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Recurrent spontaneous pneumothorax and a persistent air-leakage after three days of suction therapy are two major indications for thoracoscopy. This procedure allows coagulation of blebs and cutting of pleural adhesions as well as identification of patients with large emphysematous bullae which should be treated surgically pleurectomy. Insufflation of talcum is safe and effective in achieving definitive pleurodesis.
After talc pleurodesis performed between 1954 and 1964 because of spontaneous pneumothorax during thoracoscopy, 99 patients were followed up. Only 2 patients experienced a pneumothorax relapse. Mesothelioma was not observed in any case, X-ray changes in the Pleura were moderate, and lung function did not show any significant restriction. It is concluded therefrom that the method is effective and does also not produce any noticeable side effects on long-term observation.
The effectivity of sympathectomy performed via thoracoscopy as initiated by Kux, has been confirmed by examining two cases reported here.
The endoscopic-macroscopic images of thoracoscopies performed in the presence of a pleural effusion, are analysed. When comparing the various forms of the disease, the image must be resolved into its elements. It is found that the optical image is characteristic for the disease patterns; the appearance of the image elements also depends on the time at which the examination is performed.
Six new cases seen personally, and 72 cases of catamenial pneumothorax found in the literature have had thoracoscopic talcage. We shall discuss several peculiarities of this syndrome: its relative rarity, symptoms linked to periods, the specific and unique endopleural aspects, confirming certain pathogenetic theories, the first among which is pleural endometriosis. Therapeutic methods are also discussed, stressing the sharing of the association between pleural symphysis surgically and above all by thoracoscopy with antigonadotrophic hormone therapy an association which alone gives good results in 95% of cases.
We report on a prospective study of complications in 2,133 bronchoscopies, 61 transthoracic lung biopsies, 32 mediastinoscopies and 6 thoracoscopies, performed between 1985 and 1986. There were no deaths or life threatening complications. The total rate of essential complications, e.g. pneumothorax, haemorrhage, laryngospasm, and bronchospasm of all patients with bronchoscopies was 10.5%. Excluding small endobronchial haemorrhages, without influence on the patients state or endoscopic procedures the final rate of complications was 1.9%.
A total of 20 patients aged 50.5 +/- 4.5 years with 24 chronic pleural effusions associated with lymphomas underwent 24 thoracoscopic talc poudrages. Effusions were serofibrinous (32%), hemorrhagic (41%), or chylous (27%). The mean volume of pleural liquid evacuated by repeated thoracenteses before thoracoscopy was 5.2 +/- 0.6 l. Thoracoscopic biopsies confirmed a lymphomatous infiltration of the pleura in 95.5% of cases. A definitive pleural symphysis was obtained in all cases but 2 (92% positive results): in 1 case, a further single thoracentesis of 400 ml was necessary, and in the 2nd case the patient died within 6 days from an acute evolution of her Hodgkin's disease. The mean drainage time was 4.8 +/- 0.2 days. Overall results are thus identical to those obtained in solid tumor-related pleural effusions (91% positive results).
The experience of treatment of 253 cases of benign tumors and cysts of the mediastinum is summarized. Complex X-ray and endoscopic examination was used for diagnosis. Due to application of thoracoscopy, topical and morphologic diagnosis was improved. Surgery was the main method of treatment. Radical operations were carried out in 98.9% and in 6.3% they involved resection of the rib, lung, pericardium, the membranous part of the trachea and bronchus, esophageal diverticulum or removal of diaphragmatic hernia. The complicated and life-threatening nature of the procedure is mirrored in the postoperative lethality rate (1.57%) and pattern of complications and requires a strict observance of the suggested principles of surgery.
We made a retrospective analysis with regard to the therapy of all patients with spontaneous pneumothorax who were treated in the district lung hospital Lostau from 1. 1. 1983 to 30. 6. 1985. We waited for the spontaneous regression at 10 patients with a partial pneumothorax, the relapse rate was 30% in these cases. Sixty three patients were aspirated once or repeatedly with the pneumothorax apparatus. Our own success rate was 78% with this therapy, the relapse rate 26%. We treated 18 patients by rubber-tube drain. It was successful in 94%, the relapse rate was 19%. A thoracoscopy with pleurodesis was necessary in one patient who was generally inoperable. Five patients were treated primarily surgically. The same therapy was carried out in 6 patients with bullous emphysema in the free period. We consider the aspiration of spontaneous pneumothorax with pneumothorax apparatus as an effective method, which is not very burden some for the patients. The continuous suction drainage was very important too in the differential therapy of our patients.
Investigations performed in 41 patients with postoperative residual cavities after surgical interventions of different volume have shown high value of thoracoscopy as an additional diagnostic and curative method. The endoscopy findings determinate further curative tactics--surgery or conservative therapy.
Benign pleural mesothelioma is a rare tumor which is usually diagnosed by thoracotomy in a patient with an intra-thoracic mass of uncertain origin. We report a case in which both diagnosis and therapy of a small, peripheral coin-lesion were achieved through thoracoscopy. The latter was performed following the observation that the tumor moved freely in the pleural space, because of an incidental pneumothorax.
With the aim to improve the results of treatment of pneumothorax, experience has been gathered using tissue glues (Akutol-Spofa, Ankerplast-Spray). Using these preparations, it is possible to tighten small defects and porous regions of the pleura, and to induce circumscribed obliterations of the pleural fissure. The technique is simple (intubation, thoracoscopy, circumscribed application of glue to visceral pleura, insufflation of the lung, drainage of the thorax, permanent suction if necessary). The method is used only, if spontaneous resolution of pneumothorax is failing. Using this method, the relapse rate is significantly reduced as compared with the results of pure drainage with suction. Late results of pulmonary function are good.
In a prospective study of 334 consecutive patients with chronic pleural effusion 156 or 47% had a malignant etiology. The sensitivity of cytological examination of pleural fluid in detecting malignancies was 43%. Thoracoscopy had a sensitivity of 80% and could reveal malignancy in 37 of 47 patients with malignant effusions and a negative cytology. A malignant etiology must also be suspected when atypical cells are found in the pleural fluid as in our study 16 out of 19 fluid samples with atypical cytology represented malignant effusions. The predictive value for a malignant etiology was estimated for the following variables: sex, size of effusion, colour and eosinophils of pleural fluid, smoking habits and asbestos exposure. The predictive value of each variable was estimated separately, combining two by two and by a logistic regression function to exclude correlation to yet another variable. The single variable with the strongest positive predictability towards malignancy was a bloody fluid. Conversely, more than 30 per cent eosinophils in the fluid had the strongest negative predictability towards malignancy. The ability of our statistical method, a logistic regression function to discriminate between malignant and non-malignant etiology was 79%. The estimated probability of a malignant etiology should influence the choice of invasive procedures and the duration and intensity of follow-up.
Thoracoscopy is a method involving little discomfort for the patient but of high diagnostic effectiveness for pleural alterations. A histological diagnosis was established in 56 cases out of a total of 60 pleural effusions of unknown origin. In 10 pleural or pleuropulmonary diseases, anatomical classification was possible in all cases. In cases of pneumothorax (21 patients) the bronchopleural fistula could very often be seen and closure by detaching of pleural adhesions or cauterization was possible. These manipulations are usually followed by insufflation of sterile talcum powder through the thoracoscope. Suspicion of ruptured diaphragm due to accident was easily and quickly verified. No complications occurred in our 100 thoracoscopic examinations.
Pleural brushing can be performed under thoracoscopic examination. The combined use of all three methods of diagnosis (macroscopy, biopsy, cytology) achieved optimal diagnostic results. From September 1980 to October 1981 we have performed 150 thoracoscopies for pleural effusions, while the results of conventional pleural cytology and biopsy were negative. In 108 cases pleural brushing and biopsy were both performed. The diagnosis was in 37 cases non malignant diseases states associated with effusions and in 71 cases tumoral effusions. Among the 37 cases of non malignant diseases states associated with effusions were: 6 mechanical effusions, 27 inflammatory processes, 4 infectious processes. Among the 71 cases of tumoral effusions were 3 benign pleural lipomas, 50 metastatic carcinomas, 18 carcinomatous mesotheliomas. We studied the diagnostic accuracy of pleural brushing: in non malignant diseases, pleural brushing show the non tumoral features of the process, in metastatic tumours, biopsy was positive in 80% of the cases; pleural brushing in 78% of cases; taken together they allowed the diagnosis in 86% of the cases, in carcinomatous mesotheliomas biopsy was positive in 82,3%, pleural brushing in 78%; taken together they allowed the diagnosis in 89% of the cases. Pleural brushing allows a rapid cytological diagnosis, enhances the histological results and may also be used to get cellular material in areas dangerous to biopsy.
The etiology, diagnosis and management of traumatic diaphragmatic hernias were discussed, and a personal series of 61 hernias was reviewed. The need for a greater clinical awareness of the condition was stressed. Chest roentgenograms were shown to be the most effective diagnostic method, and thoracoscopy was recommended in all hernias that occurred within 24 hours of the injury. Barium contrast studies of the gastrointestinal tract have limitations, and caution was advised with these methods when dealing with patients presenting in acute crisis. Computerized tomographic scanning is becoming increasingly more valuable in the investigation of this condition, but the author hesitates to recommend its routine use. A plea was made for the abdominal approach to diaphragmatic hernias. The value of this approach was illustrated by the successful repair of 58 of 61 hernias through a laparotomy.
The Veress cannula was used in 20 patients to induce a closed pneumothorax preceding diagnostic thoracoscopy. The Veress cannula appears to be simple, safe and precise in use.
In a prospective study of 336 consecutive patients with long-term pleural effusions, 32 cases of malignant mesothelioma were found. Microscopic examination of pleural tissue specimens, preferably selected at thoracoscopy, proved superior to pleural fluid analysis as an aid to correct diagnosis. The epithelial proved to be the most common type of malignant mesothelioma. As an example of the mesothelial cells' multipotent ability, malignant cells were seen transforming into fat-like cells with lipid-containing vacuoles. In the fibrous tumour type, cytological examination of pleural fluid revealed only normal cells. Cells with malignant features were seen in fluid samples from epithelial and biphasic tumour types. The malignant cells often formed tubuli-like aggregates which could be mistaken for adenocarcinoma. Hyaluronic acid was more frequently detected in tissue specimens than in the pleural fluid samples. The morphological type and the patient's age had an impact on the survival time, whereas sex and extensive surgical treatment seemed less important.