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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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Sultan S, Gupta E, Benzaquen S. Management of complicated parapneumonic effusions. Curr Opin Pulm Med 2023; 29:54-59. [PMID: 36384805 DOI: 10.1097/mcp.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE OF REVIEW Approximately 36-57% of cases of pneumonia are associated with a parapneumonic effusion (PPE). It begins as sterile effusion, which can quickly evolve to a fibrinopurulent stage with evidence of infection called complicated parapneumonic effusions (CPPE). Marked fibrinous organization then follows. This study focuses on literature synthesis on management of CPPE. RECENT FINDINGS Ultrasound has become an indispensable tool in the identification and treatment of CPPE. Prompt antibiotic administration remains the universal standard of care. Decision to drain the fluid is based on fluid staging, characterization and assessment of risk of poor outcomes vs. risk of complications. There is growing evidence to support use of intrapleural fibrinolytic therapy (IPFT) in case of loculated effusions. Newer areas of research include antibodies against plasminogen activator inhibitors and stratification scores that can identify patients at an increased risk. Lastly, timing of surgical referral is an important area under study. SUMMARY Evolution of medical therapy over recent years has increased treatment success rates. Use of IPFT in conjunction to thoracostomy is now the standard of care for loculated effusions. Understanding available therapeutic options, both medical and interventional, can ensure evidence-based practice and improve patient-centred outcomes.
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Affiliation(s)
- Sahar Sultan
- Department of Pulmonary and Critical Care Medicine, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania
| | - Ena Gupta
- Department of Pulmonary Medicine, University of Vermont, Burlington, Vermont
| | - Sadia Benzaquen
- Department of Pulmonary, Critical Care and Sleep Medicine, Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania, USA
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Li D, Jackson K, Panchal R, Aujayeb A. Local Anaesthetic Thoracoscopy for Pleural Effusion-A Narrative Review. Healthcare (Basel) 2022; 10:healthcare10101978. [PMID: 36292425 PMCID: PMC9601808 DOI: 10.3390/healthcare10101978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/04/2022] Open
Abstract
The incidence of pleural disease is increasing, and interventions are crucial in this subspecialist area of respiratory medicine. One of the cornerstones of pleural effusion investigation and management is medical, which is also known as local anaesthetic thoracoscopy. This allows fluid drainage, biopsy for diagnosis and preventative measures for further fluid potential build-up. This article summarises the evidence around this procedure through a narrative review of the available evidence.
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Affiliation(s)
- Dana Li
- Institute for Lung Health, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Karl Jackson
- Respiratory Department, Northumbria Health Care NHS Foundation Trust, Care of Gail Hewitt, Newcastle NE23 6NZ, UK
| | - Rakesh Panchal
- Institute for Lung Health, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Health Care NHS Foundation Trust, Care of Gail Hewitt, Newcastle NE23 6NZ, UK
- Correspondence:
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Lee YCG, Creaney J. Endomicroscopy of the pleura highlights challenges and limitations of pleuroscopy. Respirology 2020; 26:138-139. [PMID: 33251664 DOI: 10.1111/resp.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia.,Department of Medicine, University of Hong Kong, Hong Kong
| | - Jenette Creaney
- Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, WA, Australia.,National Centre for Asbestos Related Diseases, University of Western Australia, Perth, WA, Australia
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Touray S, Sood RN, Lindstrom D, Holdorf J, Ahmad S, Knox DB, Sosa AF. Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score. Lung 2018; 196:623-629. [PMID: 30099584 DOI: 10.1007/s00408-018-0146-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/05/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections. METHODS In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups. RESULTS Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively). CONCLUSION Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.
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Affiliation(s)
- Sunkaru Touray
- Division of Pulmonary, Allergy & Critical Care, Department of Pulmonary Allergy & Critical Care Medicine, UMass Memorial Medical Centre, University of Massachusetts Medical School, Worcester, MA, 01605, USA.
| | - Rahul N Sood
- Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Daniel Lindstrom
- Division of Pulmonary, Allergy & Critical Care, Department of Pulmonary Allergy & Critical Care Medicine, UMass Memorial Medical Centre, University of Massachusetts Medical School, Worcester, MA, 01605, USA
| | - Jonathan Holdorf
- Division of Pulmonary, Allergy & Critical Care, Department of Pulmonary Allergy & Critical Care Medicine, UMass Memorial Medical Centre, University of Massachusetts Medical School, Worcester, MA, 01605, USA
| | - Sumera Ahmad
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Daniel B Knox
- Division of Pulmonary, Allergy & Critical Care, Department of Pulmonary Allergy & Critical Care Medicine, UMass Memorial Medical Centre, University of Massachusetts Medical School, Worcester, MA, 01605, USA
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Ferreiro L, Porcel JM, Bielsa S, Toubes ME, Álvarez-Dobaño JM, Valdés L. Management of pleural infections. Expert Rev Respir Med 2018; 12:521-535. [DOI: 10.1080/17476348.2018.1475234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Lucía Ferreiro
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
| | - José M. Porcel
- Pleural Medicine Unit. Department of Internal Medicine, Arnau de Vilanova University Hospital. Lleida, SPAIN
- Dr. Pifarré Foundation Biomedical Research Institute, IRBLLEIDA, Lleida, SPAIN
| | - Silvia Bielsa
- Pleural Medicine Unit. Department of Internal Medicine, Arnau de Vilanova University Hospital. Lleida, SPAIN
- Dr. Pifarré Foundation Biomedical Research Institute, IRBLLEIDA, Lleida, SPAIN
| | - María Elena Toubes
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
| | - José Manuel Álvarez-Dobaño
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
| | - Luis Valdés
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
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Abstract
PURPOSE OF REVIEW Patients with malignant pleural effusions (MPEs) are heterogenous in their disease course, symptom severity, responses to cancer therapies, fluid recurrence rates, and thus need for definitive fluid control measures. To tailor the most appropriate treatment for individual patients, clinicians need to 'phenotype' the patients and predict their clinical course. This review highlights the recent efforts to develop better predictive tools and knowledge gaps for further research. RECENT FINDINGS The LENT scoring system, which includes pleural fluid lactate dehydrogenase, performance status, serum neutrophil-to-lymphocyte ratio and tumor type, allows prediction of the survival of patients with MPE. Symptomatic response after therapeutic pleural drainage is highly variable; ongoing studies aim to identify those who would derive symptomatic benefit from fluid drainages. Multivariate analysis found that patients with low pleural fluid pH [odds ratio (OR) 37.04], large effusions (OR 3.31), and increasing age (OR 1.02) were more likely to require pleurodesis or indwelling pleural catheter placement for fluid control. Better predictive tools for rate of fluid recurrence and likelihood of successful pleurodesis would help guide clinical decision-making. SUMMARY Phenotyping MPE would guide the formulation of optimal management for individual MPE patients.
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Abstract
The burden of pleural diseases has substantially increased in the past decade because of a rise in the incidence of pleural space infections and pleural malignancies in a patient population that is older and more immunocompromised and has more comorbidities. This complexity increasingly requires minimally invasive diagnostic options and tailored management. Implications for patients are such that the limitations of current diagnostic methods need to be addressed by multidisciplinary teams of investigators from the fields of imaging, biology, and engineering. Ignored for a long time as an epiphenomenon at the crossroad of many unrelated medical problems, pleural diseases are finally getting the attention they deserve and have spurred a vibrant and exciting field of research.
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Affiliation(s)
- Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue South, T-1218 Medical Center North, Nashville, TN, 37232, USA
| | - Robert J Lentz
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue South, T-1218 Medical Center North, Nashville, TN, 37232, USA
| | - Richard W Light
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue South, T-1218 Medical Center North, Nashville, TN, 37232, USA
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Safety and Efficacy of Intrapleural Tissue Plasminogen Activator and DNase during Extended Use in Complicated Pleural Space Infections. Can Respir J 2016; 2016:9796768. [PMID: 27445574 PMCID: PMC4944060 DOI: 10.1155/2016/9796768] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/01/2016] [Accepted: 06/13/2016] [Indexed: 11/24/2022] Open
Abstract
The use of intrapleural therapy with tissue plasminogen activator and DNase improves outcomes in patients with complicated pleural space infections. However, little data exists for the use of combination intrapleural therapy after the initial dosing period of six doses. We sought to describe the safety profile and outcomes of intrapleural therapy beyond this standard dosing. A retrospective review of patients receiving intrapleural therapy with tissue plasminogen activator and DNase was performed at two institutions. We identified 101 patients from January 2013 to August 2015 receiving intrapleural therapy for complicated pleural space infection. The extended use of intrapleural tissue plasminogen activator and DNase therapy beyond six doses was utilized in 20% (20/101) of patients. The mean number of doses in those undergoing extended dosing was 9.8 (range of 7–16). Within the population studied there appears to be no statistically significant increased risk of complications, need for surgical referral, or outcome differences when comparing those receiving standard or extended dosing intrapleural therapy. Future prospective study of intrapleural therapy as an alternative option for patients who fail initial pleural drainage and are unable to tolerate/accept a surgical intervention appears a potential area of study.
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Corcoran JP, Wrightson JM, Belcher E, DeCamp MM, Feller-Kopman D, Rahman NM. Pleural infection: past, present, and future directions. THE LANCET RESPIRATORY MEDICINE 2016; 3:563-77. [PMID: 26170076 DOI: 10.1016/s2213-2600(15)00185-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 02/09/2023]
Abstract
Pleural space infections are increasing in incidence and continue to have high associated morbidity, mortality, and need for invasive treatments such as thoracic surgery. The mechanisms of progression from a non-infected, pneumonia-related effusion to a confirmed pleural infection have been well described in the scientific literature, but the route by which pathogenic organisms access the pleural space is poorly understood. Data suggests that not all pleural infections can be related to lung parenchymal infection. Studies examining the microbiological profile of pleural infection inform antibiotic choice and can help to delineate the source and pathogenesis of infection. The development of radiological methods and use of clinical indices to predict which patients with pleural infection will have a poor outcome, as well as inform patient selection for more invasive treatments, is particularly important. Randomised clinical trial and case series data have shown that the combination of an intrapleural tissue plasminogen activator and deoxyribonuclease therapy can potentially improve outcomes, but the use of this treatment as compared with surgical options has not been precisely defined, particularly in terms of when and in which patients it should be used.
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Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Elizabeth Belcher
- Department of Cardiothoracic Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Malcolm M DeCamp
- Division of Thoracic Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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Lee H, Park S, Shin H, Kim K. Assessment of the usefulness of video-assisted thoracoscopic surgery in patients with non-tuberculous thoracic empyema. J Thorac Dis 2015; 7:394-9. [PMID: 25922717 DOI: 10.3978/j.issn.2072-1439.2014.12.42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 11/20/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND The purpose of this retrospective study was to investigate the effectiveness and the outcomes of video-assisted thoracic surgery (VATS) treatment and medical therapy (including chest tube drainage, antibiotic treatment) in empyema patients. METHODS Thirty-two consecutive patients with thoracic empyema were treated by VATS or tube drainage from 2006 to 2011. An analysis reviewed outcomes between the operation group and the drainage group. In addition, the operation group was divided into two groups for analysis. RESULTS The drainage period was 15.1±11.3 days in the drainage group and 8.3±4.6 days in the operation group. The length of hospital stay was 22.4±10.0 days in the drainage group and 16.3±5.0 days in the operation group. There were five in-hospital deaths in the drainage group, but no in-hospital deaths in the operation groups. In addition, patients in the early operation group had a significantly shorter hospital stay and postintervention drainage period than patients in the late operation group. CONCLUSIONS VATS for nontuberculous thoracic empyema was more effective than tube drainage and required a shorter hospital stay. The results also indicated that patients who receive early surgical treatment may show better outcomes with late surgical management.
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Affiliation(s)
- Heesung Lee
- 1 The Department of Thoracic and Cardiovascular Surgery, Dongtan Secred Heart Hospital, Hallym University, Korea ; 2 The Division of Pulmonary and Allergy and Critical care Medicine, 3 The Department of Thoracic and Cardiovascular Surgery, Kangnam Secred Heart Hospital, Hallym University, Seoul, Korea
| | - Sangmyeon Park
- 1 The Department of Thoracic and Cardiovascular Surgery, Dongtan Secred Heart Hospital, Hallym University, Korea ; 2 The Division of Pulmonary and Allergy and Critical care Medicine, 3 The Department of Thoracic and Cardiovascular Surgery, Kangnam Secred Heart Hospital, Hallym University, Seoul, Korea
| | - Hoseung Shin
- 1 The Department of Thoracic and Cardiovascular Surgery, Dongtan Secred Heart Hospital, Hallym University, Korea ; 2 The Division of Pulmonary and Allergy and Critical care Medicine, 3 The Department of Thoracic and Cardiovascular Surgery, Kangnam Secred Heart Hospital, Hallym University, Seoul, Korea
| | - Kunil Kim
- 1 The Department of Thoracic and Cardiovascular Surgery, Dongtan Secred Heart Hospital, Hallym University, Korea ; 2 The Division of Pulmonary and Allergy and Critical care Medicine, 3 The Department of Thoracic and Cardiovascular Surgery, Kangnam Secred Heart Hospital, Hallym University, Seoul, Korea
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Ferreiro L, San José ME, Valdés L. Management of Parapneumonic Pleural Effusion in Adults. Arch Bronconeumol 2015; 51:637-46. [PMID: 25820035 DOI: 10.1016/j.arbres.2015.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 11/30/2022]
Abstract
Pleural infections have high morbidity and mortality, and their incidence in all age groups is growing worldwide. Not all infectious effusions are parapneumonic and, in such cases, the organisms found in the pleural space are not the same as those observed in lung parenchyma infections. The diagnostic difficulty lies in knowing whether an infectious effusion will evolve into a complicated effusion/empyema, as the diagnostic methods used for this purpose provide poor results. The mainstays of treatment are to establish an early diagnosis and to commence an antibiotic regimen and chest drain as soon as possible. This should preferably be carried out with fine tubes, due to certain morphological, bacteriological and biochemical characteristics of the pleural fluid. Fluid analysis, particularly pH, is the most reliable method for assessing evolution. In a subgroup of patients, fibrinolytics may help to improve recovery, and their combination with DNase has been found to obtain better results. If medical treatment fails and surgery is required, video-assisted thoracoscopic surgery (VATS) is, at least, comparable to decortication by thoracotomy, so should only undertaken if previous techniques have failed. Further clinical trials are needed to analyze factors that could affect the results obtained, in order to define new evidence-based diagnostic and therapeutic strategies that provide more effective, standardized management of this disease.
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Affiliation(s)
- Lucía Ferreiro
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España
| | - María Esther San José
- Servicio de Análisis Clínicos, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España
| | - Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España.
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Abstract
PURPOSE OF REVIEW In managing pleural diseases, medical thoracoscopy is often performed as a diagnostic and/or therapeutic procedure, particularly in undiagnosed pleural effusions. Flexi-rigid pleuroscopes are now widely available as an alternative to conventional rigid thoracoscopes. There is an ongoing debate on which is the better instrument. This review analyses the current literature that compared rigid and flexi-rigid approaches, and outlines the medical advances that may influence the future role of thoracoscopy. RECENT FINDINGS Both rigid and flexi-rigid thoracoscopies are well tolerated. Although biopsies are smaller with flexi-rigid biopsy forceps, two small randomized trials reported similar diagnostic yield using either instrument. No studies have specifically examined patient comfort or the outcome of talc poudrage using the two devices. New techniques (e.g. insulated-tip knife and cryobiopsy) have been used as adjuncts with flexi-rigid pleuroscopy to overcome the difficulties in sampling thickened pleura. SUMMARY The rigid and flex-rigid instruments have different merits and limitations. Both approaches provide comparable diagnostic yields in the overall patient population undergoing diagnostic thoracoscopy, though their performances specifically in patients with fibrotic pleural thickening have not been examined. Operators using the flexi-rigid approach should have alternative strategies for sampling thickened pleura. Advances in cytopathology and imaging-guided biopsy will likely reduce the need of medical thoracoscopy in the future.
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Henderson DW, Reid G, Kao SC, van Zandwijk N, Klebe S. Challenges and controversies in the diagnosis of mesothelioma: Part 1. Cytology-only diagnosis, biopsies, immunohistochemistry, discrimination between mesothelioma and reactive mesothelial hyperplasia, and biomarkers. J Clin Pathol 2013; 66:847-53. [DOI: 10.1136/jclinpath-2012-201303] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Rosenstengel A. Pleural infection-current diagnosis and management. J Thorac Dis 2012; 4:186-93. [PMID: 22833824 DOI: 10.3978/j.issn.2072-1439.2012.01.12] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 01/26/2012] [Indexed: 11/14/2022]
Abstract
Pleural infection is a common and increasing clinical problem in thoracic medicine, resulting in significant morbidity and mortality. In recent years there has been a marked increase in interests and publications relating to evolving interventions and management options for pleural infection and empyema. Recently published research data as well as guidelines have suggested better approaches of radiological assessment, updated management algorithms for pleural infection, intrapleural adjunct therapies and re-examined the roles of biomarkers, pleural drainage techniques, and the role of surgery. This review highlights some of the recent advances and recommendations relevant to clinical care of pleural infection.
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Affiliation(s)
- Andrew Rosenstengel
- Clinical Pleural Fellow, Respiratory Dept, Sir Charles Gairdner Hospital, Perth WA 6009, Australia
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Thoracomyoplasty in the treatment of empyema: current indications, basic principles, and results. Pulm Med 2012; 2012:418514. [PMID: 22666583 PMCID: PMC3361311 DOI: 10.1155/2012/418514] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 02/05/2012] [Accepted: 02/12/2012] [Indexed: 11/17/2022] Open
Abstract
Empyema remains a challenge for modern medicine. Cases not amenable to lung decortication are particularly difficult to treat, requiring prolonged hospitalizations and mutilating procedures. This paper presents the current role of thoracomyoplasty procedures, which allow complete and definitive obliteration of the infected pleural space by a combination of thoracoplasty and the use of neighbourhood muscle flaps (latissimus dorsi, serratus anterior, pectoralis, rectus abdominis, omentum, etc). Recent publications show an overall rate of success of 90%, with a quick and definitive healing. Although rarely indicated in our days, this kind of procedures remain in the armamentarium of modern thoracic surgery. The importance of thoracomyoplasty derives from the fact that it may be a simple and definitive solution for complicated cases of chronic empyema not amenable to standard decortication.
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