 2008 to 2021. The primary endpoint was the observation of complete radiographical lung re-expansion and absence of air supply from the chest drain within 7 days of medical thoracoscopy. The secondary endpoint was achieving no recurrence of ipsilateral PNX at 24 months post-discharge. RESULTS A total of 95 patients affected by primary spontaneous PNX (PSP), secondary spontaneous PNX (SSP), iatrogenic, and traumatic PNX were enrolled. An additional procedure was required by 17.89% of patients, and only one patient with SSP required subsequent surgery. Recurrence of PNX occurred on the same side within 24 months after discharge in 9.47% of patients, with a median time to recurrence of 13.5 months. The PSP group was significantly more likely to achieve the primary endpoint. Pleural morphology was significantly associated with reaching the primary endpoint, while receiving a cumulative dose of talc greater than or equal to 4 g during hospitalization was associated with a lower risk of meeting it. Receiving a cumulative dose of talc greater than or equal to 4 g led in all cases to the achievement of the secondary endpoint. Patients with iatrogenic and traumatic PNX had an excellent prognosis in both the short- and long-term evaluation. CONCLUSION Medical thoracoscopy is an effective procedure for treating PNX in the acute setting in selected cases while preventing long-term relapses. Large prospective clinical studies are needed to support and better define the role of medical thoracoscopy in current clinical practice.
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Affiliation(s)
- Alberto Fantin
- Department of Pulmonology, Santa Maria della Misericordia University Hospital, Via Colugna, 33100, Udine, Italy.
| | - Nadia Castaldo
- Department of Pulmonology, Santa Maria della Misericordia University Hospital, Via Colugna, 33100, Udine, Italy
| | - Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giulia Sartori
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Paolo Vailati
- Department of Pulmonology, Santa Maria della Misericordia University Hospital, Via Colugna, 33100, Udine, Italy
| | - Giuseppe Morana
- Department of Pulmonology, Santa Maria della Misericordia University Hospital, Via Colugna, 33100, Udine, Italy
| | - Filippo Patrucco
- Division of Respiratory Diseases, Department of Medicine, Maggiore della Carità University Hospital, Novara, Italy
| | - Maria de Martino
- Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Miriam Isola
- Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Vincenzo Patruno
- Department of Pulmonology, Santa Maria della Misericordia University Hospital, Via Colugna, 33100, Udine, Italy
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Piazzolla M, De Pace CC, Porcel JM, Tondo P. Local Anesthetic Thoracoscopy: A Focus on Indications, Techniques and Complications. Arch Bronconeumol 2024; 60:423-430. [PMID: 38744546 DOI: 10.1016/j.arbres.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/16/2024]
Abstract
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.
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Affiliation(s)
- Michele Piazzolla
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Thoracic Surgery Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Cosimo C De Pace
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Department of Specialistic Medicine, Institute of Respiratory Diseases, University Hospital Policlinico of Foggia, Foggia, Italy.
| | - José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
| | - Pasquale Tondo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Department of Specialistic Medicine, Institute of Respiratory Diseases, University Hospital Policlinico of Foggia, Foggia, Italy
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Panou V, Bhatnagar R, Rahman N, Christensen TD, Pietersen PI, Arshad A, Laursen CB. Advances in the diagnosis and follow-up of pleural lesions: a scoping review. Expert Rev Respir Med 2024; 18:423-434. [PMID: 38995221 DOI: 10.1080/17476348.2024.2375421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/28/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION Pleural lesions may have heterogeneous presentation and causes. In recent years, there have been significant advances in pleural lesions diagnostics. The aim of this review is to provide an overview of the state-of-the-art, and recent updates for diagnostic modalities and monitoring regimes for pleural lesions. AREAS COVERED A literature search was conducted through PubMed and Web of Science for relevant articles published from 1 January 2000- 1 March 2023. This article critically appraises the radiological modalities and biopsy techniques that are employed in pleural lesions diagnostics, including chest radiography, thoracic ultrasound, computed tomography, F-fluorodeoxyglycose positron emission tomography, magnetic resonance imaging, percutaneous, and thoracoscopic pleural biopsies with reference to their strengths, limitations, and clinical use. The review asserts also the available literature regarding monitoring algorithms. EXPERT OPINION Despite the recent advances in the field, there are several key areas for improvement, including the development and validation of minimal invasive methods and tools for risk stratification, the integration of multi-omics technologies, the implementation of standardized, evidence-based diagnostic and monitoring guidelines and increased focus on research and patient-centric approaches. The broad establishment of dedicated pleural clinics may significantly assist toward this direction.
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Affiliation(s)
- Vasiliki Panou
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN) - Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rahul Bhatnagar
- Odense Respiratory Research Unit (ODIN) - Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Respiratory Medicine Department, North Bristol National Health Service Trust, Southmead Hospital, Bristol, UK
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Najib Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Pleural Unit, Churchill Hospital, Oxford, UK
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery & Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Pia Iben Pietersen
- Department of Radiology, Odense University Hospital, Odense, Denmark
- UNIFY - Research and Innovation Unit of Radiology, University of Southern Denmark, Odense, Denmark
| | - Arman Arshad
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN) - Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Ferguson J, Tsim S, Kelly C, Alexander L, Shad S, Neilly M, Tate M, Zahra B, Saleh M, Cowell G, Banks E, Grundy S, Corcoran J, Downer N, Stanton A, Evison M, Rahman NM, Maskell N, Blyth KG. Staging by Thoracoscopy in potentially radically treatable Lung Cancer associated with Minimal Pleural Effusion (STRATIFY): protocol of a prospective, multicentre, observational study. BMJ Open Respir Res 2023; 10:e001771. [PMID: 37996118 PMCID: PMC10668291 DOI: 10.1136/bmjresp-2023-001771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 10/27/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Recurrence rate following radical therapy for lung cancer remains high, potentially reflecting occult metastatic disease, and better staging tools are required. Minimal pleural effusion (mini-PE) is associated with particularly high recurrence risk and is defined as an ipsilateral pleural collection (<1/3 hemithorax on chest radiograph), which is either too small to safely aspirate fluid for cytology using a needle, or from which fluid cytology is negative. Thoracoscopy (local anaesthetic thoracoscopy (LAT) or video-assisted thoracoscopic surgery (VATS)) is the gold-standard diagnostic test for pleural malignancy in patients with larger symptomatic effusions. Staging by Thoracoscopy in potentially radically treatable Lung Cancer associated with Minimal Pleural Effusion (STRATIFY) will prospectively evaluate thoracoscopic staging in lung cancer associated-mini-PE for the first time. METHODS AND ANALYSIS STRATIFY is a prospective multicentre observational study. Recruitment opened in January 2020. The primary objective is to determine the prevalence of detectable occult pleural metastases (OPM). Secondary objectives include assessment of technical feasibility and safety, and the impact of thoracoscopy results on treatment plans, overall survival and recurrence free survival. Inclusion criteria are (1) suspected/confirmed stages I-III lung cancer, (2) mini-PE, (3) Performance Status 0-2 (4), radical treatment feasible if OPM excluded, (5) ≥16 years old and (6) informed consent. Exclusion criteria are any metastatic disease or contraindication to the chosen thoracoscopy method (LAT/VATS). All patients have LAT or VATS within 7 (±5) days of registration, with results returned to lung cancer teams for treatment planning. Following an interim analysis, the sample size was reduced from 96 to 50, based on a lower-than-expected OPM rate. An MRI substudy was removed in November 2022 due to pandemic-related site setup/recruitment delays. These also necessitated a no-cost recruitment extension until October 2023. ETHICS AND DISSEMINATION Protocol approved by the West of Scotland Research Ethics Committee (Ref: 19/WS/0093). Results will be published in peer-reviewed journals and presented at international meetings. TRIAL REGISTRATION NUMBER ISRCTN13584097.
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Affiliation(s)
- Jenny Ferguson
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Selina Tsim
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Caroline Kelly
- Cancer Research UK Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Laura Alexander
- Cancer Research UK Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Shumaila Shad
- Cancer Research UK Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Mark Neilly
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Matthew Tate
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Baryab Zahra
- Glasgow Clinical Research Facility, Queen Elizabeth University Hospital, Glasgow, UK
| | - Merna Saleh
- Glasgow Clinical Research Facility, Queen Elizabeth University Hospital, Glasgow, UK
| | - Gordon Cowell
- Department of Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Elspeth Banks
- Cancer Research UK Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Seamus Grundy
- Department of Respiratory Medicine, Salford Royal Hospital, Salford, UK
| | - John Corcoran
- Interventional Pulmonology Service, Department of Respiratory Medicine, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Nicola Downer
- Department of Respiratory Medicine, King's Mill Hospital, Sutton-in-Ashfield, UK
| | - Andrew Stanton
- Department of Respiratory Medicine, Freeman Hospital, Newcastle, UK
| | - Matthew Evison
- Department of Respiratory Medicine, University Hospital of South Manchester, Manchester, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
| | - Nick Maskell
- Bristol Medical School, University of Bristol Academic Respiratory Unit, Bristol, UK
| | - Kevin G Blyth
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
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Dos Santos GMF, Gupta A, Souza CA, Bayanati H. Review of Image-Guided Pleural Interventions. Semin Roentgenol 2023; 58:454-462. [PMID: 37973274 DOI: 10.1053/j.ro.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/19/2023] [Indexed: 11/19/2023]
Affiliation(s)
| | - Ashish Gupta
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Carolina A Souza
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Hamid Bayanati
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
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Ishii S, Ishida A, Sugiura Y, Takasaki J, Izumi S, Hojo M. Examination of the utility of cryobiopsy for tuberculous pleurisy in thoracoscopy: A report of seven cases. Respir Med Case Rep 2023; 43:101840. [PMID: 37064571 PMCID: PMC10091113 DOI: 10.1016/j.rmcr.2023.101840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/12/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023] Open
Abstract
Thoracoscopy under local anaesthesia is effective for the diagnosis of tuberculous pleurisy (TP), mesothelioma and pleural metastases of lung cancer, etc. It has recently been reported that cryobiopsy is useful for obtaining sufficient tissue, achieving a greater depth, and avoiding crush artefact than biopsy forceps. However, the utility of the tissue obtained by cryobiopsy for culture for diagnosing TP is unknown. We compared positivity rates of tissue culture obtained by biopsy forceps and cryobiopsy in seven TP patients. The median tissue size was 2 mm by biopsy forceps and 6 mm by cryobiopsy. The pathological diagnostic rate of pleural tissue was 85.7% with biopsy forceps and 100% with cryobiopsy. However, the positivity rate of tissue culture was 57.1% with biopsy forceps and 28.5% with cryobiopsy. Since rapid freezing with a cryoprobe makes it difficult for bacteria to grow, it is possible that cryobiopsy might not be useful for obtaining a tissue culture in TP cases. However, since the sample size of this study was small, analysis of more cases is required to confirm our results.
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Eze NJ, Nwagboso CI, Ogbudu SO, Chidiebere E, Bassey OO, Etiuma AU. Diagnostic role of video-assisted thoracoscopy in the management of indeterminate pleural effusion. Niger J Clin Pract 2022; 25:1978-1983. [PMID: 36537454 DOI: 10.4103/njcp.njcp_311_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The management of pleural effusion usually involves the drainage of the effusion, identification, and treatment of the underlying cause (s). Studies have shown that the initial diagnostic techniques do not give conclusive diagnosis in some cases of pleural effusion. This group of patients described as patients with indeterminate or undiagnosed pleural effusion constitutes a significant proportion of patients with pleural effusion in clinical practice. In this study, we examined the role of video-assisted thoracoscopy (VAT) in the diagnostic work-up of these patients. AIM To determine the diagnostic outcome of VAT in the management of indeterminate pleural effusion in our center. PATIENTS AND METHODS Consecutive patients who presented with pleural effusions and who met the inclusion criteria had video-assisted thoracoscopy for diagnostic purposes. Outcome measures including the diagnostic yield, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAT in patients with indeterminate pleural effusion, duration of the procedure, duration of hospitalization after the procedure, and complications for all the patients were documented and analyzed. RESULTS Of the 22 patients with indeterminate pleural effusion, conclusive diagnosis was obtained in 18 (81.8%) with a sensitivity of 91.7% [95% confidence interval (CI); 61.5-99.8%], specificity of 100% (95% CI; 69.1-100%), PPV of 100% (95% CI; 0-100%), and NPV of 90.9% (95% CI; 60.5-98.5%) for malignancy and a sensitivity of 78% (95% CI; 40-97%), a specificity of 100% (95% CI; 75.3-100%), PPV of 100% (95% CI; 0-100%), and NPV of 86.7% (95% CI; 65.7-95.7%) for tuberculosis. CONCLUSION Our results show that video-assisted thoracoscopy plays a useful role in our center in obtaining diagnosis in patients with indeterminate pleural effusion.
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Affiliation(s)
- N J Eze
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - C I Nwagboso
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - S O Ogbudu
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - E Chidiebere
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - O O Bassey
- Department of Surgery, University of Calabar Teaching Hospital Calabar, Calabar, Cross River State, Nigeria
| | - A U Etiuma
- Department of Surgery, University of Calabar and University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria
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Possible Role of Chest Ultrasound in the Assessment of Costo-Phrenic Angle Lesions Prior to Medical Thoracoscopy: A Retrospective Pilot Case Series. Diagnostics (Basel) 2022; 12:diagnostics12112587. [PMID: 36359431 PMCID: PMC9689413 DOI: 10.3390/diagnostics12112587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Pleural malignancy (PM) and malignant pleural effusion (MPE) represent an increasing burden of diseases. Costo-phrenic angle (CPA) could be involved by malignant small nodularities or thickenings in the case of MPE. The aim of this study was to evaluate whether lung ultrasound (LUS), performed prior to medical thoracoscopy (MT), could detect pleural abnormalities in CPA not easily detectable by chest computed tomography scan (CCT). Methods: Patients suspected for PM and MPE were retrospectively recruited. Patients underwent both LUS examination with a linear array and CCT prior to diagnostic medical thoracoscopy. LUS pathological findings in CPA were compared with pathological findings detected by CCT. Findings were confirmed by subsequent MT, the gold standard for PMs. Results: Twenty-eight patients were recruited. LUS detected 23 cases of pleural abnormalities in CPA. CCT was detected 12 pleural abnormalities. Inter-rater agreement between the two techniques was minimal (Cohen’s Kappa: 0.28). MT detected PMs in CPA in 22 patients. LUS had a sensitivity of 100% and specificity of 83%. CCT had a sensitivity of 54% and specificity of 100%. A better sensitivity for CCT was reached analysing only all abnormalities > 5 mm (64.3%). Conclusions: LUS examination, in the case of PMs, could change and speed up diagnostic workup.
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Chang CH, Ost DE. Malignant pleural disease: a pragmatic guide to diagnosis. Curr Opin Pulm Med 2022; 28:282-287. [PMID: 35749791 DOI: 10.1097/mcp.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The diagnosis of malignant pleural disease is important in the care of patients with cancer. However, a one-size-fits-all approach to diagnosis may lead to delays in care as the sensitivity of each biopsy modality varies and can be dependent on the tumor type. We review current literature on pleural biopsy techniques and propose a diagnostic algorithm for suspected malignant pleural disease. RECENT FINDINGS Recent literature has shown that the sensitivity of pleural fluid cytology varies based on tumor type resulting in a limited value of repeated thoracenteses in many cases. Furthermore, the ability to test for molecular biomarkers on pleural fluid samples has contributed to the recommendations to send large volumes of pleural fluid for analysis. Studies have also supported the consideration of medical thoracoscopy earlier in the diagnostic work-up of malignant pleural disease. SUMMARY The decision to repeat a diagnostic thoracentesis when suspecting malignant pleural effusions should take into account the primary tumor type. Open pleural biopsy with medical thoracoscopy has been shown to be a relatively safe diagnostic modality with high sensitivity and should be considered in patients with a nondiagnostic thoracentesis.
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Affiliation(s)
- Christopher H Chang
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Deschuyteneer EP, De Keukeleire T. Diagnostic value and safety of thoracoscopic pleural biopsies in pleural exudative effusions of unknown origin, including follow-up. BMJ Open Respir Res 2022; 9:9/1/e001161. [PMID: 35277425 PMCID: PMC8919466 DOI: 10.1136/bmjresp-2021-001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/28/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Pleural exudative effusions without diagnosis after initial work up are a frequent problem in any respiratory division. Several ways to obtain pleural biopsy exist. Thoracoscopy is one of the most frequently used. Differential diagnosis mainly exists out of malignant pleuritis, tuberculosis, nonspecific pleuritis and rarely systemic or autoimmune disease. We performed a retrospective data analysis of our almost 10-year period experience, the first Belgian data to be published. METHODS We performed a retrospective data analysis of all patients with unexplained pleural exudates who underwent diagnostic medical thoracoscopy under general anaesthesia in our respiratory department during the period 2006-2015. We report on diagnoses made, sensitivity and specificity, safety of thoracoscopy and follow-up of patients after thoracoscopy. RESULTS 131 patients underwent diagnostic medical thoracoscopy during the inclusion period. 44.3% (n=58) of the patients were diagnosed with malignant pleuritis, 45.0% (n=59) with nonspecific pleuritis, 7.6% (n=10) with tuberculous pleuritis and some with other benign conditions. Complications are comparable to other data published. Six months follow-up of patients with non-specific pleuritis reveal 8.5% (n=5) of these patients to have malignant pleuritis, and another 8.5% (n=5) with infectious or other benign conditions. CONCLUSION Medical thoracoscopy under general anaesthesia for diagnostic work up of pleural exudates of unknown origin generally has a high diagnostic yield. It is generally safe, certainly compared with the information it delivers. During follow-up, minority of patients with nonspecific pleuritis will prove to be malignant in origin, benign or autoimmune disease related.
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Affiliation(s)
- Evan Patrick Deschuyteneer
- Respiratory Division, AZ Sint-Elisabeth Ziekenhuis Zottegem vzw, Zottegem, Belgium .,Intensive Care Unit, AZ Sint-Elisabeth Ziekenhuis Zottegem vzw, Zottegem, Belgium
| | - Tom De Keukeleire
- Respiratory Division, AZ Sint-Elisabeth Ziekenhuis Zottegem vzw, Zottegem, Belgium.,Respiratory Division, UZ Brussel, Brussel, Belgium
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Grott M, Eichhorn M, Eichhorn F, Schmidt W, Kreuter M, Winter H. Thoracic surgery in the non-intubated spontaneously breathing patient. Respir Res 2022; 23:379. [PMID: 36575519 PMCID: PMC9793515 DOI: 10.1186/s12931-022-02250-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 11/12/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The interest in non-intubated video-assisted thoracic surgery (NIVATS) has risen over the last decade and numerous terms have been used to describe this technique. They all have in common, that the surgical procedure is performed in a spontaneously breathing patient under locoregional anaesthesia in combination with intravenous sedation but have also been performed on awake patients without sedation. Evidence has been generated favouring NIVATS compared to one-lung-ventilation under general anaesthesia. MAIN BODY We want to give an overview of how NIVATS is performed, and which different techniques are possible. We discuss advantages such as shorter length of hospital stay or (relative) contraindications like airway difficulties. Technical aspects, for instance intraoperative handling of the vagus nerve, are considered from a thoracic surgeon's point of view. Furthermore, special attention is paid to the cohort of patients with interstitial lung diseases, who seem to benefit from NIVATS due to the avoidance of positive pressure ventilation. Whenever a new technique is introduced, it must prove noninferiority to the state of the art. Under this aspect current literature on NIVATS for lung cancer surgery has been reviewed. CONCLUSION NIVATS technique may safely be applied to minor, moderate, and major thoracic procedures and is appropriate for a selected group of patients, especially in interstitial lung disease. However, prospective studies are urgently needed.
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Affiliation(s)
- Matthias Grott
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Martin Eichhorn
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Florian Eichhorn
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Werner Schmidt
- grid.5253.10000 0001 0328 4908Department of Anaesthesiology and Intensive Care Medicine, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany
| | - Michael Kreuter
- Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany ,grid.5253.10000 0001 0328 4908Center for Interstitial and Rare Lung Diseases, Pneumology Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany
| | - Hauke Winter
- grid.5253.10000 0001 0328 4908Department of Thoracic Surgery, Thoraxklinik, University Hospital Heidelberg, Roentgenstrasse 1, 69126 Heidelberg, Germany ,Translational Lung Research Centre Heidelberg (TLRC-H), German Centre for Lung Research (DZL), Heidelberg, Germany
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Abstract
Medical thoracoscopy is an effective and safe modality to visualize and sample contents of the pleural cavity. It is an outpatient procedure that can be performed while the patient is spontaneously breathing, with the use of local anesthesia and intravenous medications for sedation and analgesia. Medical thoracoscopy has indications in the management of a variety of pleural diseases. It is most commonly performed as a diagnostic procedure but has therapeutic applications as well. Although it has its advantages, management strategies of certain pleural diseases should take place within a multidisciplinary environment including general pulmonologists, interventional pulmonologists, and thoracic surgeons.
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Kostroglou A, Kapetanakis EI, Rougeris L, Froudarakis ME, Sidiropoulou T. Review of the Physiology and Anesthetic Considerations for Pleuroscopy/Medical Thoracoscopy. Respiration 2021; 101:195-209. [PMID: 34518491 DOI: 10.1159/000518734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/22/2021] [Indexed: 11/19/2022] Open
Abstract
Pleuroscopy or medical thoracoscopy is the second most common utilized procedure after bronchoscopy in the promising field of interventional pulmonology. Its main application is for the diagnosis and management of benign or malignant pleural effusions. Entry into the hemithorax is associated with pain and patient discomfort, whereas concurrently, notable pathophysiologic alterations occur. Therefore, frequently procedural sedation and analgesia is needed, not only to alleviate the patient's emotional stress and discomfort by mitigating the anxiety and minimizing the pain but also for yielding better procedural conditions for the operator. The scope of this review is to present the physiologic derangements occurring in pleuroscopy and compare the various anesthetic techniques and sedative agents that are currently being used in this context.
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Affiliation(s)
- Andreas Kostroglou
- 2nd Department of Anesthesiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Emmanouil I Kapetanakis
- Department of Thoracic Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Loizos Rougeris
- 2nd Department of Anesthesiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marios E Froudarakis
- Department of Respiratory Medicine, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Tatiana Sidiropoulou
- 2nd Department of Anesthesiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Dorry M, Davidson K, Dash R, Jug R, Clarke JM, Nixon AB, Mahmood K. Pleural effusions associated with squamous cell lung carcinoma have a low diagnostic yield and a poor prognosis. Transl Lung Cancer Res 2021; 10:2500-2508. [PMID: 34295657 PMCID: PMC8264347 DOI: 10.21037/tlcr-21-123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/22/2021] [Indexed: 01/01/2023]
Abstract
Background Malignant pleural effusion (MPE) portends a poor prognosis in non-small cell lung cancer (NSCLC). However, the yield of pleural fluid cytology as well as survival of patients with MPE associated with squamous cell carcinoma versus adenocarcinoma is not well understood. We conducted this study to assess the diagnostic yield of pleural cytology and survival of patients with NSCLC related MPE. Methods We performed a single-center, retrospective analysis of patients with NSCLC related MPE between 2010 and 2017. Kaplan-Meier method was used to compare survival and Cox proportional hazards analysis to assess if squamous cell cytopathology was associated with mortality. Results We identified 277 patients, 29 with squamous cell and 248 with adenocarcinoma MPE. Pleural fluid cytology from initial thoracentesis was diagnostic in 13.8% (4/29) patients with squamous cell and 80.2% (199/248) with adenocarcinoma (P<0.001). Cytology from second thoracentesis was diagnostic in 13.3% (2/15) patients with squamous cell carcinoma, compared to 37.5% (12/32) with adenocarcinoma (P=0.17). There was no statistically significant difference in the pleural biopsy yield from medical pleuroscopy or video-assisted thoracoscopic surgery (VATS) in the two groups. The median survival of patients with squamous cell MPE was 112 [interquartile range (IQR): 44-220] days versus 194 (IQR: 54-523) days in adenocarcinoma (Log-rank test P=0.04). Multivariate Cox proportional hazards analysis showed that squamous cell cytopathology was independent predictor of mortality (hazard ratio for death of 1.73, 95% CI: 1.1-2.6; P=0.01). Conclusions Pleural fluid cytology has a low diagnostic yield in squamous cell carcinoma MPE, and these patients have a poor survival compared to lung adenocarcinoma.
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Affiliation(s)
- Michael Dorry
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC, USA
| | - Kevin Davidson
- Department of Medicine, WakeMed Hospital, Raleigh, NC, USA
| | - Rajesh Dash
- Department of Pathology, Duke University, Durham, NC, USA
| | - Rachel Jug
- Department of Pathology, Duke University, Durham, NC, USA
| | - Jeffrey M Clarke
- Division of Thoracic Oncology, Department of Medicine, Duke University, Durham, NC, USA
| | | | - Kamran Mahmood
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC, USA
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15
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Gu Q, Deng X, Li Z, Wang J, Hu C, Lei S, Cai X. The Intrapleural Bridge Connection is One of the Reasons for Unknown Localized Pleural Adhesion. Int J Gen Med 2021; 14:1429-1435. [PMID: 33907447 PMCID: PMC8068496 DOI: 10.2147/ijgm.s299606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background Simple signs of local pleural adhesion are often found in people during a physical examination. In the present study, we aimed to clarify whether the merely localized pleural adhesion was just caused by previous pleural inflammation or physiological variation. Materials and Methods Chest X-ray image materials were collected to analyze the incidence of simple pleural adhesions. Moreover, the causes of these simple pleural adhesions were further analyzed using thoracoscopy under direct vision and biopsy data. Results In all 2218 chest X-ray images, 68 cases were found to have pleural lesions (3.07%), including 15 cases of localized pleural adhesion only. Subsequently, we analyzed the characteristics of 70 cases of pleural lesions using thoracoscopy. In two lung cancer patients with pleural metastasis, we found an unusual pleural junction. This connective strip was smooth and free of inflammation, resembling the normal pleura. Conclusion Some of these purely localized pleural adhesions might be attributed to previous inflammation. However, there was still at least a possibility that there must be a physiological pleural junction, which could be the cause of the purely localized pleural adhesion shown in the chest radiograph.
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Affiliation(s)
- Qihua Gu
- Department of Respiratory Medicine, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People's Republic of China.,Key Cite of National Clinical Research Center for Respiratory Disease, Changsha, Hunan Province, 410008, People's Republic of China
| | - Xinhao Deng
- Department of Respiratory Medicine, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People's Republic of China.,Key Cite of National Clinical Research Center for Respiratory Disease, Changsha, Hunan Province, 410008, People's Republic of China
| | - Zhao Li
- Department of Respiratory Medicine, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People's Republic of China.,Key Cite of National Clinical Research Center for Respiratory Disease, Changsha, Hunan Province, 410008, People's Republic of China
| | - Jing Wang
- Department of Pathology, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People's Republic of China
| | - Chengping Hu
- Department of Respiratory Medicine, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People's Republic of China.,Key Cite of National Clinical Research Center for Respiratory Disease, Changsha, Hunan Province, 410008, People's Republic of China
| | - Shuhua Lei
- Department of Respiratory Medicine, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People's Republic of China.,Key Cite of National Clinical Research Center for Respiratory Disease, Changsha, Hunan Province, 410008, People's Republic of China
| | - Xiaoling Cai
- Department of Respiratory Medicine, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People's Republic of China.,Key Cite of National Clinical Research Center for Respiratory Disease, Changsha, Hunan Province, 410008, People's Republic of China
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16
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Gokce M, Altinsoy B, Piskin O, Bahadir B. Uniportal VATS pleural biopsy in the diagnosis of exudative pleural effusion: awake or intubated? J Cardiothorac Surg 2021; 16:95. [PMID: 33879212 PMCID: PMC8056594 DOI: 10.1186/s13019-021-01461-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 04/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background The aim of this study is to compare the diagnostic efficacy and safety of video-assisted thoracoscopic surgery (VATS) with awake VATS (AVATS) pleural biopsy in undiagnosed exudative pleural effusions. Methods The diagnostic efficacy of pleural biopsy by uniportal VATS under general anesthesia or AVATS under local anesthesia and sedation performed by the same surgeon in patients with undiagnosed exudative pleural effusion between 2007 and 2020 were retrospectively evaluated. Test sensitivity, specificity, positive predictive value and negative predictive value were compared as well as age, gender, comorbidities, procedure safety, additional pleural-based interventions, duration time of operation and length of hospital stay. Results Of 154 patients with undiagnosed exudative pleural effusion, 113 (73.37%) underwent pleural biopsy and drainage with VATS, while 41 (26.62%) underwent AVATS pleural biopsy. Sensitivity, specificity, positive predictive value and negative predictive value were 92, 100, 100, and 85.71% for VATS, and 83.3, 100, 100, and 78.9% for AVATS, respectively. There was no significant difference in diagnostic test performance between the groups, (p = 0.219). There was no difference in the rate of complications [15 VATS (13.3) versus 4 AVATS (9.8%), p = 0.557]. Considering additional pleural-based interventions, while pleural decortication was performed in 13 (11.5%) cases in the VATS group, no pleural decortication was performed in AVATS group, (p = 0.021). AVATS group was associated with shorter duration time of operation than VATS (22.17 + 6.57 min. Versus 51.93 + 8.85 min., p < 0.001). Length of hospital stay was relatively shorter in AVATS but this was not statistically significant different (p = 0.063). Conclusions Our study revealed that uniportal AVATS pleural biopsy has a similar diagnostic efficacy and safety profile with VATS in the diagnosis and treatment of patients with undiagnosed pleural effusion who have a high risk of general anesthesia due to advanced age and comorbidities. Accordingly, uniportal AVATS pleural biopsy may be considered in the diagnosis and treatment of all exudative undiagnosed pleural effusions.
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Affiliation(s)
- Mertol Gokce
- Department of Thoracic Surgery, Bulent Ecevit University Faculty of Medicine, Zonguldak, Turkey.
| | - Bulent Altinsoy
- Department of Pulmonary Medicine, Bulent Ecevit University Faculty of Medicine, Zonguldak, Turkey
| | - Ozcan Piskin
- Department of Anesthesiology and Reanimation, Bulent Ecevit University Faculty of Medicine, Zonguldak, Turkey
| | - Burak Bahadir
- Department of Pathology, Bulent Ecevit University Faculty of Medicine, Zonguldak, Turkey
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17
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Velagapudi RK, Egan JP. Thoracic Endometriosis: a Clinical Review and Update of Current and Evolving Diagnostic and Therapeutic Techniques. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-021-00269-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Abstract
Purpose of Review
The goal of this review is to provide a comprehensive understanding of the pathophysiology, clinical presentation, diagnostic workup, and clinical management of thoracic endometriosis (TE), as well as highlight our personal experience with TE workup and management.
Recent Findings
TE can present in a wide range of clinical manifestations. Without high clinical suspicion, diagnosis can be delayed. Since no specific laboratory testing is available, diagnosis is often based on careful history taking, imaging, and direct visualization of endometrial lesions through video-assisted thoracoscopic surgery (VATS). Medical thoracoscopy (MT) may also be a useful tool in the diagnostic workup of TE.
Summary
The diagnosis and management of TE require a multidisciplinary approach and a high index of clinical suspicion. While VATS remains the gold standard for diagnosis, we share our experience using MT to diagnose and manage a case of TE-related hemothorax.
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18
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Diagnostics in Pleural Disease. Diagnostics (Basel) 2020; 10:diagnostics10121046. [PMID: 33291748 PMCID: PMC7761906 DOI: 10.3390/diagnostics10121046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 02/08/2023] Open
Abstract
Pleural disease diagnostics represent a sprawling topic that has enjoyed a renaissance in recent years from humble beginnings. Whilst pleural patients are heterogeneous as a population and in the aetiology of the disease with which they present, we provide an overview of the typical diagnostic approach. Pleural fluid analysis is the cornerstone of the diagnostic pathway; however, it has many shortcomings. Strong cases have been made for more invasive upfront investigations, including image-guided biopsies or local anaesthetic thoracoscopy, in selected populations. Imaging can guide the diagnostic process as well as act as a vehicle to facilitate therapies, and this is never truer than with the recent advances in thoracic ultrasound.
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19
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Aujayeb A, Jackson K. A review of the outcomes of rigid medical thoracoscopy in a large UK district general hospital. Pleura Peritoneum 2020; 5:20200131. [PMID: 33575462 PMCID: PMC7823154 DOI: 10.1515/pp-2020-0131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 09/10/2020] [Indexed: 01/06/2023] Open
Abstract
Objectives Local anesthetic medical thoracoscopy (LAT) is a well-established diagnostic, therapeutic, and preventative intervention in undiagnosed pleural effusions with a high diagnostic sensitivity and low complication rates. There is a large variability in practice. We describe a nine-year experience in a large district general hospital in England. Methods Two hundred seventy-five patients had LAT between January 2010 and December 2018. Data on outcomes and complications were obtained from the patients’ notes, electronic records, laboratory, and radiographic findings. Results The main diagnoses were malignant pleural mesothelioma (MPM) (n=110, 40%), chronic inflammation/fibrinous pleuritis (77, 28%), lung cancer (26, 9.5%), and breast cancer (16, 6%). LAT failed to diagnose cancer in 7/275 patients (false-negative rate 2.5%, diagnostic sensitivity 97.5%). Out of the 105 patients with chronic inflammation/fibrinous pleuritis or atypical proliferative processes, 21 (20%) were subsequently diagnosed with malignancy. Talcum pleurodesis was performed in 146 patients, and was successful in 86%. Seventy eight (28%) patients had trapped lung; 27 of those had a repeat procedure. The median length of stay was 3.96 days. There was one hospital death (0.3% mortality). Complications of LAT included pleural (3, 1%) and wound infections (4, 1.4%), persistent air leaks (9, 3.2%), subcutaneous emphysema (10, 3.6%), and tumor extension to the access port (1, 0.3%). Conclusions In this cohort, LAT was safe, effective, and enabled high diagnostic sensitivity. Further areas of study include optimal sedation and anesthetic pathways and combining LAT with indwelling pleural catheters (IPC).
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Affiliation(s)
- Avinash Aujayeb
- Northumbria HealthCare NHS Foundation Trust, Care of Tracy Groom, Cramlington, Northumberland, UK
| | - Karl Jackson
- Northumbria HealthCare NHS Foundation Trust, Care of Tracy Groom, Cramlington, Northumberland, UK
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20
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Abstract
Advanced malignancy is a prevalent cause of exudative pleural effusion. The management of malignant pleural effusion (MPE) has been the subject of several recent randomized controlled trials and excellent reviews. Less attention has been focused on another controversial and challenging aspect of MPE: establishing the diagnosis. Before selecting the optimal management strategy, the presence of an MPE must first be correctly identified with an emphasis on minimizing invasiveness and discomfort in a patient with late-stage cancer. The aim of the present review is to summarize the current knowledge about MPE diagnostics and to propose an algorithm for the diagnosis of MPE in established or suspected malignancy.
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21
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Ishii S, Watanabe H, Suzuki M, Hashimoto M, Iikura M, Izumi S, Hojo M, Sugiyama H. Evaluation of the efficacy and safety of a new flex-rigid pleuroscope. CLINICAL RESPIRATORY JOURNAL 2020; 15:91-96. [PMID: 32949105 PMCID: PMC7891332 DOI: 10.1111/crj.13274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/04/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022]
Abstract
Objective New flex‐rigid pleuroscope enables observations with a maximum angle of curvature of 180°, allowing visualization of the area near the insertion site of the pleuroscope. And, it improved the image quality and channel inner diameter. The aim of this study was to evaluate the clinical effectiveness and safety of a new flex‐rigid pleuroscope. Methods A retrospective analysis of patients who were examined with a new flex‐rigid pleuroscope under local anesthesia at our institution was conducted. Pleuroscopy was performed in 33 patients with undiagnosed exudative pleural effusions from December 2016 to March 2019. Results A total of 33 patients (10 women, 23 men); their median age 74 years (range 24‐90) were investigated. Pleuroscopy showed that 18 had malignant pleural disease (54%), and 15 had benign pleural diseases (46%). The top three most frequent causes of pleural disease were pleural metastases of lung carcinoma (30.3%), pyothorax (15.1%), and malignant pleural mesothelioma (12.1%). In 32 cases (97%), observation at the introducer insertion site was possible. It was not possible in one case due to hard adhesions. The diagnostic rate was 100%, and the complication rate was 6.1%. There were no major complications, and minor complications included mild pain (one case) and minor bleeding (one case) that was stanched spontaneously. Conclusions The new flex‐rigid pleuroscope is effective and safe for diagnosing pleural effusions. The improved bending angle is likely to minimize the blind area. The new pleuroscopy fiberscope may improve the diagnostic rate.
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Affiliation(s)
- Satoru Ishii
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan.,Course of Advanced and Specialized Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiromu Watanabe
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Manabu Suzuki
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masao Hashimoto
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Motoyasu Iikura
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinyu Izumi
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masayuki Hojo
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
| | - Haruhito Sugiyama
- Department of Respiratory Medicine, National Center for Global Health and Medicine, Tokyo, Japan
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22
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Pattison A, Jeagal L, Yasufuku K, Pierre A, Donahoe L, Yeung J, Darling G, Cypel M, De Perrot M, Waddell T, Keshavjee S, Czarnecka-Kujawa K. The impact of concordance with a lung cancer diagnosis pathway guideline on treatment access in patients with stage IV lung cancer. J Thorac Dis 2020; 12:4327-4337. [PMID: 32944345 PMCID: PMC7475595 DOI: 10.21037/jtd-20-157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Timely access to treatment of lung cancer is dependent on efficient and appropriate patient assessment and early referral for diagnostic workup. This study assesses the impact of Cancer Care Ontario (CCO) Lung Cancer Diagnostic Pathway Guideline (LCDPG) concordance on access to treatment of stage IV lung cancer patients referred to the Diagnostic Assessment Program (DAP) at a Canadian tertiary cancer centre. Methods This retrospective cohort study includes patients diagnosed with clinical stage IV lung cancer referred to the DAP at a Canadian tertiary cancer centre between November 1, 2015 and May 31, 2017. Referral concordance was determined based on CCO LCDPG. The primary outcome; time to treatment from initial healthcare presentation; was compared between the concordant and discordant referrals. Results Two hundred patients were referred for clinical stage IV lung cancer during the study period. Of these referrals, 151 (75.5%) were assessed and referred in concordance with LCDPG. Guideline concordant referrals were associated with reduced time to treatment from first healthcare presentation compared with guideline discordant referrals (55.3 vs. 108.8 days, P<0.001). Time to diagnostic procedure (32.2 vs. 86.7 days, P<0.001) and decision to treat (38.5 vs. 93.8 days, P<0.001) were also reduced with guideline concordance. The most common reason for discordant assessment and referral was delayed or inadequate investigation of symptoms in a high risk patient (32.7% of discordant referrals). Conclusions Guideline concordant assessment and referral of stage IV lung cancer patients results in reduced time to diagnosis and treatment. Future research and education should focus on improving factors that delay DAP referral.
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Affiliation(s)
- Andrew Pattison
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Luke Jeagal
- Division of Respirology, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Andrew Pierre
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Jonathan Yeung
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Gail Darling
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Marc De Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Tom Waddell
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Kasia Czarnecka-Kujawa
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.,Division of Respirology, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
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Abstract
The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.
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24
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Shaikh F, Lentz RJ, Feller-Kopman D, Maldonado F. Medical thoracoscopy in the diagnosis of pleural disease: a guide for the clinician. Expert Rev Respir Med 2020; 14:987-1000. [PMID: 32588676 DOI: 10.1080/17476348.2020.1788940] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Developing a feasible and accurate means of evaluating pleural pathology has been an ongoing effort for over 150 years. Pleural fluid cellular and biomarker analyses are simple ways of characterizing and uncovering pathologic entities of pleural disease. However, obtaining samples of pleural tissue has become increasingly important. In cases of suspected malignancy and certain infections histopathology, culture, and molecular testing are necessary to profile diseases more effectively. The pleura is sampled via several techniques including blind transthoracic biopsy, image-guided biopsy, and surgical thoracotomy. Given the heterogeneity of pleural disease, low diagnostic yields, or invasiveness no procedural gold standard has been established in pleural diagnostics. AREAS COVERED Herein, we provide a review of the literature on medical thoracoscopy (MT), its development, technical approach, indications, risks, current and future role in the evaluation of thoracic disease. Pubmed was searched for articles published on MT, awake thoracoscopy, and pleuroscopy with a focus on reviewing literature published in the past 5 years. EXPERT OPINION As the proficiency and number of interventional pulmonologists continues to grow, MT is ideally positioned to become a front-line diagnostic tool in pleural disease and play an increasingly prominent role in the treatment algorithm of various pleural pathologies.
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Affiliation(s)
- Faisal Shaikh
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of Los Angeles , Los Angeles, CA, USA
| | - Robert J Lentz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Interventional Pulmonology , Nashville, TN, USA
| | - David Feller-Kopman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins Hospital , Baltimore, MD, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Interventional Pulmonology , Nashville, TN, USA
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25
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Zhang T, Wan B, Wang L, Li C, Xu Y, Wang X, Liu H, Song Y, Lin D, Zhan P, Lv T. The diagnostic yield of closed needle pleural biopsy in exudative pleural effusion: a retrospective 10-year study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:491. [PMID: 32395535 PMCID: PMC7210145 DOI: 10.21037/atm.2020.03.47] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Pleural effusion is a common presentation in clinical practice. About 40% of exudative pleural effusion is unable to be diagnosed through thoracentesis, and closed pleural biopsy (CPB) is needed. This study was designed to investigate the diagnostic yield of CPB in exudative pleural effusion. Methods This was a retrospective 10-year study of patients with unexplained exudative pleural effusion who underwent CPB in two centers. Malignant pleural effusion (MPE) was diagnosed when there was histopathological evidence of pleural tissue, pulmonary tissue, or pleural fluid. Tuberculous pleural effusion (TPE) was confirmed when granuloma or coagulative necrosis was observed in pleural tissue, Ziehl-Neelsen acid-fast staining was positive, or adenosine deaminase (ADA) in pleural effusion was higher than 35IU with clinical symptoms of TB orγ-interferon increased with symptoms of TB. Results A total of 644 patients were enrolled, of which 479 were specifically diagnosed (217 patients with TPE and 262 patients with MPE). The sensitivity of CPB in the diagnosis of MPE was 51.5%. Among the pathological types of MPE, lung adenocarcinoma accounted for 77.9% (204/262) of cases, making up the largest proportion. The sensitivity of CPB for diagnosing TPE was 68.7%. Conclusions CPB has a relatively high sensitivity in the diagnosis of exudative pleural fluid, especially in relation to tuberculous lesions. CPB could provide an alternative technique in clinical practice, especially for basic hospital units without thoracoscopy.
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Affiliation(s)
- Tianli Zhang
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing 210002, China
| | - Bing Wan
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Li Wang
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Chuling Li
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, China
| | - Yangyang Xu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, China
| | - Xiangdong Wang
- Department of Laboratory Medicine, Nanjing Chest Hospital, Medical School of Southeast University, Nanjing 210002, China
| | - Hongbing Liu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing 210002, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, China
| | - Yong Song
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing 210002, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, China
| | - Dang Lin
- Department of Respiratory and Critical Care Medicine, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215001, China
| | - Ping Zhan
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing 210002, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, China
| | - Tangfeng Lv
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing 210002, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing 210002, China
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Jordano Q, Aiello TF, Rami R, Jaen A, Sierra ADL. Video-thoracoscopy for the evaluation of undiagnosed pleural effusion: Is it possible to optimize its indication? Eur J Intern Med 2020; 73:105-107. [PMID: 31932191 DOI: 10.1016/j.ejim.2019.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/20/2019] [Accepted: 12/28/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Queralt Jordano
- Internal Medicine Department, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa, Barcelona, Spain.
| | - Tommaso Francesco Aiello
- Internal Medicine Department, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa, Barcelona, Spain.
| | - Ramon Rami
- Thoracic Surgery Department, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa, Barcelona, Spain.
| | - Angels Jaen
- Research Foundation, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa Barcelona, Spain.
| | - Alejandro de la Sierra
- Internal Medicine Department, University Hospital Mutua Terrassa, Universitat de Barcelona, Plaza Dr.Robert, 5, 08221 Terrassa, Barcelona, Spain.
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Comparison of Diagnostic Yield and Safety between Semirigid Pleuroscopic Cryobiopsy and Forceps Biopsy for Undiagnosed Pleural Effusion. Can Respir J 2019; 2019:5490896. [PMID: 31929846 PMCID: PMC6939421 DOI: 10.1155/2019/5490896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/18/2019] [Accepted: 11/28/2019] [Indexed: 01/09/2023] Open
Abstract
For undiagnosed pleural effusion, diagnostic yields and safety were similar between pleuroscopic cryobiopsy and forceps biopsy, but cryobiopsy obtained a larger pleural tissue sample than forceps biopsy.
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Yu MG, Jing R, Mo YJ, Lin F, Du XK, Ge WY, Dai HJ, Hu ZK, Zhang SS, Pan LH. Non-intubated anesthesia in patients undergoing video-assisted thoracoscopic surgery: A systematic review and meta-analysis. PLoS One 2019; 14:e0224737. [PMID: 31714904 PMCID: PMC6850529 DOI: 10.1371/journal.pone.0224737] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Non-intubated anesthesia (NIA) has been proposed for video-assisted thoracoscopic surgery (VATS), although how the benefit-to-risk of NIA compares to that of intubated general anesthesia (IGA) for certain types of patients remains unclear. Therefore, the aim of the present meta-analysis was to understand whether NIA or IGA may be more beneficial for patients undergoing VATS. METHODS A systematic search of Cochrane Library, Pubmed and Embase databases from 1968 to April 2019 was performed using predefined criteria. Studies comparing the effects of NIA or IGA for adult VATS patients were considered. The primary outcome measure was hospital stay. Pooled data were meta-analyzed using a random-effects model to determine the standard mean difference (SMD) with 95% confidence intervals (CI). RESULTS AND DISCUSSION Twenty-eight studies with 2929 patients were included. The median age of participants was 56.8 years (range 21.9-76.4) and 1802 (61.5%) were male. Compared to IGA, NIA was associated with shorter hospital stay (SMD -0.57 days, 95%CI -0.78 to -0.36), lower estimated cost for hospitalization (SMD -2.83 US, 95% CI -4.33 to -1.34), shorter chest tube duration (SMD -0.32 days, 95% CI -0.47 to -0.17), and shorter postoperative fasting time (SMD, -2.76 days; 95% CI -2.98 to -2.54). NIA patients showed higher levels of total lymphocytes and natural killer cells and higher T helper/T suppressor cell ratio, but lower levels of interleukin (IL)-6, IL-8 and C-reactive protein (CRP). Moreover, NIA patients showed lower levels of fibrinogen, cortisol, procalcitonin and epinephrine. CONCLUSIONS NIA enhances the recovery from VATS through attenuation of stress and inflammatory responses and stimulation of cellular immune function.
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Affiliation(s)
- Mei-gang Yu
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Anesthesiology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Ren Jing
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yi-jie Mo
- Department of Anesthesiology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Fei Lin
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xue-ke Du
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wan-yun Ge
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hui-jun Dai
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhao-kun Hu
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Sui-sui Zhang
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ling-hui Pan
- Department of Anesthesiology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- The Laboratory of Perioperative Medicine Research Center, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
- * E-mail:
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Comparison of awake and intubated video-assisted thoracoscopic surgery in the diagnosis of pleural diseases: A prospective multicenter randomized trial. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 27:550-556. [PMID: 32082924 DOI: 10.5606/tgkdc.dergisi.2019.18214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/05/2019] [Indexed: 11/21/2022]
Abstract
Background This study aims to compare the safety and diagnostic accuracy of awake and intubated video-assisted thoracoscopic surgery in the diagnosis of pleural diseases. Methods This prospective randomized study was conducted between October 2016 and April 2018 and included 293 patients (201 males, 92 females; mean age 53.59 years; range, 18 to 90 years) from five medical centers experienced in video-assisted thoracoscopic surgery. The patients were randomized into two groups as awake video-assisted thoracoscopic surgery with sedoanalgesia (non-intubated) and video-assisted thoracoscopic surgery with general anesthesia (intubated). Patients with undiagnosed pleural effusions and pleural pathologies such as nodules and masses were included. Conditions such as pain, agitation, and hypoxia were indications for intubation. The groups were compared in terms of demographic data, postoperative pain, operative time, complications, diagnostic accuracy of the procedures, and cost. All patients completed a follow-up period of at least 12 months for samples that were non-specific, suspicious for malignancy or inadequate. Results Awake video-assisted thoracoscopic surgery was performed in 145 and intubated video-assisted thoracoscopic surgery was performed in 148 patients. Pleural disease was unilateral in 83% (243/293) and bilateral in 17% (50/293) of the patients. There was no difference between the groups in terms of presence of comorbidity (p=0.149). One patient in the awake video-assisted thoracoscopic surgery group (0.6%) was converted to general anesthesia due to refractory pain and agitation. As postoperative complications, fluid drainage and pneumonia were observed in one patient in the awake video-assisted thoracoscopic surgery group (0.6%) and fluid drainage was detected in one patient in the video-assisted thoracoscopic surgery group (0.6%). There were no differences in pain intensity measured with visual analog scale at postoperative 4, 8, 12, or 24 hours (p>0.05). Distribution and rates of postoperative pathological diagnoses were also similar (p=0.171). Both operative cost and total hospital cost were lower in the awake video-assisted thoracoscopic surgery group (p<0.001, p=0.001). Conclusion Our study showed that awake video-assisted thoracoscopic surgery is safe, has similar reliability and diagnostic accuracy compared to video-assisted thoracoscopic surgery performed under general anesthesia, and is less costly. Awake video-assisted thoracoscopic surgery can be the first method of choice in all patients, not only in those with comorbidities.
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Ali MS, Light RW, Maldonado F. Pleuroscopy or video-assisted thoracoscopic surgery for exudative pleural effusion: a comparative overview. J Thorac Dis 2019; 11:3207-3216. [PMID: 31463153 DOI: 10.21037/jtd.2019.03.86] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Exudative pleural effusions, such as malignant and tuberculous pleural effusions, are associated with notable morbidity and mortality. Unfortunately, a significant number of these effusions will remain undiagnosed despite thoracentesis. Traditionally, closed pleural biopsies have been the next best diagnostic step, but the diagnostic yield of blind closed pleural biopsies for malignant pleural effusions is insufficient. When image-guided targeted biopsies are not possible, both pleuroscopy and video-assisted thoracoscopic surgery are reasonable options for obtaining pleural biopsies, but the decision to select one procedure over the other continues to raise much debate. Pleuroscopy (aka. medical thoracoscopy, local anaesthetic thoracoscopy) is a relatively common procedure performed by interventional pulmonologists in the bronchoscopy suite with local anesthesia, often as an outpatient procedure, on spontaneously breathing patients. Video-assisted thoracoscopic surgery, on the other hand, is performed by thoracic surgeons in the operating room, on mechanically ventilated patients under general anesthesia, though admittedly considerable overlap exists in practice. Both pleuroscopy and video-assisted thoracoscopic surgery have reported diagnostic yields of over 90%, although pleuroscopy more often leads to the unsatisfactory diagnosis of 'non-specific' pleuritis. These cases of 'non-specific' pleuritis need to be followed up for at least one year, as 10-15% of them will eventually lead to the diagnosis of cancer, typically malignant pleural mesothelioma. Both procedures have their pros and cons, and it is therefore of paramount importance that all cases be discussed as part of a multidisciplinary approach to diagnosis within a "pleural team" that should ideally include interventional pulmonologists and thoracic surgeons.
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Affiliation(s)
- Muhammad Sajawal Ali
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Wauwatosa, WI 53226, USA
| | - Richard W Light
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN 37235, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN 37235, USA
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Hoek RAS, Gaitanakis S, Hellemons ME. Insights from the European Respiratory Society 2018 Annual International Congress in the fields of thoracic surgery and lung transplantation. J Thorac Dis 2018; 10:S3005-S3009. [PMID: 30310690 PMCID: PMC6174134 DOI: 10.21037/jtd.2018.09.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 08/22/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Rogier A. S. Hoek
- Department of Pulmonary Medicine, division of lung transplantation, Erasmus Medical Center Rotterdam, The Netherlands
| | | | - Merel E. Hellemons
- Department of Pulmonary Medicine, division of lung transplantation, Erasmus Medical Center Rotterdam, The Netherlands
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Awakenings: From empiricism to an evidence-based management of malignant pleural effusions. J Thorac Cardiovasc Surg 2018; 156:1260-1261. [PMID: 30017449 DOI: 10.1016/j.jtcvs.2018.05.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
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