Pleuroscopy or video-assisted thoracoscopic surgery for exudative pleural effusion: a comparative overview.
ABSTRACT: Exudative pleural effusions, such as malignant and tuberculous pleural effusions, are associated with notable morbidity and mortality. Unfortunately, a significant number of these effusions will remain undiagnosed despite thoracentesis. Traditionally, closed pleural biopsies have been the next best diagnostic step, but the diagnostic yield of blind closed pleural biopsies for malignant pleural effusions is insufficient. When image-guided targeted biopsies are not possible, both pleuroscopy and video-assisted thoracoscopic surgery are reasonable options for obtaining pleural biopsies, but the decision to select one procedure over the other continues to raise much debate. Pleuroscopy (aka. medical thoracoscopy, local anaesthetic thoracoscopy) is a relatively common procedure performed by interventional pulmonologists in the bronchoscopy suite with local anesthesia, often as an outpatient procedure, on spontaneously breathing patients. Video-assisted thoracoscopic surgery, on the other hand, is performed by thoracic surgeons in the operating room, on mechanically ventilated patients under general anesthesia, though admittedly considerable overlap exists in practice. Both pleuroscopy and video-assisted thoracoscopic surgery have reported diagnostic yields of over 90%, although pleuroscopy more often leads to the unsatisfactory diagnosis of 'non-specific' pleuritis. These cases of 'non-specific' pleuritis need to be followed up for at least one year, as 10-15% of them will eventually lead to the diagnosis of cancer, typically malignant pleural mesothelioma. Both procedures have their pros and cons, and it is therefore of paramount importance that all cases be discussed as part of a multidisciplinary approach to diagnosis within a "pleural team" that should ideally include interventional pulmonologists and thoracic surgeons.
Project description:Establishing the etiology of exudative pleural effusions in the setting of an unrevealing pleural fluid analysis often requires biopsies from the parietal pleura. While closed pleural biopsy (CPB) has been a popular minimally-invasive approach, it has a poor diagnostic yield, barring a diagnosis of tuberculous pleurisy. Medical thoracoscopy (MT) is a minimally-invasive ambulatory procedure performed under local anesthesia or moderate sedation which allows for direct visualization of biopsy targets as well as simultaneous therapeutic interventions, including chemical pleurodesis and indwelling tunneled pleural catheter (ITPC) placement. The excellent yield and favorable safety profile of MT has led to it replacing CPB for many indications, particularly in the management of suspected malignant pleural effusions. As experience with MT amongst interventional pulmonologists has grown, there is an increased appreciation for its important role alongside percutaneous and surgical approaches in the diagnosis and treatment of pleural disease.
Project description:Medical thoracoscopy has been shown to be an efficacious procedure in diagnosing unexplained exudative pleural effusions with excellent safety. This study aimed to assess the diagnostic significance of thoracoscopy in the management of patients with malignant pleural effusion (MPE).Consecutive patients with malignant pleural effusion were retrospectively reviewed, and their demographic, radiographic, thoracoscopic and histological data were collected.Between July 2005 and June 2014, 342 of 833 patients undergoing thoracoscopy were finally confirmed to suffer from MPE. The top three frequent causes of MPE were metastatic carcinoma (79.5%), malignant mesothelioma (10.2%), and lymphoma (2.9%). Among metastatic malignancies, the most common cancer was lung cancer (85.2%), followed by breast cancer (4.4%), ovarian cancer (2.2%), pancreatic cancer (1.8%), etc. No serious adverse events associated with thoracoscopy were recorded.Medical thoracoscopy is a valuable and safe tool in diagnosing malignant pleural effusion with minimal complication rates.
Project description:Background:The long-term outcome after non-diagnostic thoracoscopy (idiopathic pleuritis) has not been investigated in nationwide studies, and the survival has never been estimated. Therefore, we decided to investigate the three-year incidence of malignancy and survival of patients with idiopathic pleuritis. Methods:Retrospective, register-based, nationwide study of patients undergoing diagnostic video-assisted thoracoscopic surgery (VATS) thoracoscopy ≤30 days after thoracentesis, using The National Patient Registry and The Danish Cancer Registry. Idiopathic pleuritis was defined as; no diagnosis of malignancy within 31 days after VATS. Patients were followed for 36 months after VATS. Results:In total, idiopathic pleuritis were identified in 547 out of 658 patients undergoing VATS (83%), and 29 (5%) were diagnosed with malignancy during the 3 years follow-up period after VATS. Of these, 93% were diagnosed with malignancy within the first year. Numbers-needed-to-follow-up for detecting one case of malignancy was 18 during the first year after VATS and 250 in the two subsequent years. Survival was independent on type of malignancy (MPM vs. other malignancies; P=0.13) and of time from VATS to diagnosis (≤31 days vs. 1-36 months; P=0.15). Median survival in the non-malignant group was 1,095 days. Conclusions:Our study confirms a low incidence of malignancy in idiopathic pleuritis after VATS. Nearly all incident cases of malignancy were diagnosed within 12 months from VATS. No survival disadvantage was observed in patients with incident malignancy. Our data suggest that follow-up of idiopathic pleuritis could safely be limited to 1 year. The optimal follow-up strategy remains to be investigated.
Project description:A 41-year-old man with rheumatoid arthritis (RA) presented with worsening dyspnea and deconditioning. He had recently been treated with adalimumab for rheumatoid pleural effusions but developed non-tuberculous mycobacterial pleurisy due to Mycobacterium heckeshornense. Despite therapy with appropriate anti-mycobacterial agents, he ultimately required video assisted thoracoscopy for decortication. While Mycobacterium heckeshornense has been reported to cause infection in multiple sites including the lung, this is the first case to our knowledge of infection confined to the pleural space. Rheumatoid pleural effusions can be complex and difficult to treat, especially when complicated by mycobacterial infection.
Project description:Although technical advances in non-invasive and minimally invasive approaches to lung and pleural cancer diagnosis and staging have become more widely available and accurate, surgical techniques remain the gold standard in assessing the extent of loco-regional involvement. Precise surgical staging of lung or pleural tumours is pivotal in the selection of surgical candidates and for predicting survival. In some patients, both mediastinal and pleural exploration may be needed for many different reasons. Transcervical videomediastino-thoracoscopy (VMT) combines simultaneously the exploration of both the mediastinum and the pleural cavities through a single cervical incision, allowing for biopsies or sampling of the mediastinal lymph nodes, lymphadenectomy and pleuropulmonary assessment (mainly pleural effusions, tumour involvement of the visceral and parietal pleura and pulmonary nodules). Thoracic surgeons should be aware of this combined surgical approach and completely familiar with classical indications and technical details of the transcervical approach to the mediastinum and thoracoscopic exploration of the pleural cavities.
Project description:The National Comprehensive Cancer Network (NCCN) clinical practice guideline of non-small cell lung cancer (NSCLC) in 2018 points out that anatomic pulmonary resection is a preferred option for early stage NSCLC. With the development of video-assisted thoracoscopy, minimally invasive thoracic surgery represented by thoracoscopy has been widely used in clinical practice. Video-assisted thoracoscopic segmentectomy has become one of the treatment options for early stage NSCLC. Clinical studies have found that sublobar resection can achieve similar results and preserve more pulmonary function in the treatment of early stage NSCLC compared with lobectomy, but the changes of pulmonary function after segmentectomy are still controversial. This article focuses on the research progress of pulmonary function changes in NSCLC patients after video-assisted thoracoscopic segmentectomy.?.
Project description:BACKGROUND Traditional diagnostic methods for tuberculosis (TB) cannot be reliably applied to tuberculous pleurisy. Therefore, this prospective, randomized, controlled trial was performed to compare the diagnostic sensitivity and safety of ultrasound-guided cutting-needle pleural biopsy versus thoracoscopic pleural biopsy in patients suspected of tuberculous pleurisy following inconclusive thoracentesis. MATERIAL AND METHODS A total of 196 adult patients with acid-fast bacillus (AFB)-negative exudative pleural effusions clinically suspected of tuberculous pleurisy were recruited. Enrollees were randomized into 2 cohorts: ultrasound-guided cutting-needle pleural biopsy (n=96) or thoracoscopic pleural biopsy (n=96). The overall diagnostic yields, diagnostic sensitivities for tuberculous pleurisy, and post-procedural complications for both cohorts were statistically compared. RESULTS Ultrasound-guided pleural biopsy displayed an overall diagnostic yield of 83%, while thorascopic pleural biopsy displayed a similar overall diagnostic yield of 86% (?²=1.88, df=1, p=0.17). There were 127 patients conclusively diagnosed with tuberculous pleurisy, resulting in a tuberculous pleurisy prevalence of 65% in this patient population (66% in the ultrasound cohort vs. 63% in the thoracoscopy cohort; p>0.05). Ultrasound-guided pleural biopsy displayed a sensitivity of 82% in detecting tuberculous pleurisy, while thorascopic pleural biopsy displayed a similar sensitivity of 90% (?²=1.05, df=1, p=0.30). The sensitivities of these 2 modalities did not significantly differ based on the degree of pleural thickening (p>0.05). Post-procedural complications were minor. CONCLUSIONS Ultrasound-guided and thoracoscopic pleural biopsy both display strong (>80%) but statistically similar overall diagnostic yields for diagnosing pleural effusions following inconclusive thoracentesis. Both modalities also display strong (>80%) but statistically similar sensitivities in detecting tuberculous pleurisy.
Project description:Objective:Single-incision thoracoscopic surgery is a favorable treatment choice for primary spontaneous pneumothorax, and manual ligation of the bleb during thoracoscopic surgery appears to offer better economic results. In this study we undertook ligation of the bleb by hand under uniportal thoracoscopic surgery for primary spontaneous pneumothorax. Methods:Between June 2015 and December 2016, a series of 26 patients with primary spontaneous pneumothorax underwent hand ligation of blebs using the technology of uniportal thoracoscopy, followed by pleural abrasion as necessary. Results:No case was converted to two- or three-port video-assisted thoracoscopic surgery during the operation. No patients experienced prolonged (>5 days) air leakage. No other complication was recorded. No recurrence of pneumothorax was encountered during 29-47 months follow-up. Compared with the group treated by bullectomy using stapler, we found a significant reduction in medical costs in the group with bleb ligation. Conclusions:Ligation of the bleb by hand under uniportal thoracoscopic surgery for primary spontaneous pneumothorax is a safe and offers better economic results, which is applicable for low income family.
Project description:A complex para-pneumonic effusion is a descriptive term for exudative effusions, which complicate or are likely to complicate the anatomy of the pleural space after pneumonia. We performed an online search was performed using the resources PubMed and Google Scholar to provide an update on the management of such effusions based on review of published literature. Search terms including pleural effusion (PE), parapneumonic effusion, and empyema were used. Relevant studies were identified and original articles were studied, compared and summarized. References in these articles were examined for relevance and included where appropriate. Studies involving pediatric patients were excluded. Management of para-pneumonic PE has changed tremendously over the last decade. As we accumulate more evidence in this area, approach to pleural fluid drainage is becoming more specific and guideline based. An example of a practice changing study in this aspect is the Multi-center Intrapleural Streptokinase Trial (MIST) 2 trial which demonstrated that a combination of intra-pleural tPA and DNAse improved outcomes in pleural infections compared to DNase or t-PA alone. More randomized control trials are needed to describe the role of surgical techniques like VATS (video-assisted thoracoscopic surgery) when MIST 2 protocol fails; this combination has revolutionized the management of empyema in recently.
Project description:Closed pleural biopsy was previously considered a procedure of choice in cases of undiagnosed pleural effusion with good efficacy. Currently, the closed pleural biopsy has been replaced by thoracoscopic biopsy but not easily available in resource-limited setups.The objective of this study was to analyze the diagnostic yield and safety of closed needle pleural biopsy in exudative pleural effusion and assessment of patients' characteristics with the yield of pleural biopsy.This was a cross-sectional study.This study was conducted at Institute of Respiratory Diseases, SMS Medical College, Jaipur, a tertiary care center of West India.A total of 250 cases of pleural effusion were evaluated with complete pleural fluid biochemical, microbiological, and cytological examination. Out of these 250 patients, 59 were excluded from the study as the diagnosis could be established on initial pleural fluid examination. The remaining (191) patients were considered for closed pleural biopsy with Abrams pleural biopsy needle.The main outcome measure was diagnostic yield in the form of confirming diagnosis.Out of the 191 patients with exudative lymphocytic pleural effusion, 123 (64.40%) were diagnosed on the first pleural biopsy. Among the remaining 68 patients, 22 patients had repeat pleural biopsy with a diagnostic yield of 59.9%. The overall pleural biopsy could establish the diagnosis in 136 (71.20%) patients with pleural effusion. The most common diagnosis on pleural biopsy was malignancy followed by tuberculosis.Closed pleural biopsy provides diagnostic yield nearly comparative to thoracoscopy in properly selected patients of pleural effusions. In view of good yield, low cost, easy availability, and very low complication rate, it should be used routinely in all cases of undiagnosed exudative lymphocytic pleural effusion.There was no comparison with a similar group undergoing thoracoscopic pleural biopsy.