Diagnostic yield of medical thoracoscopy in exudative pleural effusions in a region with high tuberculosis burden

INTRODUCTION

Pleural effusion is frequently encountered in respiratory medicine. However, despite thorough assessment including closed pleural biopsy, the cause of around 20% of pleural effusions remains undetermined. Medical thoracoscopy (MT) is the investigation of choice in these circumstances especially if malignancy is suspected. The aim of this study is to evaluate the diagnostic yield of MT in exudative pleural effusions in a single center from East Malaysia.

METHODS

Retrospective chart review of all adult patients who underwent MT for undiagnosed exudative pleural effusion in a 24-month duration.

RESULTS

Our cohort comprised of 209 patients with a median age of 61 years old (IQR 48.5-69.5). There were 92 (44%) patients with malignant pleural effusion (MPE) and 117 (56%) benign effusions; which included 85 tuberculous pleural effusion (TBE) and 32 cases of non-tuberculous exudative pleural effusion. Conclusive pathological diagnosis was made in 79.4% of the cases. For diagnosis of MPE, MT had a sensitivity of 89.1% (95% CI 80.4-94.3), specificity of 100% (95% CI 96.0-100.0), and positive predictive value (PPV) of 100% (95% CI 94.4-100) and negative predictive value (NPV) of 92.1% (95% CI 85.6-95.9). For TBE, MT had a sensitivity of 90.5% (95% CI 81.8-95.6), specificity of 100% (95% CI 96.3- 100.0) PPV of 100% (95% CI 94.1-100) and NPV of 93.9% (95% CI 88.0-97.2). Overall complication rate was 3.3%.

CONCLUSIONS

MT showed excellent sensitivity and specificity in the diagnosis of exudative pleural effusion in this region. It reduces empirical therapy by providing histological evidence of disease when initial non-invasive investigations were inconclusive.

Lung volume reduction surgery since the National Emphysema Treatment Trial: study of Society of Thoracic Surgeons Database

OBJECTIVES

The National Emphysema Treatment Trial demonstrated that lung volume reduction surgery is an effective treatment for emphysema in select patients. With chronic lower respiratory disease being the third leading cause of death in the United States, this study sought to assess practice patterns and outcomes for lung volume reduction surgery on a national level since the National Emphysema Treatment Trial.

METHODS

Aggregate statistics on lung volume reduction surgery reported in the Society of Thoracic Surgeons Database from January 2003 to June 2011 were analyzed to assess procedure volume, preoperative and operative characteristics, and outcomes. Comparisons with published data from the National Emphysema Treatment Trial were made using chi-square and 2-sided t tests.

RESULTS

In 8.5 years, 538 patients underwent lung volume reduction surgery, with 20 to 118 cases reported in the Society of Thoracic Surgeons Database per year. When compared with subjects in the National Emphysema Treatment Trial, subjects in the Society of Thoracic Surgeons Database were younger (P < .001), a larger proportion underwent the procedure thoracoscopically (P < .001), and forced expiratory volume in 1 second was 31% versus 28% of predicted (P < .001). When mortality was compared between subjects in the Society of Thoracic Surgeons Database and all subjects in the National Emphysema Treatment Trial randomized to surgery, there were no significant differences. However, mortality was 3% higher in subjects in the Society of Thoracic Surgeons Database when compared with the non-high-risk National Emphysema Treatment Trial subset (P = .005).

CONCLUSIONS

This study demonstrates the importance of patient selection and the need to develop consensus on appropriate benchmarks for mortality rates after lung volume reduction surgery. It underscores the need for dedicated centers to increasingly address the heavy burden of chronic lower respiratory disease in the United States in a multidisciplinary fashion, particularly for preoperative evaluation and postoperative management of emphysema.

Video-based skill assessment of endoscopic suturing in a pediatric chest model and a box trainer

PURPOSE

Pediatric endoscopic surgery requires special surgical skills because of the small working space and tissue fragility. This article presents a video-based skill assessment method for endoscopic suturing using a pediatric chest model.

MATERIALS AND METHODS

A commercial suture pad was placed in a rapid-prototyped pediatric chest model of a 1-year-old patient to simulate the thoracoscopic repair of esophageal atresia type C. Twenty-eight pediatric surgeons (9 experts, 9 intermediates, and 10 trainees) performed an endoscopic intracorporeal suturing and knot-tying task both in the pediatric chest model and in a box trainer. The tasks were video-recorded and rated by two blinded observers using the 29-point checklist method and a suturing errors score sheet method. The task completion time and the number of needle manipulations were measured.

RESULTS

The expert group showed better performance than the intermediate and trainee groups in the pediatric chest model, and the differences were larger than those in the box trainer. Significant differences between the expert and the trainee groups were observed in the items related to safety such as the skills for keeping the needle in view at all times. Significant differences between the expert and intermediate groups were observed in the items related to task quality and efficiency such as the smoothness of knot tying and the number of needle manipulations.

CONCLUSIONS

Video-based skill assessment of endoscopic suturing using the pediatric chest model and a box trainer distinguished pediatric endoscopic surgeons according to their clinical experience, and pediatric-specific skills were identified.

[Optimization of surgical strategy in trauma of the chest: correlation of thoracoscopy and thoracotomy]

The authors analyzed an experience with treatment of 4372 patients. Videothoracoscopy allowed the number of usual drainages of the pleural cavity to be reduced in closed trauma from 16.3% to 2.3%, in wounds--from 3.9% to 0.4%. Persistent hemo- and airstasis were obtained by coagulation of the vessels of the thoracic wall and lung, suturing lung wounds. The coagulated hemothorax was removed, diaphragm wounds were sutured, the pericardium wounds were revised, the character of intrathoracic lesions was reliably determined in 98% of cases. Conversion into thoracotomy was fulfilled in 91 (5.5%) patients. Thoracotomy was fulfilled in 344 (8%) patients with indications to operative interventions and severe condition and unstable hemodynamics. The number of thoracotomies and lethality in patients with penetrating wounds of the chest became 1.5-2 times less, was not considerably changed in closed traumas.

State of the art: pleuroscopy

The terms pleuroscopy, thoracoscopy, medical thoracoscopy, and video-assisted thoracic surgery are often used interchangeably to describe a minimally invasive procedure that provides access to the pleural space, parietal pleura, lung, and other structures within the thoracic cavity. Pleuroscopy is a more exact term for describing visualization of the pleura and contents of the pleural cavity using an endoscope. This procedure provides physicians a window into the pleural space, to perform biopsy of the parietal pleura under direct visual guidance, particularly for biopsies in cases of exudative effusions with unclear origin, chest tube placement, and pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. In this state-of-the-art review, we discuss the indications, contraindications, and complications of pleuroscopy, and its role in thoracic oncology.

Video-assisted thoracoscopic surgery compared with thoracotomy: early and late follow-up of radiographical and functional outcome

BACKGROUND CONTEXT

Video-assisted thoracoscopic surgery (VATS) is a new technique that allows for access to anterior spinal pathology using a minimally invasive approach. Proponents of this procedure argue that anterior thoracic spine surgery can be performed with the same accuracy and completeness as is possible by the conventional open approach but through much smaller skin and muscle incisions. Advantages of VATS include decreased blood loss, shorter hospital stay, and improved cosmesis.

PURPOSE

To detect if VATS is equally as effective as open thoracotomy, both combined with instrumented posterior spinal fusion, with respect to fusion rate, percent curve correction, and functional outcome.

STUDY DESIGN

Retrospective case control.

PATIENT SAMPLE

Seventeen patients underwent VATS/instrumented posterior spinal fusion for thoracic curvatures exceeding 50 degrees . A control cohort of patients that were age matched, sex matched, and curve magnitude matched underwent open thoracotomy/instrumented posterior spinal fusion.

OUTCOME MEASURES

Percentage of curve correction, fusion rate, intraoperative and postoperative clinical parameters, and functional outcome scores.

METHODS

Preoperative and postoperative radiographs were analyzed to calculate the percentage of major curve correction in the coronal and sagittal planes as well as the rate of fusion. In addition, operative reports and medical records were analyzed for the following outcomes: estimated operative blood loss, length of surgery, chest tube output, length of hospitalization, and complications. Average follow-up time was 26 months in the VATS group and 27 months in the thoracotomy group. Finally, functional outcome was assessed using the Scoliosis Research Society (SRS-22) and Oswestry Disability Index (ODI) scoring system.

RESULTS

The VATS group (mean age, 30) averaged 5.4 anterior levels and 11 posterior levels fused. The thoracotomy group (mean age, 32) averaged 5.8 anterior levels and 12 posterior levels fused. Estimated blood loss was nearly identical for the posterior procedures in both groups, whereas the anterior blood loss was significantly higher in the thoracotomy group as compared with the VATS group (541 cc vs. 288 cc). Operative time did not differ significantly between the two cohorts. Percent curve correction immediately postoperative (52% correction VATS; 51% correction thoracotomy) as well as at the 2-year follow-up (50% VATS and 54% thoracotomy) was nearly identical. There was no difference in postoperative ODI (p=.6) or SRS scores (p=.5) between groups. Complications were frequent but not significantly different between the two groups (p=.3).

CONCLUSION

VATS is equally effective as thoracotomy with respect to fusion rate, major curve correction, and functional outcome scores. Although a decrease in operative blood loss was seen in the VATS patients, this was not clinically significant.

Different outcomes between two sides after bilateral sympathetic ganglion interruption for hyperhidrosis

BACKGROUND

Although the determination of the correct ganglion under direct vision through thoracoscopy by an experienced surgeon is almost unerring, there is still a 4.3% rate of clipping at the unintended level.

METHODS

Through the review of the most recent patients (N = 117) with various sympathetic disorders undergoing thoracoscopic sympathetic interruption over different ganglions by clipping, we found that 5 cases were clipped at the unplanned level. The immediate manifestations were the different outcomes between both sides of the face, trunk, and extremities. The postoperative chest radiographs demonstrated the error.

RESULTS

All patients received a second operation in which the unintended clip was removed, and a new one was applied to the appropriate ganglion. The results were satisfactory.

CONCLUSIONS

Although the authors in this study have the experience of more than 1000 cases of hyperhidrosis, such an error is still inevitable. Luckily, by using the clipping method, the error is detectable and amendable.

The use and development of medical thoracoscopy in the United Kingdom over the past 5 years

INTRODUCTION

Medical thoracoscopy is a safe, reliable and therapeutic procedure used in the management of pleural disease. For reasons that are unclear it is under utilised in the United Kingdom (UK) when compared to the rest of Europe. We have studied its development and use over the past 5 years.

METHOD

We have performed national postal surveys in 1999 and 2004 to assess the provision of medical thoracoscopy, its indications for use, local practices as well as, training and audit issues.

RESULTS

11 centres in 1999 and 17 centres in 2004 perform medical thoracoscopy, there were more district general hospitals providing this service than teaching hospitals. Twenty-seven centres in 1999 and 54 centres in 2004 stated plans to begin providing a service. Centres were performing between 10 and 30 thoracoscopies per year. There were differences between centres in local practices and training received. The majority of currently performing centres offered training and were interested in national audit.

DISCUSSION

This study has shown there are still only a small proportion of UK respiratory centres performing medical thoracoscopy. There is a growing interest in the procedure, however, issues regarding standardisation of care across the UK, on going competency and training have been highlighted. A British Thoracic Society (BTS) working group has been set up to address these.

[Current status and evaluation of thoracoscopic esophagectomy for thoracic esophageal cancer]

The current status and evaluation of esophagectomy by thoracoscopic approach for thoracic esophageal cancer are described. The esophagectomy by thoracoscopic approach for thoracic esophageal cancer have been reported in some Instituts since 1996 in Japan. In 10 years, series consisting a large number of esophageal cancer patients have been treated with esophagectomy by thoracoscopic approach and evaluated about operative safety, curabirity and postoperative morbidity. Now, the establishment of training system is the most important subject to achieve the standardization of thoracoscopic esophagectomy for thoracic esophageal caner.

Image-guided thoracoscopic spinal surgery: a merging of 2 technologies

STUDY DESIGN

Retrospective clinical and intraoperative navigational data review.

OBJECTIVE

To evaluate quantitatively the application of frameless stereotactic image guidance in thoracoscopic discectomy procedures.

SUMMARY OF BACKGROUND DATA

Thoracoscopic spinal surgery has technical and anatomic challenges that result in difficult orientation with a 2-dimensional imaging procedure in a complex 3-dimensional structure.

METHODS

There were 16 patients who underwent image-guided thoracoscopic discectomy procedures that combine these 2 technologies. Accuracy was determined by the registration (calculated) error and actual navigation (intraoperative) error. The clinical outcomes and complications were reviewed.

RESULTS

Accuracy determined by registration (calculated) and navigation (intraoperative) was 1.7 and 1.2 mm, respectively. The additional time required for the image guidance portion of the procedure was countered by the efficiency of the remaining procedure. Clinical outcomes and complication were comparable with previous experience.

CONCLUSIONS

Image-guided thoracoscopic spinal surgery can provide 3-dimensional orientation to a 2-dimensional imaging procedure that ultimately improves accuracy, efficiency, and safety. Future developments in combining guidance technology with standard surgical procedures will likely continue.

Optimizing the surgical management of lung nodules in children with osteosarcoma: thoracoscopy for biopsies, thoracotomy for resections

BACKGROUND

The goal of this study was to assess the role of thoracoscopy (TS) and thoracotomy (TT) in the management of lung nodules in children with osteosarcoma.

METHODS

Charts of 16 osteosarcoma patients undergoing surgery for lung nodules were retrospectively analyzed for a correlation between nodule localization at CT scan, findings at surgery, and pathology.

RESULTS

Fourteen TSs were performed in 10 children, eight of which were converted: two for technical problems, and six for inconsistency between CT scan and intraoperative findings. In three converted cases, TT allowed detection of more nodules than CT scan and/or TS. Eight TTs were performed as primary intention in seven children, in one as secondary surgery after a previous TS. In three cases, TT detected more nodules than CT scan. Overall, TT detected more nodules than CT scan in seven of 16 cases (sensitivity, 56.2%), six of whom had a predicted bilateral involvement. Neoplastic tissue was present in lung samples of all but three patients (86.4%).

CONCLUSIONS

Lung nodules in osteosarcoma patients are usually metastases. CT scan is unreliable in detecting all the nodules, especially in the case of predicted bilateral involvement. If excision of all metastases is considered the goal of surgery, a TT approach should be chosen in patients with more than one thoracic nodule.

Indications for endoscopic thoracic sympathectomy

The thoracoscopic approach to the sympathetic chain has diminished the trauma of previous open sympathectomy. The minimal trauma has opened the way to manipulate the chain for several conditions. Hand sweat is the most common indication resulting in patient satisfaction 2-13 years after surgery in more than 90%. High satisfaction was also obtained in patients with angina pectoris and a very disabling condition, facial blushing (85 %). Somewhat poorer results were obtained in patients with facial and axillary sweating. In patients with Mb Raynaud-all had recurrences within a year. Since severe side effects, especially compensatory sweating, may occur, the ETS procedure should be reserved only for patients with severe problems where other treatments have failed.

Cavitary endoscopy in trauma: 2001

Laparoscopy and thoracoscopy have been used in the evaluation of injured patients for over 30 years. Despite this long history, indications for use of these techniques remains controversial. The widespread availability of videoscopic equipment which followed the introduction of laparoscopic cholecystectomy increased interest and utilization of minimally invasive techniques in evaluation of trauma patients. Laparoscopy has been most beneficial in the evaluation of hemodynamically stable victims of stabbings and gunshots. This technique has primarily been used to detect peritoneal penetration in tangential wounds of the abdominal wall and for evaluation of the diaphragm in patients with thoracoabdominal wounds. Laparoscopic evaluation in blunt trauma patients is of unproven utility, but has been used in the assessment of patients with documented solid organ injury and in the evaluation of patients with suspected hollow viscus injury. Small subsets of patients are candidates for therapeutic laparoscopic interventions, i.e., suture repair of diaphragmatic lacerations. Thoracoscopy or videoassisted thoracic surgery (VATS) is useful for evaluation of the diaphragm, early evacuation of clotted hemothorax, and assessment of ongoing bleeding.

[Clinical utility and safety of diagnostic thoracoscopy]

The increasing use of thoracoscopy performed under local anesthesia has made contributions to the diagnosis of pleural disease with effusion. During the past 7 years, we have performed 100 such thoracoscopy procedures using a flexible fiberoptic bronchoscope. On the basis of our clinical findings, we are able to discuss the utility and safety of this procedure. The causes of pleural effusion were carcinomatous pleurisy in 72 cases, tuberculosis pleurisy in 15 cases, infection without tuberculosis in 4 cases, malignant pleural mesothelioma in 8 cases and one case of asbestosis. The success rate of thoracoscopic pleural biopsies were 97% for carcinomatous pleurisy, 100% for malignant pleural mesothelioma and 86% for tuberculosis pleurisy. This procedure was performed with no serious effect on blood pressure, oxygen saturation, monitored ECG or BGA data, and with no serious complications. Therefore, we concluded that this method is very useful for the diagnosis of pleural effusions and has few complications.

Evaluation of minimally invasive approaches to achalasia in children

BACKGROUND

Achalasia is an uncommon disease in children, but when present can result in severe disabling symptoms often requiring surgical intervention. This report describes the authors' experience with thoracoscopic (TH) and later laparoscopic Heller (LH) myotomy for definitive treatment of this disease.

METHODS

Nine patients with achalasia were referred for surgical therapy. Ages ranged from 5 to 17 years and weight from 23 to 78 kg. All had undergone at least one dilatation with recurrence of symptoms. The first 4 were treated by TH and the last five by LH. The 5 LH procedures also included a partial fundoplication.

RESULTS

All procedures were completed successfully using minimally invasive techniques. Operating times averaged 95 minutes for TH and 62 minutes for LH. One patient undergoing TH had a small esophageal perforation repaired primarily. The other 3 TH patients were started on clear liquids within 1 day and discharged on day 2. One patient had recurrent symptoms at 6 months and underwent a LH for an incomplete TH. All 5 LH patients were discharged on postoperative day 1. One had an esophageal perforation 4 days after operation requiring laparoscopic repair. Seven of 9 patients are asymptomatic. Studies of pH levels in 2 asymptomatic TH patients show mild gastroesophageal reflux (GER).

CONCLUSIONS

Minimally invasive Heller myotomy is a safe and effective procedure in children. TH results in a slightly longer operating time and hospital stay and, without a partial fundoplication, also may be associated with a higher incidence of silent GER. From these results, we prefer LH with a Dor fundoplication for treatment of achalasia in children.

Evaluation of high-speed treadmill videoendoscopy for diagnosis of upper respiratory tract dysfunction in horses

OBJECTIVE

To evaluate high-speed treadmill videoendoscopy as a diagnostic technique and document the abnormalities found in Australian horses referred for poor performance associated with abnormal upper respiratory tract noise but where a definitive diagnosis could not be made at rest.

DESIGN

A retrospective clinical study using client-owned horses.

PROCEDURE

The clinical records and videorecordings of all horses referred to the University of Sydney for poor performance associated with abnormal upper respiratory tract noise during a 13-month period were examined. Only horses with a normal physical examination including absence of lameness, and where a definitive diagnosis of the cause of the abnormal upper respiratory tract noise could not be made from the resting videoendoscopic examination were included in the study. The age, gender, breed of horse and the purpose for which the horse was used were ascertained from the record and videorecordings were reviewed by the authors and any abnormalities noted.

RESULTS

There were 37 horses included in the study. An upper airway abnormality was identified during high-speed treadmill videoendoscopy in 73% of horses. One abnormality was identified in 22 horses, 2 abnormalities in 4 horses and 3 abnormalities in 1 horse. Abnormalities identified included laryngeal hemiparesis (n = 15), axial deviation of the aryepiglottic folds (n = 10), pharyngeal collapse (n = 3), dorsal displacement of the soft palate (n = 2), epiglottic collapse (n = 1), axial deviation of the vocal cord (n = 1) and laryngeal collapse (n = 1).

CONCLUSIONS

The results of this study are similar to reports from overseas and suggest high-speed treadmill videoendoscopy appears to be a useful technique to diagnose the cause of upper airway dysfunction in Australian horses referred specifically for poor performance associated with abnormal upper respiratory noise. However, a diagnosis will not be made in all horses undergoing this procedure. There were five horses with two or three abnormalities none of which were apparent at rest. This would suggest that in all horses making abnormal upper respiratory noise associated with poor performance, even where an abnormality is identified at rest, high-speed treadmill videoendoscopy should be performed for a complete diagnosis.

Endoscopic thoracic discectomy

OBJECT

Thoracoscopic discectomy is a minimally invasive procedure simulating a thoracotomy and is an alternative to the costotransversectomy and transpedicular approaches. In recent studies authors have concluded that thoracoscopic discectomy is the preferred procedure; however, relative historical comparisons were difficult to interpret. The authors conducted a prospective nonrandomized study in which they compared data on 36 patients undergoing thoracoscopic discectomy with eight patients undergoing thoracotomy between 1995 and 1999.

METHODS

Patients affected with one- or two-level lesions underwent a thoracoscopic discectomy, and patients with three-level lesions or more underwent thoracotomy and discectomy. Data were collected on operative time, blood loss, chest tube duration, narcotic agent use, and hospital length of stay (LOS). Longer-term follow-up study of pain-related symptoms and neurological function was conducted. Patients who underwent thoracoscopic discectomy had shorter operative times, less blood loss, a shorter period of chest tube drainage dependence, less narcotic usage, and a shorter LOS. These findings were statistically significant (p < 0.05) for narcotic usage and shorter LOS. Pain related to radiculopathy was improved by means of 75%, and no patients experienced worsened pain. In patients with myelopathy there was an improvement of two Frankel grades in the thoracoscopic group and one Frankel grade in the thoracotomy discectomy group, but patients in the thoracotomy group were significantly worse preoperatively. One myelopathic patient from each group suffered a worsened outcome postoperatively, although this was not attributed to the method of surgery. The incidence of complications (minor and major) was 31% in the thoracoscopic group and greater than 100% (that is, more than one complication per patient) in the thoracotomy/discectomy group.

CONCLUSIONS

One advantage to thoracoscopic discectomy is its reduced incidence of morbidity compared with thoractomy, but its steep learning curve and unfamiliar surgical techniques make this procedure less practical for surgeons not performing it frequently. The more familiar costotransversectomy, transpedicular, and thoracotomy procedures remain viable alternatives for surgeons more experienced in these procedures.

[Thoracoscopy versus thoracotomy. The dilemma of the comparison and its meaning for quality assurance in thoracic surgery]

The need for scientific investigation into the benefits of thoracoscopy in comparison to thoracotomy as well as State intervention to assure quality in the field of surgery motivated the members of the commission of endoscopic surgery of the German Society of Thoracic Surgery to conduct a pilot project at their hospitals. This pilot project was expected to analyse data on the outcome and a selection of variables concerning trauma and postoperative quality of life of some 400 patients treated between 8/95 and 10/95 at 5 thoracic surgical clinics. On completion of the pilot project the course of 141 patients undergoing different thoracic operations at 4 thoracic surgery departments had been documented to various degrees. 60 patients for various indications received a thoracoscopy, 72 a thoracotomy. In 9 patients thoracoscopy was converted to thoracotomy (6.4%). Eight of the 141 patients died in the postoperative course (5.7%), overall morbidity was 15.6%. There was a slight but statistically not significant difference concerning mortality and morbidity in favor of thoracoscopy (1.7 vs. 9.7% and 10 vs. 19.4%). But, there was a selection of malignant diseases, higher age and high risk patients towards thoracotomy. In subgroups of patients undergoing operations not bigger than the resection of three lung wedges only time of operation and length of incision revealed to be significantly shorter for thoracoscopy (69(25-190) min vs. 128(24-240)min, p = 0.0013; 6(4-8)cm vs. 23(12-35)cm, p = 0.0001). Borderline significance was reached by the Spitzer-Index in advantage for thoracoscopy (8(2-10)points vs. 7(0-10)points, p = 0.0728). Thoracotomy and thoracoscopy are access procedures used with different indications in different patients. Differences concerning trauma and quality of life if present are marginal and will need studies to be outlined. Quality assurance in thoracic surgery using a standardized documentation will not succeed under the given circumstances.

Diagnostic value of closed percutaneous pleural biopsy vs pleuroscopy in suspected malignant pleural effusion or tuberculous pleurisy in a region with a high incidence of tuberculosis: a comparative, age-dependent study

OBJECTIVE

To compare the value of closed percutaneous pleural biopsy versus pleuroscopy for diagnosis of undiagnosed exudative pleural effusion in an age-dependent manner.

DESIGN

Prospective clinical study.

SETTING

University hospitals.

PATIENTS

Forty-nine consecutive patients with undiagnosed exudative pleural effusion following the initial clinical and paraclinical investigations, including bronchoscopy. Cases were divided into younger and older groups according to their ages.

INTERVENTION

Closed pleural biopsy immediately followed by pleuroscopy with a flexible fiberoptic bronchoscope from the same incision site.

RESULTS

In the older age group, pleuroscopy was superior to closed pleural biopsy for the diagnosis of the underlying pleural disease (P = 0.0007), while they were almost equally diagnostic in the younger cases (P = 0.58).

CONCLUSION

For those patients with undiagnosed exudative pleural effusion who are older than 50 years of age, pleuroscopy could be chosen as the first procedure of choice as compared to closed pleural biopsy if malignant pleural effusion is suspected.

Thoracoscopic pleurectomy for treatment of complicated spontaneous pneumothorax

This report describes a thoracoscopic approach for performing parietal pleurectomy. We have developed and used this technique successfully in 12 patients for treatment of recurrent spontaneous pneumothorax with extended bullous lung alterations (stage 4 according to the classification of Vanderschueren). For this purpose we need videoendoscopy and specially designed equipment, including pliable silicone trocars and angled instruments. The mean age of the patients was 38 years; no deaths and no complications occurred. The average period of postoperative hospitalization was 3.3 days. During the follow-up period ranging between 5 and 10 months (mean 7.5), no relapsing pneumothorax was observed.

Laser thoracoscopy for pleural effusion

A potential, new, therapeutic modality for the treatment of recurrent symptomatic pleural effusion in a patient with metastatic carcinoma is presented using "minimal access surgery." Diagnosis at the time of thoracoscopy, as well as treatment using free-beam and contact-tip modalities, is outlined in detail. Also, a complication of inter-costal artery bleeding is presented, as well as its solution using the end-firing endoclip applier. This is an effective and useful procedure that should be particularly of interest to surgeons already using various scope methods. Surgeons currently express strong interest in accomplishing diagnosis and treatment goals in a variety of clinical situations using "minimal access surgery," a phrase coined at the 1989 International Congress of the Society of American Gastrointestinal and Endoscopic Surgeons. Enthusiasm about this procedure is evident across the country by the number of laparoscopic courses offered at a variety of institutions. Similarly, the chest allows certain applications of minimal access surgery resulting in accurate diagnosis and possible definitive treatment by use of the thoracoscope.

Endoscopic oesophagectomy through a right thoracoscopic approach

A technique of subtotal endoscopic oesophagectomy through the right thoracoscopic approach is described. It has been used in five patients, four with cancer and one with benign motility disorder. The operative blood loss during the endoscopic dissection stage was unmeasurable in four patients and amounted to 300 ml in one. The mean (range) duration of the endoscopic dissection was 3.3 (3.0-4.0) h and of the total procedure was 5.5 (4.5-7.5) h. After the operation, the mean (range) duration of stay in the intensive care unit was 19.5 (16-26) h. From the time of the operation, the mean (range) hospital stay was 11 (8-18) days. One patient developed left vocal cord palsy which prolonged this.

[Indications, technics and results of thoracoscopy]

Indications, materials, technique and contraindications of diagnostic thoracoscopy are described. Examination of 67 thoracoscopies carried out in the past four years shows the technique studied to be the best available diagnostic tool in the field of pleural and peripheral lung diseases: neoplasia, pleuritis and bullous disease. Whether done under narcosis or local anaesthetic, the examination proved to be well tolerated, given the minimum, temporary damage caused to respiratory function. Complications were few and not lethal. A final diagnosis was achieved in the majority of cases. There were a number of false negatives in circumscribed neoplasia localised at points that could not be reached by the instrument, and in cases complicated by pleural adhesions, which prevent correct examination.