Medical Thoracoscopy


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

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Medical Thoracoscopy

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