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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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Lovato JB, Laroumagne S, Tronchetti J, Nguyen NAT, Dutau H, Astoul P. Fast pleurodesis combining talc poudrage and indwelling pleural catheter for the management of recurrent malignant pleural effusions. Respir Med Res 2024; 86:101124. [PMID: 38968680 DOI: 10.1016/j.resmer.2024.101124] [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: 01/18/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND AND OBJECTIVES Malignant pleural effusions (MPE) are a frequent and major turning point in neoplastic disease usually leading to poor life expectancy. Improve quality of life and relieve the dyspnea are the main objectives in this palliative care setting. This can be achieved by the placement of an indwelling catheter (IPC) or talc pleurodesis ideally performed by thoracoscopy route (talc poudrage). Beside to misidentify a trapped-lung, the latter requires a prolonged hospital stay and the IPC placement does not allow a high pleurodesis rate. To overcome these drawbacks, a combination of both technique could be proposed for the management of recurrent malignant pleural effusions. Safety and efficacy of this pragmatic approach are reported. METHODS Consecutive patients who have been managed for recurrent MPE by a combination of talc poudrage for pleural symphysis by thoracoscopy route ending with the insertion of IPC using the same thoracic point of entry. Demographic data, hospital length of stay (LOS), procedural-related complications, patients' quality of life (QoL) and success of pleurodesis were collected. Patients were followed-up for 6 months. RESULTS The data of twenty-five consecutive patients undergoing the procedure were analyzed. Successful pleurodesis was obtained for 14/25 patients (66 %) at one month, 17/20 patients (85 %) at 3 months and 13/15 patients (86 %) at 6 months respectively. On average, the hospital LOS after the procedure was 3.24 days (IQR 1-4) with a median of 1 day. A prolonged hospitalization (>1 day) was never due to the procedure except for one patient (pneumothorax). No IPC related infection or procedure related deaths were noted. CONCLUSION Among patients with recurrent MPE, the combination of talc poudrage symphysis by thoracoscopy route and IPC placement on the same time results in a shortened hospital LOS and higher rate of pleurodesis. Further randomized clinical trials are needed to confirm these results.
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Affiliation(s)
- Jean-Baptiste Lovato
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France.
| | - Sophie Laroumagne
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France
| | - Julie Tronchetti
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France; Aix-Marseille University, Marseille, France
| | - Ngoc Anh Thu Nguyen
- CEReSS - Health Services and Quality of Life Research, Aix Marseille University, Marseille, France; Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
| | - Hervé Dutau
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, Chemin des Bourrely, 13015 Marseille, France; Aix-Marseille University, Marseille, France
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Goh KJ, Leong CKL, Young SL, Chua BLW, Wong JJY, Phua IGCS, Lim WT, Anantham D, Tan QL. Diagnostic value and safety of medical thoracoscopy in undiagnosed pleural effusions-a prospective observational cohort study. J Thorac Dis 2024; 16:3142-3151. [PMID: 38883638 PMCID: PMC11170383 DOI: 10.21037/jtd-24-219] [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: 02/06/2024] [Accepted: 04/07/2024] [Indexed: 06/18/2024]
Abstract
Background With the need for "actionable histology" in the current era of targeted cancer treatment, and the increasing practice of upfront thoracoscopy (without a prior diagnostic thoracentesis) or a "biopsy first" approach in suspected malignant pleural effusions (MPEs), we sought to prospectively evaluate the diagnostic accuracy, including full molecular profiling of cancer, and safety of medical thoracoscopy (MT) at a tertiary referral hospital. Methods Patients with MT performed for an undiagnosed pleural effusion between January 2020 and December 2022 were included in this observational cohort study. All procedures were performed with a semirigid thoracoscope under conscious sedation. Clinical outcomes and adverse events were recorded prospectively. Results We evaluated 141 patients, with a mean age of 67±12 years. Talc poudrage was performed in 67 (47.5%) patients with a median of 2 [interquartile range (IQR), 1-4] hospitalisation days after MT. Upfront thoracoscopy was performed in approximately half (55.3%) of patients. The overall diagnostic accuracy of MT was 95.7% in our cohort. A final diagnosis of cancer was made in 116 (82.3%) patients, with lung (67.2%) and breast cancer (8.6%) the most common. The diagnostic sensitivity of MT for malignancy was 94.8%, and molecular profiling of relevant cancer types for oncogenic mutations was achieved in all patients with malignancy seen on histopathology. The most common non-malignant diagnosis was tuberculous pleuritis in 14 patients (9.9%). Major complications occurred in 3 (2.1%) patients. Two patients had re-expansion pulmonary edema that resolved with low flow oxygen supplementation in the general ward, and one patient required intensive care unit admission for cardiac tamponade from a malignant pericardial effusion. There were no cases of mortality, bleeding complications or persistent air leaks. Conclusions MT is a well-tolerated and effective option for the evaluation of undiagnosed pleural effusions. With expanding utility and expertise with MT and other pleural interventions, the challenge for respiratory physicians is integrating these into expeditious diagnostic and effective therapeutic pathways, individualised to patients' needs.
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Affiliation(s)
- Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Carrie Kah-Lai Leong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Si Ling Young
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Brian Lee Wei Chua
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | | | | | - Wen Ting Lim
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Devanand Anantham
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Qiao Li Tan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
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Fantin A, Castaldo N, Palou MS, Viterale G, Crisafulli E, Sartori G, Patrucco F, Vailati P, Morana G, Mei F, Zuccatosta L, Patruno V. Beyond diagnosis: a narrative review of the evolving therapeutic role of medical thoracoscopy in the management of pleural diseases. J Thorac Dis 2024; 16:2177-2195. [PMID: 38617786 PMCID: PMC11009601 DOI: 10.21037/jtd-23-1745] [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: 11/13/2023] [Accepted: 02/02/2024] [Indexed: 04/16/2024]
Abstract
Background and Objective Medical thoracoscopy (MT) is an endoscopic technique performed by interventional pulmonologists with a favorable safety profile and few contraindications, providing diagnostic and therapeutic intervention in a single sitting. This narrative review was designed to summarize the therapeutic role of MT based on the latest results from the available literature. Methods Pertinent literature published in English, relative to human studies, between 2010-2022 was searched in Medline/PubMed and Cochrane databases. Publications regarded as relevant were considered for inclusion in this review; additional references were added based on the authors' knowledge and judgment. The review considered population studies, meta-analyses, case series, and case reports. Key Content and Findings MT has mostly been described and is currently used globally in the diagnostic approach to exudative pleural effusion of undetermined origin. Carefully evaluating the literature, it is clear that there is initial evidence to support the use of MT in the therapeutic approach of malignant pleural effusion, pneumothorax, empyema, and less frequently hemothorax and foreign body retrieval. Conclusions MT is an effective procedure for treating the clinical entities presented in this document; it must be carried out in selected patients, managed in centers with high procedural expertise. Further evidence is needed to assess the optimal indications and appropriate patients' profiles for therapeutic MT. The endpoints of length of hospital stay, surgical referral, complications and mortality will have to be considered in future studies to validate it as a therapeutic intervention to be applied globally.
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Affiliation(s)
- Alberto Fantin
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Nadia Castaldo
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Michelangelo Schwartzbaum Palou
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Viterale
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, 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
| | - Filippo Patrucco
- Respiratory Diseases Unit, Medical Department, AOU Maggiore della Carità di Novara, Novara, Italy
- Translational Medicine Department, University of Eastern Piedmont, Novara, Italy
| | - Paolo Vailati
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Giuseppe Morana
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Federico Mei
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Lina Zuccatosta
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Vincenzo Patruno
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
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Chaddha U, Porcel JM, Murgu SD. Indwelling pleural catheters or chest drains for managing malignant pleural effusions: a distinction without a difference? Eur Respir J 2024; 63:2302268. [PMID: 38331440 DOI: 10.1183/13993003.02268-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 02/10/2024]
Affiliation(s)
- Udit Chaddha
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - José M Porcel
- Pleural Medicine and Clinical Ultrasound Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLLEIDA, Lleida, Spain
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Turner M, Craighead F, MacKenzie JD, Aujayeb A. Day Case Local Anaesthetic Thoracoscopy: Experience from 2 District General Hospitals in the United Kingdom. Med Sci (Basel) 2023; 11:medsci11010023. [PMID: 36976531 PMCID: PMC10056019 DOI: 10.3390/medsci11010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Local anaesthetic thoracoscopy (LAT) can be a vital procedure for diagnosis of unexplained pleural effusions. Traditionally, poudrage for pleurodesis and insertion of a large bore drain necessitated admission. There has been a shift towards performing LAT as a day case procedure with indwelling pleural catheter (IPC) insertion. This was advocated during the COVID pandemic by the British Thoracic Society (BTS). To determine the feasibility of such pathways, continuous evaluations are required. Methods: All day case LAT procedures with IPC insertion, performed in theatre, were identified at two large district general hospitals (Northumbria HealthCare in the North East of England and Victoria Hospital, NHS Fife, in Scotland). Rapid pleurodesis with talc was not performed due to local staffing problems. All patients had their LAT in theatre under conscious sedation with a rigid scope. Demographics, clinical, radiological and histopathological characteristics and outcomes were collected. Results: 79 patients underwent day case LAT. The lung did not deflate, meaning biopsies were not enabled, in four of the patients. The mean age was 72 years (standard deviation 13). Fifty-five patients were male and twenty-four were female. The main diagnoses were lung cancers, mesotheliomas and fibrinous pleuritis with an overall diagnostic sensitivity of 93%. Other diagnoses were breast, tonsillar, unknown primary cancers and lymphomas. Seventy-three IPCs were simultaneously placed and, due to normal macroscopic appearances in two patients, two large bore drains were placed and removed within one hour of LAT termination. Sixty-six (88%) patients were discharged on the same day. Seven patients required admission: one for treatment of surgical emphysema, four because they lived alone, one for pain control and one for control of a cardiac arrythmia. Within 30 days, there were five IPC site infections with two resultant empyemas (9%), with no associated mortality. Two patients developed pneumonia requiring admission and one patient required admission for pain management. The median number of days for which the IPCs remained in situ was 78.5 days (IQR 95). The median length of stay (LoS) was 0 days (IQR 0). No patients required further interventions for pleural fluid management. Conclusions: Day case LAT with IPC insertion is feasible with this current set up, with a median stay of 0 days, and should be widely adopted. The health economics of preventing admission are considerable, as our previous analysis showed a median length of stay of 3.96 days, although we are not comparing matched cohorts.
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Affiliation(s)
- Megan Turner
- Respiratory Trainee, Victoria Hospital, Hayfield Rd, Kirkcaldy KY2 5AH, UK
| | - Felicity Craighead
- Respiratory Trainee, Victoria Hospital, Hayfield Rd, Kirkcaldy KY2 5AH, UK
| | | | - Avinash Aujayeb
- Respiratory Consultant, Department of Respiratory Medicine, Northumbria Healthcare NHS Trust, Northumbria Way, Cramlington NE23 6NZ, UK
- Correspondence:
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Yang L, Wang Y. Malignant pleural effusion diagnosis and therapy. Open Life Sci 2023; 18:20220575. [PMID: 36874629 PMCID: PMC9975958 DOI: 10.1515/biol-2022-0575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/09/2023] [Accepted: 01/22/2023] [Indexed: 03/06/2023] Open
Abstract
Malignant pleural effusion (MPE) is a serious complication of advanced tumor, with relatively high morbidity and mortality rates, and can severely affect the quality of life and survival of patients. The mechanisms of MPE development are not well defined, but much research has been conducted to gain a deeper understanding of this process. In recent decades, although great progress has been made in the management of MPE, the diagnosis and treatment of MPE are still major challenges for clinicians. In this article, we provide a review of the research advances in the mechanisms of MPE development, diagnosis and treatment approaches. We aim to offer clinicians an overview of the latest evidence on the management of MPE, which should be individualized to provide comprehensive interventions for patients in accordance with their wishes, health status, prognosis and other factors.
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Affiliation(s)
- Liangliang Yang
- Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Erdao District, Changchun 130033, China
| | - Yue Wang
- Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Street, Erdao District, Changchun 130033, China
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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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Jacobs B, Sheikh G, Youness HA, Keddissi JI, Abdo T. Diagnosis and Management of Malignant Pleural Effusion: A Decade in Review. Diagnostics (Basel) 2022; 12:diagnostics12041016. [PMID: 35454064 PMCID: PMC9030780 DOI: 10.3390/diagnostics12041016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality. Treatment is mainly palliative, with symptomatic management achieved via effusion drainage and pleurodesis. Pleurodesis may be hastened by administering a sclerosing agent through a thoracostomy tube, thoracoscopy, or an indwelling pleural catheter (IPC). Over the last decade, several randomized controlled studies shaped the current management of MPE in favor of an outpatient-based approach with a notable increase in IPC usage. Patient preferences remain essential in choosing optimal therapy, especially when the lung is expandable. In this article, we reviewed the last 10 to 15 years of MPE literature with a particular focus on the diagnosis and evolving management.
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Affiliation(s)
| | | | | | | | - Tony Abdo
- Correspondence: ; Tel.: +1-405-271-6173; Fax: +1-405-271-5892
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Aujayeb A. Increasing diagnostic yield at medical thoracoscopy. Respirology 2022; 27:558. [DOI: 10.1111/resp.14254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Avinash Aujayeb
- Care of Gail Hewitt Northumbria HealthCare NHS Foundation Trust Newcastle UK
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