Medical Thoracoscopy

Medical Thoracoscopy : 

Medical Thoracoscopy By Dr. Emad KORRAA Prof. of Pulmonology, Ain Shams University

Introduction : 

Introduction Thoracoscopy was introduced by JACOBAEUS, an internist in Stockholm in 1910. He used modified cystoscope as a diagnostic procedure in two cases of exudative (tuberculous) pleuritis.

Introduction : 

Introduction In 1915 lysis of pleural adhesions by means of thoracocautery was done "Jacobaeus' Operation" to facilitate pneumothorax treatment of tuberculosis (TB) .

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In 1990s, with the advances in endoscopy technology and the trend toward less invasive operations, thoracoscopy was rediscovered by the thoracic surgeons, and termed "surgical" thoracoscopy (VATS). In 1960s, thoracoscopy was used, mainly by pulmonologists, for diagnosis of many pleuropulmonary diseases. In USA, in1994, more than 5% of all pulmonologists were applying medical thoracoscopy

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Examination can be performed under local anaesthesia with or without conscious sedation after adequate premedication (without support of an anaesthetist). M. thoracoscopy is less expensive (700 LE) because it may be safely performed with nondisposable instruments and in an appropriate endoscopy room. Advantages of medical thoracoscopy compared to VATS

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Indications for thoracoscopy: comparison between 1971–1979, 1980–1988 and 1995–1996 Lungenklinik Heckeshorn, Berlin, Germany

Contraindications : 

Contraindications Absolute • Lack of pleural space • Uncorrectable bleeding disorder • Respiratory insufficiency • Severe pulmonary hypertension • Severe pulmonary fibrosis Relative • Health status • Intractable cough • Unstable cardiovascular status • Pulmonary hypertension • hypoxemia

Complications : 

Complications Major hemorrhage (<0.1%) Injury to adjacent organs (?) Empyema (<0.1%) Air embolism (<0.03%) Mortality (<0.01%) Mathur PN, APJ, 2003

Advantages : 

Advantages Inspection and palpation of the pleural cavity and the two pleurae, this helps in the staging of lung cancer, diffuse malignant mesothelioma and metastatic cancers. Complete drainage of pleural fluid. Fibrinous loculations in tuberculosis and empyema can be easily removed, thus creating a single pleural cavity which can be treated more efficiently. Enough pleural biopsies for an accurate pathological assessment. Evaluation of the potential re-expansion of the lung. Enables effective talc powder pleurodesis. Enables introduction of intercostal tube in an accurate position. Early start of drug treatment (e.g. TB) Local gene therapy ?

Safety : 

Safety In properly selected patients, thoracoscopy under Local anaesthesia is a safe procedure.

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Inspection and palpation of the pleural cavity and the two pleurae, this helps in the staging of lung cancer, diffuse malignant mesothelioma and metastatic cancers.

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Complete drainage of pleural fluid. Empyema

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Fibrinous loculations in tuberculosis and empyema can be easily removed, thus creating a single pleural cavity which can be treated more efficiently. Fibrin membranes in the pleural cavity Typical empyema loculations

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Enough pleural biopsies for an accurate pathological assessment.

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Evaluation of the potential re-expansion of the lung. Captured lung

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Enables effective talc powder pleurodesis.

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Enables introduction of intercostal tube in an accurate position. Multiple emphysematous bullae Pleural bleps on the surface of visceral pleura

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Early start of drug treatment (e.g. TB) Local gene therapy ? Diffuse malignant pleural mesothelioma Tuberculous pleura effusion

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malignant pleural effusions Sensitivity of different biopsy methods R. Loddenkemper et al. 1983

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Diffuse malignant pleural mesothelioma Sensitivity [%] of different biopsy methods Boutin et al., Cancer 1993;72:389-93

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Tuberculous pleural effusions Sensitivity of different biopsy methods R. Loddenkemper et al. 1983

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• Diagnostic yield of pleuroscopy 95 % • Pleural fluid cytology 62 % • Closed pleural biopsy 44 % • Pleural fluid cytology and closed pleural biopsy 74 % • Combined non-surgical methods 97 % Janssen at al.: J Bronchol 11(3)2004 Diagnostic value of thoracoscopy

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insufficient and nonrepresentative biopsies, that depend largely on the experience of the thoracoscopist the presence of adhesions which deny access to neoplastic tissue Reasons for false-negative thoracoscopy

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„Thank you for your attention … !“ emad_korraa@hotmail.com