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Medical Thoracoscopy

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Talk given by me on Medical Thoracoscopy for Mangalore Chest Association CME

Talk given by me on Medical Thoracoscopy for Mangalore Chest Association CME

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  • 1. Dr Subin Ahmed Dept of Pulmonary Medicine YMCH
  • 2. Thoracoscopy: A window to the pleural space
  • 3. Historical Background
    • Thoracoscopy is not a new technique; H.C.Jacobeus, the Swedish internist, was the first to perform thoracoscopy in 1910, as a diagnostic procedure for exudative pleuritis.
    • H.C.Jacobeus published the first series of thoracoscopy cases in 1921, describing the value of thoracoscopy in the diagnosis of tuberculous and malignant effusions.
  • 4. Historical Background
    • Thoracoscopy was used mainly as a therapeutic tool for adhesiolysis in patients with tuberculosis (TB), in order to obtain a ‘‘therapeutic’’ pneumothorax – Jacobeus Procedure
    • Pioneers like Swierenga et al, Brandt and Boutin et al confirmed its value in publications in the 1970 s
    • Around 1990, instruments such as endoscopic stapler devices, scissors, grasping and biopsy forceps were developed for surgical interventions by means of thoracoscopy
  • 5. Historical Background
    • The development of endoscopic video systems and instrumentation lead to the widespread use, by (thoracic) surgeons, of therapeutic thoracoscopy for a wide variety of major thoracic procedures.
    • Medical thoracoscopy is generally characterized as thoracoscopy performed under local anesthesia in the endoscopy suite with the use of non-disposable instruments, and is generally for diagnostic purposes.
  • 6. Definition
    • Medical thoracoscopy/pleuroscopy is a minimally invasive procedure that allows access to the pleural space using a combination of viewing and working instruments. It also allows for basic diagnostic (undiagnosed pleural fluid or pleural thickening) and therapeutic procedures (pleurodesis) to be performed safely.
    • Interventional pulmonary procedures : Guidelines from ACCP
    • Chest 2003;123:1693-1717
  • 7. VATS vs MEDICAL THORACOSCOPY VATS Medical Thoracoscopy Operator Thoracic surgeon Pulmonologist Site OR Endoscopy suite/ OR Anesthesia GA Conscious sedation/LA MV Double lumen ETT, Single lung ventilation Spontaneous breaths Ports Multiple Single or double Indications
    • Minimally invasive surgery
    • -Resection of Pulm. nodule
    • -Bullectomy
    • Lung Bx/Lobectomy
    • Pneumonectomy
    • Pericardial window
    • Diagnostic/Therapeutic
    • Pleural biopsy
    • Pleural biopsy
    • Chest Tube insertion
    • Talc Pleurodesis
    • Deloculation
  • 8. Indications for Medical Thoracoscopy
    • Diagnostic :
    • – Pleural effusions of unknown origin-
    • Diagnostic Yield is 93-100% ( 44% with closed biopsy & 62% with fliud cytology )
    • – Suspected tuberculous effusions
    • – Suspected malignancy with inconclusive cytology
    • – Evaluating Chest Trauma
  • 9. Indications for Medical Thoracoscopy
    • Therapeutic:
    • 1) For pleurodesis in malignant or recurrent pleural effusion, recurrent pneumothorax
    • 2) To divide adhesions in recurrent/persistent spontaneous pneumothorax
    • 3) To perform pleural toilet in the fibrino-purulent stage of empyema
  • 10. Medical thoracoscopy : steps
  • 11. The Semi-rigid Pleuroscope or the Rigid Pleuroscope
  • 12. Instruments
  • 13. Anesthesia
    • LOCAL INFILTRATION + CONSIOUS SEDATION
    • Midazolam (2 mg upto 10 mg) or
    • Neuroleptic Analgeisa (Fentanyl + Droperidol) or
    • Opiods + Benzodiazepines &
    • Local Infiltration with 2% Lidocaine
    • Propofol – be ready with intubation/ventilatory settings
  • 14. Trocar insertion: Access to the pleural space
    • • Vessels to avoid: internal mammary, the subclavian and the lateral thoracic artery
    • Lateral thoracic region between the mid- and anterior axillary line in the fourth to seventh intercostal space
  • 15. The intercostal space
    • 3 muscles, with a neurovascular bundle in the middle and innermost
    • Lies in a grove in the inferior aspect of the rib
    • Posteriorly, the bundle lies in the middle of the intercostal space until 5-8 cm lateral to the spine.
    • *Intercostal vessels may sag in geriatric patients onto the superior costal margin of the adjacent rib
  • 16. STEPS
    • Patient in the lateral decubitus position with the arms placed over the head in order to increase the size of the intercostal spaces.
    • Local anesthesia (intercostal block) with 2% lidocaine and sedation with midazolam drip
    • A small caliber trocar (14F) introduced into the intercostal space after incising the chest – to induce a pneumothorax
    • Increase the pneumothorax by insufflating air with a 60 ml syringe
  • 17. STEPS
    • Larger flexible trocar (10mm) then introduced after enlarging the channel.
    • A rigid thoracoscope 7 mm diameter inserted into the pleural cavity
    • Thoracoscope connected to a video camera and viewed on a screen
    • Biopsy, lysing of adhesion or electrocoagulation or cutting - a second smaller (5 mm) incision was made to enable insertion of a second instrument (usually a biopsy forceps)
  • 18. Pleural Biopsies
    • Most pleural pathology in the posterior costal pleura
    • Biopsy specimens from the parietal pleura over the rib
    • Ideally, specimens should not be taken from the apex, anterior parietal pleura
  • 19. Pleural Pathology – Tuberculous PE
    • Diagnostic yield from closed pleural biopsy is 70-90% (with specimens sent for microbiological analysis)
    • Needs 6 or more specimens
    • Thoracoscopy may offer higher tissue-culture positive rates
  • 20. Pleural Pathology – Tuberculous PE
    • Visualization of grayish-white granuloma (parietal & diaphragmatic pleura esp. costo-vertebral gutter)
    • Multiple biopsies from selected sites (HP Diagnosis 94-98 %)
    • TB cultures more frequently positive (esp. when fibrin production is significant)
    • Diagnosis by MT + Culture+ HPE∼ 100% (> Closed needle Biopsy + Culture of Pleural Effusion)
  • 21. Thoracoscopy in Pleural Malignancies
    • Pleural fluid cytology is only positive in 60-70% of cases of pleural malignancy, with marginal benefit when closed pleural biopsy is added
    • Patchy involvement of pleural cavity, involvement of the visceral pleura, lower hemithorax/diaphragm involvement
    • Allows receptor analysis
  • 22. Thoracoscopy in Pleural Malignancies
    • Thoracoscopy is the recommended procedure in patients with an undiagnosed effusion and negative pleural fluid cytology, who are suspected of having malignancy.
    • The diagnostic yield with thoracoscopy is over 90% in malignant effusions.
    • Pleurodesis can be performed during the same procedure if the biopsy is positive (on-site cytology during thoracoscopy), or if the macroscopic appearance is strongly suggestive of malignancy and adequate biopsies have been taken
  • 23. Malignant Mesothelioma and Thoracoscopy
    • Routine cytology examination of pleural fluid has a sensitivity of only 32%
    • Blind percutaneous needle biopsy specimens gives a diagnosis in less than 50% of cases
    • Thoracoscopy allows complete visualization of the pleural cavity and multiple biopsy samples.
    • Helps in diagnosis of early lesions
  • 24. Malignant Mesothelioma and Thoracoscopy
    • Concern of tumor spread along chest drain and aspiration sites
    • Seeding
    • Irradiation with 7 Gray over 3 days within 15 days of procedure
  • 25. Recurrence prevention in malignant effusions
    • 80% lung, breast , lymphomas, ovarian or Primary pleural malignancies mesothelioma
    • Diagnosis in 95% with thoracoscopy
    • Palliate symptoms
    • Complete evacuation of pleural fluid, maximization of lung expandability by removing adhesions
    • Prevention of fluid reaccumulation: obliterating the pleural space by pleurodesis ( long-term success rates of > 90%)
    • Chemical Pleurodesis:
    • Talc - 7 g (Poudrage)
    • Tetracycline/Doxycycline
    • Bleomycin, Thiotepa
    • Various: Iodopovidine, Silver nitrate
  • 26. Recurrent Pleural Effusion of Benign Etiology & Thoracoscopy
    • Recurrent pleural effusion of benign etiology (heart failure, cardiac surgery, nephrotic syndrome, connective tissue diseases, and other inflammatory disorders)
    • Thoracoscopic pleurodesis is indicated when the recurrent effusion causes symptoms and is not controlled by repeated large-volume thoracocentesis
  • 27. Spontaneous Pneumothorax & Thoracoscopy
    • Persistent or recurrent pneumothorax
    • Recurrence rate of 23-50% after the first episode and higher after recurrence
    • Pleurodesis is achieved in these cases by talc insufflation (1.5 grams)
    • Excellent alternative to repeated chest tube drainage
  • 28. Empyema & Complicated Para-Pneumonic Effusions - Thoracoscopy
    • After failure of chest tube drainage and fibrinolytic treatment
    • Fibrino-purulent stage with pleural peels entrapping the lung
    • Deloculation, Fibrinolysis, chest tube insertion under direct visualization
    • Mechanical removal of infected material and permits lung re-expansion
  • 29. Empyema – Thoracoscopic Drainage
    • Especially in frail patients with high surgical risk
    • Entry site confirmed by USG
    • Aspiration of the liquid
    • Exploration of the thoracic cavity to identify loculations or, rarely, foreign bodies
    • Opening the loculations
    • .
  • 30. Empyema – Thoracoscopic Drainage
    • 4)Removal of fibrinopurulent membranes from the cavity and from parietal and visceral surfaces;
    • 5) Cleansing of the pleural space with saline solution.
    • When the thoracic cavity has been emptied a careful exploration of the pleural surfaces is carried out and, if necessary biopsies performed. Finally a large-bore chest drain ( >28 F) is introduced, possibly under visual control, to remove dense and viscous pus or fibrin debris
  • 31. Chest Trauma - Thoracoscopy
    • Evaluation/Management in blunt/penetrating chest trauma:
    • Diaphragmatic injury
    • Chest wall bleeding
    • Traumatic pneumothorax/ chylothorax/ hemothorax
    • Lung parenchymal lacerations
    • Trapped lung (after prolonged Hemothorax) Removal of fibrous peel + loculations/adhesions  lung re- expansion  pleurodesis
  • 32. Complications of Thoracoscopy
    • One of the safest procedure
    • Desaturation during procedure – <2 %
    • Persistent air-leak (2%)
    • Subcutaneous emphysema (0.5%)
    • Postoperative fever (16%)
    • Empyema (2.5%)
    • Death (0.01%)
    • Negligible – benign cardiac arrhythmias, transient hypotension
    • Colt HG. Chest 108:324-329, 1995
    • Loddenkemper R. J Bronchol 7:207-209, 2000
  • 33. Prevention Of Complications
    • Postpone thoracoscopy for several days if patient is coughing
    • Measure blood gases & monitor cardiac status by simultaneous ECG
    • Oxygenate the patient during thoracoscopy
    • Avoid taking biopsy samples from internal parts of the fissures or from mediastinum
    • Coagulate & ensure hemostasis if hemorrhage exceeds 20ml
  • 34. Prevention Of Complications
    • Insert a chest tube (at least till the lung expands) to prevent subcutaneous emphysema
    • Start physiotherapy on the day of thoracoscopy to exercise the diaphragm & avoid accumulation of secretions & obstruction
    • To prevent invasion in cases of mesothelioma, administer radiation therapy of 7 grays/day for 3 days to the scar area on post operative day 10
  • 35. Contraindications
    • Absolute Contraindication:
    • Absence of a potential pleural space ( < 6-10 cm usually due to extensive adhesions)
    • Relative Contraindications:
    • – Uncorrectable coagulopathy
    • – Multiple pleural adhesions
    • – Unstable cardio-respiratory status
    • – uncontrollable cough
    • – Inability to lie flat for an hour
    • – Severe chest wall deformity
  • 36. Thoracoscopy - Variants
    • Medical Thoracoscopy using Fiber Optic -bronchoscope inserted through a chest tube under L/A
    • -Argyle type 32F chest tube
    • -5mm outside diameter FOB
    • -1.5 mm incision
    • -only 1 trocar entry (biopsy forceps put into the FOB port)
  • 37. Thoracoscopy - Variants
    • Mini Thoracoscopy
    • two 3.8 mm trocars
    • one 3.3 mm telescope
    • one 3.0 mm biopsy forceps
    • Good visibility, Easy maneuverability, Less pain, Less local anesthetic, No stitches, Better cosmetic results
    • Conversion to conventional thoracoscopy sometimes required, lung biopsy specimens can be inadequate, chest drains >8F cannot be inserted
    • Small loculated PE
  • 38. Conclusion
    • Pleuroscopy allows the pleural cavity to be visualized under local anesthesia with sedation/intravenous anesthesia
    • Procedure of choice in the diagnostic workup of patients suspected of a malignant effusion with an indeterminate cytology
    • Allows for pleurodesis in the same setting
    • Physicians performing this procedure should have training requirements vary between institutions, but the operator should have sound knowledge of pleural and thoracic anatomy, and sufficient surgical skill.
  • 39.  
  • 40. “ Once you touch the lungs you should be ready to convert it into a Thoracotomy any time”

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