Medical thoracoscopy (MT) is a minimally invasive, endoscopic procedure for exploration of the pleural cavity under conscious sedation and local anesthesia. MT has been performed at the Seoul National University Hospital since February 2014. This paper summarizes the findings and outcomes of MT cases at this hospital.
Patients who had undergone MT were enrolled in the study. MT was performed by pulmonologists, using both rigid and semi-rigid thoracoscopes. During the procedure, patients were under conscious sedation with fentanyl and midazolam. Medical records were reviewed for clinical data.
From February 2014 to January 2016, 50 procedures (47 cases) were performed (diagnostic MT, 26 cases; therapeutic MT, 24 cases). The median age of patients was 66 years (59–73 years), and 38 patients (80.9%) were male. The median procedure duration from initial incision to insertion of the chest tube was 37 minutes. The median doses of fentanyl and midazolam were 50 µg and 5 mg, respectively. All procedures were performed without unexpected events. Of the 26 cases of pleural disease with an unknown cause, 19 were successfully diagnosed using MT. Additionally, diagnostic MT provided clinically useful information in the other six patients. Therapeutic MT was very effective for treatment of malignant pleural effusion or empyema. The median number of days with chest tube drainage was 6 (3 days for diagnostic MT and 8 days for therapeutic MT).
MT is a useful and necessary procedure for both diagnosis and treatment of pleural diseases.
Medical thoracoscopy (MT) is a minimally invasive, endoscopic procedure for exploration of the pleural cavity under conscious sedation and local anesthesia
As a therapeutic procedure, chemical pleurodesis performed during or after MT for recurrent and symptomatic malignant pleural effusions has a success rate of ~90%
In this report, we summarize the findings and outcomes of MT performed at Seoul National University Hospital, Seoul, South Korea since February 2014.
Patients who underwent at least one MT procedure at Seoul National University Hospital, Seoul, South Korea from February 2014 to January 2016 were included in the study. MT was performed for both diagnostic and therapeutic purposes in patients with various pleural diseases. The study protocol was approved by the Institutional Review Board (IRB) of Seoul National University Hospital (IRB number: 1605-051-760) and was conducted in accordance with the amended Declaration of Helsinki.
All MT procedures were performed by pulmonologists under conscious sedation in the bronchoscopy room. All patients received oxygen by nasal cannula and were placed in the lateral decubitus position with the ipsilateral arm abducted and elevated over the head to maximize access to the hemithorax
Procedure duration was defined as the time from skin incision to insertion of the chest tube. Tissue biopsies and/or microbiological results of samples were reviewed. Clinicians assessed the effectiveness of therapeutic MT. Major and minor complications were recorded.
Continuous variables are presented as median values (interquartile range); categorical variables, relative frequencies, and percentages. Comparison of MT for diagnosis and treatment was evaluated using the Mann-Whitney U test for continuous variables, or the chi-square test for categorical variables. A two-tailed p-value less than <0.05 indicated statistical significance. All statistical analyses were performed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA).
During a 2-year period, 47 patients underwent 50 procedures, including 26 diagnostic and 24 therapeutic MT (
The median procedure time was 37 minutes, although the duration of the procedure was generally longer for patients who underwent therapeutic MT. The doses of fentanyl and midazolam that were used were different for diagnostic and therapeutic MT; fentanyl was used at a dose of 50 µg for both diagnostic and therapeutic MT, whereas midazolam was used at a dose of 5 mg for therapeutic MT and 4.5 mg for diagnostic MT (4.5 mg vs. 5 mg, p=0.048) (
Nineteen of 26 cases of unexplained pleural disease were successfully diagnosed. Twelve patients were diagnosed with pleural metastases: pulmonary adenocarcinoma (five patients), non-pulmonary adenocarcinoma (one patient), squamous cell carcinoma (one patient), sarcomatoid carcinoma (one patient), small cell carcinoma (two patients), epithelioid sarcoma (one patient), and metastasis of unknown origin (one patient) (
Seven patients remained undiagnosed even after MT; however, three had pleural biopsy findings that showed the presence of atypical cells, and they were clinically diagnosed with malignant pleural effusion. Finally, one patient was finally diagnosed with adenocarcinoma via video-assisted thoracoscopic surgery (VATS). Among four patients who showed nonspecific inflammation, pleural effusion was spontaneously resolved without specific treatment in three, whereas one was finally diagnosed with mesothelioma using VATS after 3 months of MT. Although a specific diagnosis was established in 19 of 26 patients, diagnostic MT provided clinically useful information in the other six. Overall diagnostic yield in the study was 96.2%.
For therapeutic purposes, 21 patients underwent 24 procedures. Ten patients with malignant pleural effusion underwent 11 procedures. One patient underwent MT twice because pleural effusion had progressed on both sides. Eleven patients with empyema underwent 13 procedures. With the exception of one procedure, therapeutic MT was generally determined to be helpful according to clinicians.
For 41 patients, the median number of days with chest tube drainage was 6 (3 days for patients who underwent diagnostic MT and 8 days for those who underwent therapeutic MT) (
Re-expansion pulmonary edema occurred in one patient and required drainage of 3.03 L of pleural fluid over a 3–4 hour period (
MT is a minimally invasive procedure for inspection and biopsy of the pleural space and therapeutic intervention
Patients who need therapeutic MT usually have poor lung function or performance status. MT can be performed in patients with poor lung function or those with a high anesthetic risk associated with an open procedure. Migliore et al.
TUS can be performed at the bedside and is very useful during MT. TUS can safely and reliably identify entry sites for trocar placement during MT, and a TUS exam adds only minutes to the duration of the procedure
MT is typically performed under local anesthesia, although premedication with an intravenous anxiolytic or analgesic may be accommodated
MT allows direct visual assessment of the pleura and subsequent biopsy of visually abnormal areas, which maximizes diagnostic yield
Although MT has become more readily available in Europe and North America over the past two decades
Traditionally, diagnoses of the causes of pleural effusion or pleurodesis in patients with malignant disease are the two major indications for MT
A single thoracentesis procedure using TUS rarely provides long-lasting relief. MT is more effective than conventional thoracentesis using TUS, in draining pus to provide palliation. Some patients with malignant pleural effusion have adhesions in the pleural space
In summary, MT is a useful and necessary procedure for both the diagnosis and treatment of various pleural diseases.
Characteristic | Value (n=47) |
---|---|
Age, yr | 66 (59–73) |
Male sex | 38 (80.9) |
Smoking status | |
Current | 10 (21.3) |
Former | 22 (46.8) |
Never | 14 (29.8) |
Unknown | 1 (2.1) |
Pack-year | 15.0 (0–32.5) |
History of tuberculosis | 6 (12.8) |
History of malignancy | |
Solid tumor | 21 (44.7) |
Hematologic malignancy | 2 (4.3) |
Values are presented as median (interquartile range) or number (%).
Parameter | Total procedures (n=50) | Diagnostic procedure (n=26) | Therapeutic procedure (n=24) | |
---|---|---|---|---|
Procedure time*, min | 37:29 (27:15–55:29) | 33:59 (24:44–40:00) | 51:29 (37:14–1:07:44) | 0.001 |
Instruments | ||||
Rigid scope | 29 (58.0) | 16 (61.5) | 13 (54.2) | 0.598 |
Semi-rigid scope | 21 (42.0) | 10 (38.5) | 11 (45.8) | |
TUS-guided | 39 (78.0) | 19 (73.1) | 20 (83.3) | 0.382 |
Doses of sedatives/analgesics | ||||
Fentanyl, μg | 50 (50–50) | 50 (50–50) | 50 (50–50) | 0.808 |
Midazolam, mg | 5 (4.0–7.0) | 4.5 (3.0–6.0) | 5.0 (4.0–7.0) | 0.048 |
Duration of post-procedure chest tube drainage, day | 6.0 (3.0–10.0) | 3.0 (3.0–7.0) | 8.0 (6.75–19.0) | 0.005 |
Values are presented as median (interquartile range) or number (%).
*Procedure time: from lidocaine injection to chest tube insertion.
TUS: thoracic ultrasound.