[Mediastinoscopy, thoracoscopy and biopsy under thoracoscopy as diagnostic methods of thoracic diseases].
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The impact of thoracoscopy on the management of pleural disease.
STUDY OBJECTIVE: To describe the diagnostic efficacy, morbidity, and patient outcome of thoracoscopy; to quantify the direct impact of thoracoscopy on clinical management; and to determine preoperative variables associated with finding malignancy at thoracoscopy to aid patient selection. DESIGN: Retrospective chart review of consecutive cases of thoracoscopy for pleural disease. SETTING: Single tertiary medical center. PATIENTS: One hundred eighty-two consecutive patients who underwent thoracoscopy for pleural disease over a 5-year period (from 1987 through 1992). MEASUREMENTS AND RESULTS: Final diagnoses were 98 (54%) malignant, 58 (32%) benign, and 26 (14%) idiopathic. Thoracoscopy had a diagnostic sensitivity of 95% for malignancy and 100% for benign disease. Malignancy was shown by thoracoscopy in 27 of 41 (66%) patients who had a preoperative nondiagnostic closed pleural biopsy, and in 24 of 35 (69%) patients who had at least 2 preoperative negative pleural cytologic specimens. Chart review by preestablished criteria showed information obtained from thoracoscopy directly influenced treatment in 155 (85%) patients. Thirty-seven (20%) patients, however, had at least one perioperative complication (15% major, 8% minor). Ten (6%) patients died during the same hospitalization in which a thoracoscopy was performed, although none died within 48 h. There was one thoracoscopy-related death. Sixty-two (34%) patients died within 6 months of thoracoscopy (death by all causes). Forty-seven (48%) patients who had intrathoracic malignancy present at thoracoscopy died within 6 months. Patients found to have malignant pleural disease by thoracoscopy were more likely to have a preoperative history of a malignancy (p = 0.001). Age more than 50 years was associated with finding malignancy at thoracoscopy (p = 0.04). A combined lymphocytic and hemorrhagic effusion was associated with malignancy (p = 0.004). Preoperative pleural data showed that idiopathic effusions had a significantly lower median lactate dehydrogenase (LDH) value (192, which was normal) compared with malignant or benign effusions. CONCLUSIONS: (1) Thoracoscopy increases yield for malignant and benign disease when thoracentesis and closed pleural biopsy are nondiagnostic. (2) Thoracoscopy directly affects clinical management in 85% of patients. (3) Significant complications can occur in patients receiving tertiary care. (4) For the evaluation of suspected malignant pleural disease, thoracoscopy has its greatest diagnostic yield in older patients who have a history of malignancy and who present with a lymphocytic, hemorrhagic, high LDH effusion.
Female↗
Clinical value of video-assisted thoracoscopy for preoperative staging of non-small cell lung cancer. A prospective study of 105 patients.
This study prospectively evaluated the usefulness of thoracoscopy for staging non-small cell lung cancer in 105 consecutive patients. A comparison was made of TNM stage grouping classification according to clinical disease, thoracoscopic data, and pathological findings. In 40 (38%) patients, thoracoscopy was unreliable for assessing extent of disease due to pleural symphysis. In 13 T1 clinical lesions, thoracoscopy was unreliable in 5, clinical and thoracoscopic staging concurred in 4, but 4 cases changed to T2. In 62 T2 clinical lesions, thoracoscopy was not feasible due to technical difficulties in 21 (34%); however, in the remaining 41 cases, 6 lesions changed to T3 and 1 to T4. In the group of 23 T3 or T doubtful clinical disease, thoracoscopy was conclusive, whereas in 12 T4 clinical lesions, thoracoscopy contributed for tailoring treatment strategies. With regard to N stage, 72 N0 clinical cases, thoracoscopy revealed false negatives in 25%. N1 clinical lesions were not evaluated due to the small number of patients. In 30 N2 clinical lesions, thoracoscopy was incomplete in 11. In another 11 cases, mediastinal node involvement at nodal groups not accessible by mediastinoscopy was confirmed by thoracoscopy. Clinical and thoracoscopic findings were not concurrent in eight cases, therefore in clinical N2 lesions, the diagnostic accuracy of thoracoscopy was 63%. Only one case of unsuspected pleural metastasis was detected. Thoracoscopy-related complications occurred in nine cases. In summary, video-assisted thoracoscopy was useful for staging T3, T4, and T doubtful clinical disease as well as N2 lesions especially for the surgical exploration of lymph nodes at the lower paratracheal level (region 4), aortopulmonary window (region 5), paraaortic (region 6), posterior subcarinal space (region 7), paraesophageal (region 8), and inferior pulmonary ligament (region 9).
Carcinoma, Non-Small-Cell Lung↗
Open tube thoracoscopy: does it have a role in modern thoracic surgery?
To determine the role of open tube thoracoscopy in the diagnosis and management of thoracic diseases, a retrospective review of 48 patients was conducted. A mediastinoscope was used for open tube thoracoscopy. Eleven patients underwent diagnostic thoracoscopy, and 4 patients had thoracoscopy for cancer staging. All 11 diagnostic procedures yielded a diagnosis, and thoracic malignancies were staged accurately in all patients. Thirty-three patients underwent therapeutic thoracoscopy. Twelve therapeutic thoracoscopies were done for pneumothorax, 9 for loculated parapneumonic effusion or empyema, 4 for malignant effusions, 2 for traumatic hemothorax, 2 for wedge resection of peripheral lung cancers, and 4 for other indications. All but 1 therapeutic procedure were successful. Three patients experienced complications specific to thoracoscopy (empyema 1, prolonged air leak 1, chest tube site leakage 1). There were 5 deaths, but none were related to thoracoscopy. Open tube thoracoscopy is very effective for evacuation of loculated pleural fluid, pus, or blood, and it appears to have advantages over video thoracoscopy in these settings. Although open tube thoracoscopy is satisfactory for other simple pleural procedures and wedge resections of lung are possible, video thoracoscopic techniques are now preferred for these indications.
Adolescent↗
Diagnostic value of medical thoracoscopy in pleural disease: a 6-year retrospective study.
STUDY OBJECTIVES: Unlike thoracocentesis and closed pleural biopsy (CPB), medical thoracoscopy permits biopsy with direct visualization. In a 6-year retrospective study of patients having undergone at least one medical thoracoscopy, we analyzed the diagnostic yield of thoracoscopy and its value in the management of pleural disease. SETTING/PATIENTS: From January 1, 1989, to December 31, 1994, 168 medical thoracoscopies were performed on 154 patients (123 men; mean age +/- SE, 61 +/- 1 years), of which 149 were diagnostic and 19 were indicated for therapeutic assessment in malignant mesothelioma (MM). Prior to thoracoscopy, at least one CPB had been performed in 120 of 149 cases, yielding a diagnosis in 96 cases. RESULTS: Thoracoscopy challenged the CPB-based diagnosis in 43 of 96 cases. In 66 cases of nonspecific inflammation diagnosed by CPB, thoracoscopy revealed MM in 16 cases, adenocarcinoma in 10 cases, undetermined carcinoma in 3 cases, and pleural tuberculosis in 3 cases. In 18 cases in which the CPB diagnosis was MM, thoracoscopy, performed for precise staging, challenged the diagnosis in 4 cases. In 12 cases of carcinoma diagnosed by CPB, thoracoscopy specified the histologic type in 7 cases. Thoracoscopic diagnoses were found to be erroneous in 10 of 149 cases, mainly owing to pleural adhesions that limited access to the pleural cavity. There was one thoracoscopy-related death, one case of sepsis, and six cases of empyema. CONCLUSIONS: Medical thoracoscopy appears to be efficient and relatively safe in the management of pleural disease. Pleural adhesions can lower its diagnostic value.
Adenocarcinoma↗
Pleuropulmonary and cardiovascular consequences of thoracoscopy performed in healthy standing horses.
Six healthy, awake, and pharmacologically restrained mature horses were studied in order to define the changes in cardiopulmonary function during and after exploratory thoracoscopy and to determine the presence of postoperative complications occurring 48 hours after thoracoscopy. In a randomised 3 x 3 latin square design with 2 replications, 18 procedures were performed: 6 right (RTH) and 6 left thoracoscopies (LTH) and 6 sham procedures (STH). Prior to each procedure a physical examination and a bronchoalveolar lavage fluid analysis were performed. During thoracoscopy and sham protocols, horses were sedated with a continual drip of detomidine HCl and data were collected at 6 time intervals: T1 (baseline), T2 (10 min detomidine administration), T3 (first 15 min pneumothorax), T4 (5 min recovery from pneumothorax), T5 (second 15 min pneumothorax), and T6 (10 min recovery from the second pneumothorax and detomidine). An endoscopic thoracic examination was conducted during the 2 pneumothorax periods. An identical protocol was followed for sham procedures without surgery or pneumothorax. Data were analysed by ANOVA with time and surgical procedure as main factors. Physical examinations, thoracic radiography and ultrasound, CBC and bronchoalveolar lavage fluid analysis were performed 48 h after thoracoscopy. Heart rate, respiratory rate, and cardiac output decreased following detomidine administration. There was a trend for cardiac output to be lower during thoracoscopy. Mild systemic hypertension was associated with thoracoscopy although there was no effect on pulmonary arterial pressure. Total and pulmonary vascular resistances were increased following detomidine administration. Thoracoscopy caused a further increase in systemic and pulmonary vascular resistances especially during the second pneumothorax. Arterial O2 tension decreased following detomidine administration and was further decreased during the second pneumothorax period. PaO2 values were lower when thoracoscopy was performed on the left rather than the right hemithorax. No significant complications were found during the 48 h follow-up evaluation. A subclinical postoperative pneumothorax occurred in 2 horses, one of which had sustained a lung laceration by the trocar. Thoracoscopy performed in healthy, awake, and pharmacologically restrained horses did not have detrimental cardiopulmonary effects and did not cause postoperative complications within the first 48 h period.
Animals↗
Thoracoscopy for the diagnosis of pleural disease.
OBJECTIVE: To assess the accuracy and safety of thoracoscopy for the evaluation of pleural disease. DESIGN: Prospective evaluation of patients referred for thoracoscopy. SETTING: University hospital specializing in chest diseases. PATIENTS: We studied 102 patients with pleural disease, the cause of which had not been determined after initial investigation, including thoracentesis and needle biopsy. Eighty-six patients had pleural effusion, 11 had pleural mass, and 5 had pleural effusion in association with a known primary lung carcinoma. INTERVENTION: All patients had thoracoscopy under local anesthesia with mild sedation. Visually directed biopsies were done of parietal pleura. MEASUREMENTS: We recorded clinical characteristics, laboratory data, findings and duration of thoracoscopy, and any complications associated with the procedure. Hospital and clinic follow-up records were reviewed, and patients were contacted by telephone 12 and 24 months after thoracoscopy to assess their health status. MAIN RESULTS: One hundred and four thoracoscopies were done in 102 patients. A definitive diagnosis was established in 95 patients: 42 had malignant pleural disease and 53 had benign pleural disease. A diagnosis of benign pleural disease using thoracoscopy could not be confirmed in the remaining 7 patients because of insufficient follow-up information. Overall, thoracoscopy was 96% accurate with a sensitivity of 91%, a specificity of 100% and a negative predictive value of 93% for the diagnosis of pleural malignancy. Thoracoscopy was well tolerated under local anesthesia and entailed hospitalization for less than 24 hours in most cases. No deaths occurred, although 1.9% of patients had major complications, and 5.5% had minor complications. CONCLUSIONS: Among patients with pleural disease remaining undiagnosed after usual initial investigation, thoracoscopy done under local anesthesia is a rapid, safe, and well-tolerated procedure with an excellent diagnostic yield that is equivalent to that of thoracotomy.
Aged↗
Current applications of nonvideo thoracoscopy.
Video thoracoscopy has markedly improved the surgical team's ability to visualize the pleural cavity. As a result, traditional nonvideo thoracoscopy techniques have fallen into disuse. Although video technology has caused a resurgence of interest in thoracoscopy, and has made previously unimaginable endoscopic procedures feasible, it is not obviously superior to nonvideo thoracoscopy in all situations. The defining features of nonvideo thoracoscopy include an open tube type of thoracoscope (mediastinoscope), direct visualization of the pleural space through the thoracoscope, and passage of instruments through the thoracoscope. Potential clinical advantages of nonvideo thoracoscopy are related to the following features: simplicity of equipment, low cost, feasibility without one lung ventilation, feasibility under local or regional anesthesia, instrumentation through the thoracoscope (single incision), and ease of irrigation and suction. Nonvideo thoracoscopy is a simple and effective endoscopic technique for diagnostic pleural biopsy, pleurodesis of malignant effusions, debridement and drainage of empyemas, and evacuation of clotted hemothoraces. More complex thoracoscopic procedures require video thoracoscopy. Video capabilities have recently been added to several traditional open tube mediastinoscopes. In this way, it may be possible to combine some features of traditional nonvideo, open tube, thoracoscopy with video thoracoscopy.
Humans↗
Analysis of thoracoscopy in trauma.
BACKGROUND: The role of video-assisted thoracic surgery (VATS) in trauma has yet to be established. Up to the time of this writing, reviews of thoracoscopy in trauma have been primarily descriptive rather than analytic. This article analyzes the results of thoracoscopy (nonvideo and VATS) in trauma. METHODS: Analysis was done by reviewing 28 nonoverlapping studies since the introduction of thoracoscopy in 1910, with a combined total of more than 500 patients. RESULTS: Diagnostically, thoracoscopy has been used primarily to evaluate diaphragmatic injury, continued chest tube bleeding, and suspected cardiac injury. Thoracoscopy has a 98% (188/191 patients) accuracy rate in diagnosing diaphragmatic injuries. Therapeutically, thoracoscopy has been used primarily to control chest tube bleeding, evacuate retained hemothoraces, and evacuate empyemas. Thoracoscopy is 90% (89/99 patients) effective in evacuating retained hemothoraces, 86% (19/22 patients) effective in evacuating empyemas, and 82% (33/40 patients) effective in controlling chest tube bleeding. Thoracoscopy benefits include preventing 62% (323/514) of trauma patients from having a thoracotomy or laparotomy. Risks include a 2% (11/534 patients) procedure-related complication rate and a 0.8% (4/471 patients) missed injury rate. Technical failure rates are 10% (10/99 patients) and 4% (7/199 patients) in evacuation of retained hemothoraces and evaluation of diaphragmatic injuries, respectively. CONCLUSIONS: Analysis suggests that thoracoscopy (nonvideo and VATS) can be applied safely and effectively in the care of the injured patient.
Follow-Up Studies↗
A randomized, controlled trial comparing thoracoscopy and limited thoracotomy for lung biopsy in interstitial lung disease.
BACKGROUND: Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. A prospective randomized, controlled trial comparing limited thoracotomy (open lung biopsy) and thoracoscopy for lung biopsy was done. METHODS: Ambulatory patients with a clinical diagnosis of diffuse interstitial lung disease were randomized to thoracoscopy or limited thoracotomy. Data on postoperative pain, narcotic requirements, operating room time, adequacy of biopsy, duration of chest tube drainage, length of hospital stay, spirometry, and complications were collected. RESULTS: A total of 42 randomized patients underwent lung biopsy (thoracoscopy 20, thoracotomy 22). The two study groups were comparable with respect to age, gender, corticosteroid use, and preoperative spirometry. Visual analog scale pain scores were nearly identical in the two groups (p = 0.397). Total morphine dose was 50.8 +/- 27.3 mg in the thoracoscopy group and 52.5 +/- 25.6 mg in the thoracotomy group (p = 0.86). Spirometry (FEV1) values in the two groups were not significantly different on postoperative days 1, 2, 14, and 28 (p = 0.665). Duration of operation was similar in both groups (thoracoscopy 40 +/- 30 minutes, thoracotomy 37 +/- 15 minutes; p = 0.67). The thoracoscopy and thoracotomy groups had equivalent duration of chest tube drainage (thoracoscopy 38 +/- 28 hours, thoracotomy 31 +/- 26 hours; p = 0.47) and length of hospital stay (thoracoscopy 77 +/- 82 hours, thoracotomy 69 +/- 55 hours; p = 0.72). Definitive pathologic diagnoses were made in all patients. CONCLUSIONS: There is no clinical or statistical difference in outcomes for thoracoscopic and thoracotomy approaches. Both thoracoscopy and thoracotomy are acceptable procedures for diagnostic lung biopsy in diffuse interstitial lung disease.
Biopsy↗
Thoracoscopy. A prospective study of safety and outcome.
OBJECTIVE: To assess a standard classification of adverse events and evaluate the safety and long-term outcome of thoracoscopy in patients with pleural disease. DESIGN: Prospective nonrandomized cohort study. SETTING: The Pulmonary Special Procedures and Nd:YAG Laser Unit of the University of California San Diego Medical Center, San Diego. PATIENTS: Fifty consecutive patients undergoing thoracoscopy for diagnosis of pleural effusion or thickening, pleurodesis, or empyema drainage. INTERVENTION: A list of major and minor adverse events that could be temporally related to thoracoscopy performed for diagnosis or treatment of pleural processes was established before beginning this prospective study. Procedures were performed using multiple point-of-entry techniques and either local or general anesthesia. Most procedures were performed in the operating room using double-lumen intubation. Patients were seen daily during hospitalization and at least 7, 30, and 90 days after thoracoscopy. Long-term follow-up data were obtained by telephone calls, clinical visits, or medical chart reviews or all of these, until 12 months after procedures. MEASUREMENTS: Occurrence of major and minor adverse events possibly related to thoracoscopy was recorded prospectively. Demographic and clinical data, as well as efficacy and outcome after thoracoscopy, were also noted. RESULTS: Fifty-two procedures were performed in 50 patients. Median age was 60 years (range, 18 to 88 years). Thoracoscopy provided a diagnosis in 93% of patients with pleural disease of unclear origin. Pleurodesis by thoracoscopic talc insufflation was successful in 95% of cases and in 91% of patients with malignant pleural effusions still available for evaluation and follow-up examination 3 months after pleurodesis. Thoracoscopic drainage of empyema was successful in six of seven patients and led to referral for open decortication in one. There were no procedure-related deaths or intraoperative accidents. Open-chest surgery intervention was never required. Only 1 major adverse event occurred: a patient with scleroderma and trapped lung had recurrent pleural effusion requiring chest tube drainage 1 week after hospital discharge. Minor adverse events, however, were noted in ten instances (19%). These included fever after talc pleurodesis, asymptomatic pneumothorax after chest tube removal, and minor would infection in a patient with empyema. CONCLUSION: Using the proposed classification of major and minor adverse events, prospective evaluation demonstrated the safety, diagnostic utility, and long-term efficacy of thoracoscopy performed for diagnosis and management of pleural processes. Potential dangers, however, of thoracoscopy are acknowledged, and limitations of the procedure are addressed.
Adolescent↗
[Spontaneous pneumothorax. A comparison of thoracoscopy and thoracotomy].
The aims of this study were to assess the advantages of surgical thoracoscopy versus thoracotomy. Two 16-patient groups (thoracotomy, thoracoscopy) were compared. They were equivalent with regards to technique, age, etiology and lung dystrophy. Patients were called by phone to evaluate the surgical and functional results. The questionnaire was filled out by an independent physician who ignored the surgical technique used. Hospital stay was 7 +/- 2 days for thoracoscopy versus 11.5 +/- 5 days for thoracotomy (p < 0.003). During the J30 to J60 period of time, pain was mild in 94% of thoracoscopy cases and severe or unbearable in 69% of thoracotomy cases (p < 0.002). Mobility of the shoulder was fully recovered in all thoracoscopy patients within the first month versus only 62% of recovery at 3 months in the thoracotomy group (p < 0.0001). Working was possible at 1 +/- 0.8 month in the thoracoscopy group versus 2.6 +/- 0.8 months in the thoracotomy group (p < 0.002). Leisure activities were resumed at 2 +/- 1 month in the thoracoscopy group versus 4 +/- 1 months in the thoracotomy group (p < 0.0005). Only one relapse occurred in the thoracoscopy group. Thoracoscopy prevents the drawbacks of thoracotomy but keeps the same efficiency in the treatment of pneumothorax.
Adult↗
Cardiopulmonary effects of bilateral hemithorax ventilation and diagnostic thoracoscopy in dogs.
OBJECTIVE: To describe alterations in respiratory and cardiovascular variables during diagnostic thoracoscopy, using bilateral hemithorax ventilation with sustained pneumothorax. ANIMALS: 7 adult dogs. PROCEDURE: Each dog was anesthetized and instrumented for 2 episodes of cardiopulmonary monitoring that were performed at an interval of more than 14 days. The first anesthetic episode served as a control procedure for the thoracoscopy treatment performed during the second anesthetic episode. Multiple cardiopulmonary variables were evaluated by comparing changes from baseline values within treatments and between treatments. RESULTS: Arterial oxygen tension decreased significantly from baseline values during thoracoscopy but was unchanged during sham treatment. Arterial carbon dioxide tension, clinical shunt fraction, and systemic mean arterial pressure increased during thoracoscopy. In contrast, these variables were unaffected by the sham treatment. Heart rate and cardiac index increased during sham and thoracoscopy treatments; however, the increase was significantly greater during thoracoscopy. Total peripheral vascular resistance significantly decreased from baseline values for both treatments, but the decrease was greater during thoracoscopy. Significant changes were not observed for oxyhemoglobin saturation or pulmonary vascular resistance during either treatment. Dogs recovered without major clinical complications. CONCLUSIONS: Significant changes were found for several cardiopulmonary variables during bilateral hemithorax ventilation with sustained pneumothorax for diagnostic thoracoscopy of clinically normal dogs. CLINICAL RELEVANCE: Diagnostic thoracoscopy with bilateral hemithorax ventilation and sustained pneumothorax is well tolerated in clinically normal dogs and may provide a diagnostic modality enabling intrathoracic procedures with less morbidity than thoracotomy for dogs with intrathoracic disease.
Animals↗
Thoracoscopy for the management of advanced epithelial ovarian cancer--a preliminary report.
OBJECTIVE: To determine possible benefits of thoracoscopy for the management of patients with Stage IIIC and IV epithelial ovarian cancer. METHODS: Thirty patients underwent thoracoscopy at the time of primary cytoreduction to determine the presence and extent of intrathoracic disease and the feasibility of cytoreduction. Survival of patients with Stage IV disease undergoing thoracoscopy was compared to that of historical controls (Stage IV on the basis of positive pleural effusion cytology and/or pleural involvement by contiguous diaphragmatic metastases) who did not undergo thoracoscopy (log-rank analysis). RESULTS: Among the 24 patients with Stage IV disease having thoracoscopy, 11 (45.8%) did not have macroscopic intrathoracic disease, 10 (41.7%) underwent pleural implant ablation and/or excision as well as nodal excision that influenced the final cytoreductive outcome, and 3 (12.5%) had efforts to achieve complete intra-abdominal cytoreduction abbreviated after unresectable intrathoracic disease was found. The 24 patients who had thoracoscopy and the historical controls were not significantly different with respect to median age, performance status, extent of intra-abdominal disease, amount of ascites, and intra-abdominal cytoreductive outcome. The median and estimated 5-year survival for the entire cohort were 28.9 months and 42%, respectively. Log-rank analysis revealed the probability of survival to be improved by the performance of thoracoscopy (performed vs not performed, P = 0.05). CONCLUSIONS: Thoracoscopy quantifies the volume of intrathoracic disease, may allow abbreviation of the abdominal phase of cytoreduction for patients with unresectable pleural disease, and permits complete cytoreduction for some patients who might otherwise have unrecognized macroscopic residual intrathoracic disease. A multi-institutional prospective study may better define the role of this procedure in clinical practice.
Adult↗
En bloc and standard esophagectomies by thoracoscopy.
Subtotal esophagectomy was attempted by right thoracoscopy on 13 patients, 10 having cancer and 3 long caustic stenosis. Thoracoscopy was converted into thoracotomy in 2 patients, owing to loss of selectivity in one-lung ventilation in 1 and injury to a right intercostal artery flush to the aorta in the other. One patient with cancer underwent an esophageal bypass operation only, owing to tumor invasion into the lung at exploratory thoracoscopy. The ten esophagectomies that could be performed in totality by thoracoscopy consisted of seven en bloc resections of the esophagus with extensive lymph node clearance in the posterior mediastinum, and three standard resections without any lymph node dissection. Postoperative complications included one death due to hepatic failure, two cases of acute pneumonitis, and one persistent chest wall discomfort at the trocar sites. Up to 51 lymph nodes were found in the resected specimens of the cancer patients. Six of the 7 cancer patients who were discharged from the hospital after esophagectomy completed by thoracoscopy were alive at 2 to 20 months of follow-up. Five of them were disease free. The study shows that esophageal resections as extensive as those carried out by thoracotomy can be performed by thoracoscopy. It suggests that prompt management of untoward injury to any mediastinal structure adjacent to the esophagus is less easy by thoracoscopy than by thoracotomy, and that classic complications of open thoracic surgery may occur after thoracoscopy as well.
Burns, Chemical↗
Pleural effusions: is thoracoscopy a reliable investigation? A retrospective review.
In this paper, we consider the results of thoracoscopy in a busy thoracic unit where the referring physicians place their greatest emphasis upon simple standard investigation of pleural disease. Between 1985 and 1989 620 patients with a pleural effusion of unknown aetiology were referred to our thoracic medical unit. Initial investigations included aspiration of pleural fluid for cytology and culture, and blind pleural biopsy for histological examination. Recourse to thoracoscopy was only taken in the absence of a diagnosis or non-resolution of the patients symptoms and signs. Of these 620 patients only 48 (8%) remained without a diagnosis and were referred for thoracoscopy. Histological assessment of biopsies obtained at thoracoscopy revealed malignancy in 24 patients (50%) and benign conditions in 16 patients (33%). In eight patients (17%) no conclusive diagnosis was established; in this latter group, six patients continued with their symptoms and further invasive investigations revealed malignancy. In this setting where thoracoscopy was used as a last resort, the sensitivity for thoracoscopy was 83% and the specificity was 100% with a predictive value of a negative result being 25%. In conclusion, from our experience, the majority of pleural disease may be diagnosed using simple techniques but thoracoscopy can be very helpful in the more complex cases. Moreover, inconclusive histology following thoracoscopy is an indication for further investigation if the condition does not improve.
Adult↗
Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report.
Diagnosis of diaphragmatic injury (DI) can be difficult in patients with penetrating trauma because physical examination, computed tomographic scan, chest x-ray films, and diagnostic peritoneal lavage may miss these injuries. Mandatory exploration has been recommended because of the increased mortality associated with missed DI. Thoracoscopy was prospectively evaluated as a less invasive method for diagnosing DI in patients with penetrating trauma. Over a 14-month period, 14 patients were evaluated by thoracoscopy; video thoracoscopy was used in the last 9. Findings of thoracoscopy were confirmed by laparotomy or laparoscopy. Thoracoscopy correctly identified the presence or absence of DI in nine and five patients, respectively (all patients). Video thoracoscopy was easier and faster to perform than non-video thoracoscopy. This is the first reported series in which video thoracoscopy has been used for trauma. We found this procedure to be safe, accurate, and less invasive than laparotomy for diagnosing DI.
Diaphragm↗
Thoracoscopy versus thoracotomy: indications and advantages.
Although the diagnosis and treatment of intrathoracic diseases have been affected by the use of thoracoscopy, the indications and advantages of this procedure are poorly defined. To review the indications and results in a community practice, 52 consecutive cases of thoracoscopy were reviewed and the postoperative courses were compared to a control group of 43 simultaneous thoracotomies. Operative indications for thoracoscopy included investigation or treatment of a lung mass (n = 33), spontaneous pneumothorax (n = 10), mediastinal mass (n = 4), pleural effusion (n = 2), mesothelioma (n = 2), and a ruptured hemidiaphragm (n = 1). General endotracheal anesthesia was used in each case. Overall, thoracoscopy was successful in 40 cases (77%). Conversion to formal thoracotomy was required in 14 cases (27%) secondary to poor visualization or to aid in further dissection. Compared to thoracotomy, complication rates were less (7.6 vs 16.2%), hospital stay shorter (5.5 vs 8 days), ICU stay shorter (0 vs 2 days) and pleural drainage time less (2 vs 5 days) in the thoracoscopy group. In summary, 73% of the patients in this study who formerly would have undergone thoracotomy were successfully managed with thoracoscopy alone, with acceptable morbidity and mortality. These data define the indications, morbidity, and mortality of thoracoscopy and suggest that thoracoscopy may emerge as the procedure of choice in the diagnosis and management of many thoracic diseases.
Chest Tubes↗