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Original Research: Pulmonary Procedures |

Feasibility and Safety of Outpatient Medical Thoracoscopy at a Large Tertiary Medical CenterOutpatient Medical Thoracoscopy: A Collaborative Medical-Surgical Initiative FREE TO VIEW

Zachary S. DePew, MD; Dennis Wigle, MD, PhD; John J. Mullon, MD, FCCP; Francis C. Nichols, MD, FCCP; Claude Deschamps, MD; Fabien Maldonado, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.

CORRESPONDENCE TO: Fabien Maldonado, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905; e-mail: maldonado.fabien@mayo.edu


Drs DePew and Maldonado contributed equally to this manuscript.

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(2):398-405. doi:10.1378/chest.13-2113
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BACKGROUND:  Medical thoracoscopy (MT) is performed by relatively few pulmonologists in the United States. Recognizing that an outpatient minimally invasive procedure such as MT could provide a suitable alternative to hospitalization and surgery in patients with undiagnosed exudative pleural effusions, we initiated the Mayo Clinic outpatient MT program and herein report preliminary data on safety, feasibility, and outcomes.

METHODS:  All consecutive patients referred for outpatient MT from October 2011 to August 2013 were included in this study. Demographic, radiographic, procedural, and histologic data were recorded prospectively and subsequently analyzed.

RESULTS:  Outpatient MT was performed on 51 patients, with the most common indication being an undiagnosed lymphocytic exudative effusion in 86.3% of the cohort. Endoscopic findings included diffuse parietal pleural inflammation in 26 patients (51%), parietal pleural studding in 19 patients (37.3%), a normal examination in three patients (5.9%), diffuse parietal pleural thickening in two patients (3.9%), and a diaphragmatic defect in one patient (2%). Pleural malignancy was the most common histologic diagnosis in 24 patients (47.1%) and composed predominantly of mesothelioma in 14 (27.5%). Nonspecific pleuritis was the second most frequent diagnosis in 23 patients (45.1%). There were very few complications, with no significant cases of hemodynamic or respiratory compromise and no deaths.

CONCLUSIONS:  Outpatient MT can be integrated successfully into a busy tertiary referral medical center through the combined efforts of interventional pulmonologists and thoracic surgeons. Outpatient MT may provide patients with a more convenient alternative to an inpatient surgical approach in the diagnosis of undiagnosed exudative pleural effusions while maintaining a high diagnostic yield and excellent safety.

Approximately 1.5 million pleural effusions are identified yearly in the United States, an estimated 200,000 of which are malignant.1 Thoracentesis is the most commonly performed procedure by pulmonologists, with approximately 180,000 thoracenteses performed yearly.2 However, pleural fluid analysis can establish the cause of the effusion in only approximately 75% of cases, which means that additional investigations must be routinely performed.3 Other options include closed pleural biopsies, image-guided pleural biopsies (by ultrasound or CT scan), and medical or surgical thoracoscopy. Closed pleural biopsies are less sensitive than medical thoracoscopy (MT) for the diagnosis of pleural malignancy, and image-guided biopsies generally require that focal pleural abnormalities are identified, which is not always possible.4 MT training is available in only a small minority of postgraduate training programs in the United States, and as such, it is not a commonly performed procedure.5 Therefore, the course of action after negative pleural fluid analysis generally consists of either clinical observation or video-assisted thoracoscopic surgery (VATS). This contrasts with other countries in which MT is recommended and increasingly performed.6 Recognizing that an outpatient minimally invasive procedure such as MT could provide a suitable alternative to surgery in patients with undiagnosed exudative pleural effusions, we initiated the Mayo Clinic outpatient MT program in October 2011 and herein report preliminary data on the safety, feasibility, and outcomes of our program.

Study Design

We aimed to present safety, feasibility, and outcome data from our recently established outpatient MT program. This is a retrospective review of prospectively collected data, conducted in the Division of Pulmonary and Critical Care Medicine and the Division of Thoracic Surgery at Mayo Clinic, Rochester, Minnesota, from October 2011 to August 2013. This study was approved by the Mayo Clinic institutional review board (IRB 13-003772).

Patients and Selection Criteria

All consecutive patients referred to the pulmonary medicine clinic for outpatient MT, and for whom the decision to proceed with MT was made, were included in this study. All patients were evaluated by an interventional pulmonologist (F. M.) in the outpatient clinic. Each case was discussed preoperatively with a thoracic surgeon (D. W. or C. D.), and an agreement to proceed was reached prior to proceeding with MT. Procedural informed consent was obtained from all patients. Contraindications to MT included absence of a pleural space, chronic hypoxemic (need for > 2 L/min supplemental oxygen by nasal cannula) and/or hypercapnic (Paco2 > 50 mm Hg) respiratory failure, bleeding diathesis or anticoagulation, Eastern Cooperative Oncology Group performance status > 2, refractory cough, and obesity.

Collected data included age, sex, performance status, number of previous thoracenteses, pleural fluid analysis results, prior chest imaging results, procedure duration, drugs used for anesthesia and conscious sedation, pleural fluid volume removed, thoracostomy tube used for lung re-expansion, endoscopic pleural space findings, histologic diagnoses, and complications. Complications were defined and recorded as described previously by Colt.7

Procedure

All procedures were performed in the pulmonary outpatient procedural suite. After a standard procedural pause, the patient was positioned with the affected side up in the lateral decubitus position as described previously. Ultrasound (Micromaxx Ultrasound System with P17/5-1 MHz 17 mm phased array probe; Sono Site, Inc) was used to identify the trocar entry site, generally located at the mid- to anterior axillary line, between the fifth and seventh intercostal space. The patient was connected to cardiac, BP, and pulse oximetry monitors. The patient continued breathing spontaneously with supplemental oxygen via nasal cannula as needed. Fentanyl and midazolam were used for moderate sedation. The skin was prepared and draped in sterile fashion. The skin, subcutaneous tissue, adjacent ribs, and parietal pleura were anesthetized with 1% lidocaine (15-30 mL), and a small incision was made at the planned site of entry. If minimal or no fluid was seen by ultrasound (because of lateral decubitus positioning with pooling of pleural fluid against the gravity-dependent medial parietal pleura), a Boutin blunt-tip trocar was used to access the pleural space and create a pneumothorax. Large-volume effusions did not require use of the Boutin trocar. Kelly forceps were then used to bluntly dissect the subcutaneous tissues and intercostal muscles until the pleural space was accessed through the parietal pleura. The 8-mm disposable trocar was then inserted, and the flex-rigid pleuroscope (Olympus LTF 160) was introduced into the pleural space with immediate aspiration of all pleural fluid. A detailed examination of the pleural cavity was then performed, with documentation of any abnormalities by photographic and/or video recordings. Parietal pleural abnormalities were biopsied with flexible forceps. Six to eight biopsy specimens were generally obtained. Random biopsy specimens were obtained from the posterior parietal pleura in the absence of visible abnormalities.

At the end of the procedure, either a small bore (10-14F) pigtail thoracostomy tube or a tunneled indwelling pleural catheter (TIPC) was placed and was connected to a water seal suction device at −20 cm H2O pressure for lung re-expansion. The criteria for insertion of a TIPC included the presence of a recurrent symptomatic effusion with prior evidence of symptomatic improvement following thoracentesis and completion of mandatory preoperative education with informed consent. Patients not meeting these criteria for any reason had a temporary thoracostomy tube inserted. A chest radiograph was obtained prior to transferring the patient to the recovery room. After confirmation of lung re-expansion, the pigtail thoracostomy tube was removed at the bedside in the recovery room, or the TIPC was disconnected from suction and the site dressed appropriately.8 The patient was dismissed on the day of the procedure once outpatient discharge criteria were met. Patients had to satisfy the requirements of the Mayo Modified Post-Anesthesia Care Unit Discharge Scoring System prior to discharge (e-Appendix 1). Several other criteria were also required, including pain rated at < 4 on a 10-point scale, hemostasis at the operative site(s), adequate control of nausea/vomiting, and return to preoperative functional status. All procedures were carried out by one interventional pulmonologist (F. M.). Surgical backup was provided by two thoracic surgeons (C. D. and D. W.), one of whom had previously discussed the case with the interventional pulmonologist and was readily available for emergent operative intervention if necessary.

Data

Qualitative data are presented as percentages. Quantitative data are presented as mean ± SD.

Outpatient MT was attempted in 55 patients between the inception of our outpatient program in October 2011 and the drafting of this manuscript in August 2013. Four MTs (7.2%) were aborted during the procedure, three because of an inability to adequately access the pleural space and one because of mechanical equipment failure (loss of video image during the procedure). Therefore, 51 procedures were completed during the inclusion time frame. Mean age was 68.1 ± 12.3 years, and 38 patients (74.5%) were men (Table 1). Thoracentesis was performed prior to MT an average of 1.9 ± 1.2 times (range, 0-6 times). The most common result from thoracentesis was a lymphocytic exudate in 44 patients (86.3%), with the remaining patients having malignant (n = 3) or suspicious (n = 2) cytology or an eosinophilic exudate (n = 1). One patient had pleural thickening and nodularity without an effusion, so thoracentesis was not performed. A CT scan of the chest was completed within the 90 days preceding MT in 49 patients (96.1%). CT imaging revealed pleural fluid on the affected side in all but one patient. Pleural fluid alone was the most common finding present in 19 patients (37.3%). Pleural nodularity was noted in 13 patients (25.5%), parietal pleural thickening in 11 patients (21.6%), and pleural thickening with associated calcification in six patients (11.8%). The remaining two patients had routine chest radiographs demonstrating a large pleural effusion on the affected side. PET/CT scanning was completed in 18 patients (35.3%), with 14 of 18 (77.8%) demonstrating abnormally increased uptake of fluorodeoxyglucose by the parietal pleura.

Table Graphic Jump Location
TABLE 1  ] Patient Characteristics

Data are presented as mean ± SD or No. (%). ECOG = Eastern Cooperative Oncology Group; FDG = fluorodeoxyglucose.

The average procedural time was 40.2 ± 12.4 min (range, 19-75 min) (Table 2). The average procedurally related health-care visit time (defined as the time from preoperative check-in to outpatient discharge) was 294 ± 73 min (range, 174-479 min). All patients received midazolam for sedation with a mean of 4.1 ± 1.7 mg and fentanyl for analgesia with a mean of 164 ± 87.5 μg. The Boutin trocar was used to access the pleural space in 37 patients (72.5%) and was not necessary in 14 (27.5%). There was no relationship between use of the Boutin trocar and ability to adequately visualize the pleural space once a pneumothorax was established. The pleural space was evacuated of pleural fluid during the procedure, with a mean volume of 1,216 ± 1,007 mL. Endoscopic findings during MT were divided into one of five categories. The most common finding was diffuse parietal pleural inflammation in 26 patients (51%), followed by parietal pleural studding in 19 (37.3%). The remaining six patients were found to have a normal examination (n = 3), diffuse parietal pleural thickening (n = 2), or a diaphragmatic defect (n = 1). A TIPC was inserted under direct visualization in 38 patients (74.5%). One patient had a TIPC in place prior to the procedure; it was used for postoperative lung re-expansion. The remaining 12 patients (23.5%) had a small-bore pigtail thoracostomy tube placed postoperatively, which was removed prior to dismissal following radiographic confirmation of lung re-expansion.

Table Graphic Jump Location
TABLE 2  ] Procedural Details for Total Cohort

Data are presented as mean ± SD or No. (%). TIPC = tunneled indwelling pleural catheter.

The 12 patients managed with pigtail thoracostomy tubes had procedural times nearly identical to those who had a TIPC inserted at 40.9 ± 10.5 min and 39.9 ± 13.1 min, respectively (Table 3). They had slightly longer procedurally related health-care visit times with an average of 329 ± 86 min vs 283 ± 69 min. The rationale against TIPC insertion in these 12 patients included minimal baseline dyspnea (n = 3), dyspnea not improved by thoracentesis (n = 3), patient preference (n = 3), presence of minimal effusion (n = 2), and a single patient with trapped lung subsequently referred for surgery.

Table Graphic Jump Location
TABLE 3  ] Procedural Details by Thoracostomy Tube Type

Data are presented as mean ± SD or No. (%). See Table 2 legend for expansion of abbreviations.

a 

Interventional Pulmonology.

b 

Thoracic Surgery.

c 

Interventional Radiology.

MT resulted in histologic confirmation of parietal pleural malignancy in 24 patients (47.1%) (Table 4). Mesothelioma was the most common malignancy in 14 patients (27.5%) with the following subtypes: epithelioid in eight, sarcomatoid in three, undifferentiated in two, and biphasic in one. Non-small cell lung cancer was found in seven patients (13.7%), with adenocarcinoma in six patients and squamous cell carcinoma in one. The three remaining malignancies included diffuse large B-cell lymphoma, small cell lung cancer, and renal cell carcinoma. Nonspecific pleuritis (NSP), which histologically included any combination of acute and/or chronic inflammation of the pleura without evidence of malignancy or infection, was the second most frequent diagnosis and was found in 23 patients (45.1%). Four patients were found to have cellular atypia (n = 2), sarcoidosis (n = 1), or empyema (n = 1).

Table Graphic Jump Location
TABLE 4  ] Results

Data are presented as No. or No. (%).

Among the subgroup of patients with NSP (23 patients), the most common CT scan finding was pleural fluid alone in 15 patients (56.5%), followed by pleural thickening in five (21.7%) and pleural calcifications in four (17.4%). One patient did not have a preoperative CT scan. PET/CT imaging was completed in four patients, with only one patient having increased uptake of fluorodeoxyglucose by the parietal pleura. The most common endoscopic finding was diffuse pleural inflammation in 17 patients (73.9%), followed by a normal examination in three patients (13%). The remaining three patients were found to have diffuse pleural studding (n = 1), a diaphragmatic defect (n = 1), and diffuse pleural thickening (n = 1).

This cohort had few complications. According to the list of potential complications and minor adverse events related to MT as described by Colt,7 there was only one minor adverse event in a patient who developed a clinically insignificant pneumothorax ex vacuo caused by a trapped lung. In addition, three patients in whom MT was completed were admitted to the hospital following the procedure, two because of ongoing pain at the site of the incision requiring IV analgesia and one because of postanesthesia confusion requiring observation. One patient spent a total of 3 days in the hospital and the other patients spent 1 day each. These scenarios were not defined clearly in the document by Colt,7 but we considered these admissions to represent complications. As mentioned previously, four MTs had to be aborted prior to completion of the procedure. Three were related to an inability to adequately access the pleural space. Two patients had extensive pleural adhesions preventing visibility of the pleural space, and in one case we were unable to reach the pleural space with the disposable pleural trocar because of morbid obesity. The other aborted procedure was caused by mechanical equipment failure during the procedure. All four patients were referred to thoracic surgery and diagnosis was established in all. There were no other complications beyond minor expected postoperative pain. There were no significant cases of hemodynamic or respiratory compromise, and no deaths.

A total of 14 patients (27.5%) underwent a subsequent procedure for management of their pleural space (Table 3). Six of the 12 patients (50%) managed with a pigtail catheter had an additional procedure performed. Thoracenteses were performed for three patients with symptomatic recurrence of their effusions, two by Interventional Pulmonology and one by Interventional Radiology. Interventional Pulmonology staff inserted a TIPC in one patient with mesothelioma who had minimal effusion at diagnosis but developed a large symptomatic effusion 4 months later. Two patients were referred to our Thoracic Surgery colleagues for operative interventions. One with a trapped lung underwent thoracotomy with decortication and the other with mesothelioma underwent thoracotomy with extensive pleurectomy. Eight of the 39 patients (20.5%) having a TIPC inserted during MT had a subsequent procedure. Two patients underwent thoracentesis by Interventional Pulmonology for recurrent pleural effusions. The other six had operative interventions by Thoracic Surgery. Two had surgical pleural biopsies, one for subtyping of mesothelioma undifferentiated by MT and the other to collect additional tissue for mesothelioma genetic analysis. Two patients given a diagnosis of epithelioid mesothelioma by MT subsequently underwent extrapleural pneumonectomy. One patient with a trapped lung underwent VATS decortication. Finally, one patient with NSP had a recurrence of symptomatic pleural effusion several months after the TIPC was removed and subsequently opted for VATS with talc pleurodesis. Exclusion of patients who underwent subsequent thoracentesis (n = 5), extrapleural pneumonectomy (n = 2), and delayed insertion of a TIPC because of minimal pleural fluid at the time of MT (n = 1) yielded a total of six patients (11.8%) who underwent a subsequent operative intervention that may have potentially been avoided if a surgical diagnostic procedure rather than MT had been performed.

Our data are consistent with those of previously published reports demonstrating a high diagnostic usefulness of MT coupled with an excellent safety profile.7,915 Our report is unique, however, in that we have shown that this procedure can be performed safely and practically in an entirely outpatient setting at a large tertiary referral medical center. This is in contrast to the common practice of admitting patients to the hospital for MT and postoperative management.7,10,11 Performing the procedure in this manner allows for improved patient convenience without compromising safety or usefulness. Furthermore, we have demonstrated that MT can be integrated successfully into the setting of a busy medical center through a multidisciplinary collaboration between interventional pulmonologists and thoracic surgeons to the benefit of all involved, including, most importantly, the patients.

The rapid development of comprehensive interventional pulmonary programs in the United States has led to increasingly necessary collaborations between trained interventional pulmonologists and thoracic surgeons. One prerequisite for such synergistic collaboration is a clear definition of the scope and indications of MT, allowing for a multidisciplinary approach to diagnosis and treatment, and optimization of patient care. The most common indications for diagnostic MT include evaluation of “idiopathic” recurrent exudative pleural effusions and suspicious pleural thickening or nodules identified on chest imaging, many of which are ultimately proven to be caused by malignancy.1 Upwards of 25% of malignant pleural effusions will remain undiagnosed despite repeated thoracenteses with cytologic evaluation.3 MT has been shown to have a diagnostic accuracy of around 90% in the setting of malignant pleural disease, prompting the British Thoracic Society to recommend that MT be considered in the evaluation of patients with undiagnosed exudative effusions.6,7,915 Before implementation of our MT program, the most common intervention following a thoracentesis demonstrating cytology negative for malignancy at our institution was clinical observation which, in the case of an intermediate or high pretest probability for malignant pleural effusion, is a questionable option at best. In our experience, patients are commonly reluctant to undergo an invasive surgical intervention for pleural biopsies, but are often willing to consider a less invasive endoscopic procedure performed in the outpatient arena.

Previously published literature shows discrepant findings regarding MT histologic results, with some cohorts dominated by pleural malignancy and some by NSP, and others showing a near even divide.12,14,16 Malignancy was slightly more common in this cohort, present in 47.1% of the patients. Mesothelioma was the most prevalent malignant diagnosis and was found in 27.5% of this cohort. Obviously, demonstrating pleural involvement by mesothelioma, or any metastatic malignancy, has profound implications on prognosis and management. The second most common diagnosis was NSP, accounting for 45.1% of this cohort. The causes of NSP in these patients were likely varied and may have included undetected infectious processes, connective tissue or autoimmune diseases, drug reactions, vasculitis, or heart failure, among others. Despite the high diagnostic accuracy of MT, occult malignant disease must always remain in the differential for patients found to have NSP. Previous reports on the natural history of patients found to have NSP during MT have shown that between 8% to 12% of these patients will subsequently be found to have pleural malignancy, particularly mesothelioma.17,18 For this reason, it is important that patients with a diagnosis of NSP continue to follow closely with their physicians and that consideration be given to serial radiographic surveillance for at least 2 years.19 Thus far, with a mean follow-up of approximately 9 months, none of the patients with NSP have been found subsequently to have a pleural malignancy.

We had very few complications in this cohort, corroborating previous reports demonstrating the excellent safety profile of MT.7,12,13 MT had to be aborted in four patients in this cohort. Three of these were because of an inability to adequately access the pleural space, and one was because of mechanical failure of the pleuroscope during the procedure. One of the patients was obese, and the excessive adipose tissue prevented insertion of the disposable trocar into the pleural space. In retrospect, this may have been predictable and perhaps could have been avoided. We have since become more selective with respect to body habitus when considering patients for MT. The other two patients had absent pleural spaces because of extensive adhesions. We routinely perform ultrasound examinations prior to MT to evaluate for a gliding lung sign indicating the presence of a pleural space. This finding was absent in these two individuals, suggesting that the space was likely obliterated. Their cases were discussed preoperatively with our Thoracic Surgery colleagues, and it was agreed that MT may be attempted because both patients were willing to undergo surgery if MT was unsuccessful and wanted to attempt a less invasive outpatient procedure prior to committing to surgery. Among patients in whom MT was completed, one patient developed an ex vacuo pneumothorax related to trapped lung, a minor adverse event expected in that setting. Two patients had severe pleuritic pain following the procedure, requiring a short hospitalization for IV analgesia, although both these patients were already reporting significant pleuritic pain prior to the procedure, which likely contributed to their need for hospitalization independent of the procedure. Finally, one patient had postanesthesia confusion following MT and was admitted for overnight observation, with a return to normal cognitive function by the following morning.

Performing MT in our procedural suite with moderate sedation provides convenience for the patients and also may mitigate health-care expenses by preventing charges associated with anesthesia, operating room cost, and hospitalization. MT is very well tolerated, as evidenced by the amount of sedation and analgesia required by the patients. Patients received an average of 4.1 mg of midazolam and 164 μg of fentanyl during the procedure. These are values similar to the sedation and analgesia required to complete bronchoscopic procedures routinely performed in the outpatient setting. Our procedural time was also relatively short at 40 min on average, which included the time required for placement of thoracostomy tubes, the majority of which were TIPCs. Patients spent < 5 h in our office on average, including preoperative and recovery time. Patients managed postoperatively with a pigtail thoracostomy tube spent slightly more time in the recovery area than those with TIPCs; however, the difference was only 46 min on average. Patients were then released home after removal of the pigtail thoracostomy tube or following training and education for management of their newly placed TIPC. For patients in whom MT is appropriate, this approach is generally favored over an overnight hospitalization with its added expenses and personal inconvenience.

Just over one-quarter of the patients underwent a subsequent procedure for management of their pleural space. It was more frequent in those managed postoperatively with a temporary pigtail catheter, although one-half of them were a single thoracentesis, which was the most common subsequent procedure overall. Just under 12% of the patients required subsequent operative interventions that potentially could have been completed concurrently with a surgical diagnostic procedure rather than MT (three pleurectomies/decortications, two parietal pleural biopsies, and one talc pleurodesis). On the other hand, it may be stated that > 88% of the patients required no additional operative interventions beyond those that would have been required subsequently regardless of which diagnostic method was used initially, and, therefore, avoided a more invasive initial diagnostic procedure and unnecessary hospitalization.

Our study has limitations. First is the lack of long-term follow-up to confirm the absence of malignancy in the cases of NSP. There were no cases of subsequent pleural malignancy in this cohort of 23 patients with NSP, but we have only an average of approximately 9 months of follow-up in these individuals, which is insufficient to draw any concrete conclusions. However, it was not our intention to determine the diagnostic accuracy of MT or the natural history of patients found to have NSP because these issues have been elucidated in multiple prior publications.17,18 Second, although it would make sense intuitively that outpatient MT may mitigate health-care expenses, no conclusions regarding cost effectiveness may be drawn from this study. A formal cost-effectiveness analysis is needed to confirm this hypothesis. Third, although physician-directed moderate sedation with midazolam and fentanyl is well accepted and commonplace in the United States, this is not necessarily true in other countries where the use of certain medications (eg, fentanyl) is prohibited and/or requires the direction of anesthesia personnel. This is an active area of research in other countries and may limit the generalizability of our results.20 Fourth, although each case was reviewed with a thoracic surgeon prior to the procedure, and surgical coverage was available, there was no formal multidisciplinary panel discussion of cases. This may be an opportunity for improvement within our practice and warrants consideration and discussion. Fifth, around 12% of the patients underwent a subsequent operative intervention that potentially could have been avoided if they had initially undergone a surgical diagnostic procedure rather than MT. Although this certainly bears consideration, we believe it is reasonable considering that the vast majority of patients avoided a more invasive diagnostic procedure and unnecessary hospitalization. Finally, the patients included in this study were referred for outpatient ambulatory evaluation and are likely a different cohort than those referred directly to our thoracic surgeons. As evidenced by our procedural contraindications, we were cautious regarding patient selection, and patients believed to be too unstable for outpatient MT were referred for VATS following discussion with our thoracic surgeons. However, it is not our intention to suggest that all patients are appropriate for outpatient MT. Instead, our aim was to demonstrate that outpatient MT is safe and feasible in appropriately selected patients.

In summary, we believe that outpatient MT can be integrated successfully into an active thoracic disease practice, offering patients a more convenient alternative to inpatient operative approaches while maintaining a high diagnostic yield and excellent safety. This practice is best achieved through a cooperative multidisciplinary approach involving interventional pulmonologists and thoracic surgeons. It is our belief that in this era of increased scrutiny of health-care outcomes and costs, MT may offer an attractive alternative to surgery in selected patients with undiagnosed exudative pleural effusions, and it should be considered an integral component of a necessary multidisciplinary approach to pleural diseases.

Author contributions: Z. S. D. and F. M. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Z. S. D., J. J. M., and F. M. contributed to data collection; Z. S. D. and F. M. contributed to the design of the study and data analysis; and Z. S. D., D. W., J. J. M., F. C. N., C. D., and F. M. contributed to the writing of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional information: The e-Appendix can be found in the Supplemental Materials section of the online article.

MT

medical thoracoscopy

NSP

nonspecific pleuritis

TIPC

tunneled indwelling pleural catheter

VATS

video-assisted thoracoscopic surgery

Light RW. Pleural effusions. Med Clin North Am. 2011;95(6):1055-1070. [CrossRef] [PubMed]
 
Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 13. 1998;;(139):1-119.
 
Maskell NA, Butland RJ; Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax. 2003;58(suppl 2):ii8-ii17. [CrossRef] [PubMed]
 
McLean AN, Bicknell SR, McAlpine LG, Peacock AJ. Investigation of pleural effusion: an evaluation of the new Olympus LTF semiflexible thoracofiberscope and comparison with Abram’s needle biopsy. Chest. 1998;114(1):150-153. [CrossRef] [PubMed]
 
Pastis NJ, Nietert PJ, Silvestri GA; American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee. Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest. 2005;127(5):1614-1621. [CrossRef] [PubMed]
 
Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society Pleural Disease Guideline Group. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60. [PubMed]
 
Colt HG. Thoracoscopy. A prospective study of safety and outcome. Chest. 1995;108(2):324-329. [CrossRef] [PubMed]
 
Breen DP, Mallawathantri S, Fraticelli A, Greillier L, Astoul P. Feasibility of short term drainage for diagnostic thoracoscopy. Monaldi Arch Chest Dis. 2009;71(2):54-58. [PubMed]
 
Agarwal R, Aggarwal AN, Gupta D. Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions: a meta-analysis. Chest. 2013;144(6):1857-1867. [CrossRef] [PubMed]
 
Blanc FX, Atassi K, Bignon J, Housset B. Diagnostic value of medical thoracoscopy in pleural disease: a 6-year retrospective study. Chest. 2002;121(5):1677-1683. [CrossRef] [PubMed]
 
Boutin C, Rey F. Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 consecutive patients. Part 1: diagnosis. Cancer. 1993;72(2):389-393. [CrossRef] [PubMed]
 
Hansen M, Faurschou P, Clementsen P. Medical thoracoscopy, results and complications in 146 patients: a retrospective study. Respir Med. 1998;92(2):228-232. [CrossRef] [PubMed]
 
Lee P, Hsu A, Lo C, Colt HG. Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome. Respirology. 2007;12(6):881-886. [CrossRef] [PubMed]
 
Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med. 1991;114(4):271-276. [CrossRef] [PubMed]
 
Wilsher ML, Veale AG. Medical thoracoscopy in the diagnosis of unexplained pleural effusion. Respirology. 1998;3(2):77-80. [CrossRef] [PubMed]
 
Kendall SW, Bryan AJ, Large SR, Wells FC. Pleural effusions: is thoracoscopy a reliable investigation? A retrospective review. Respir Med. 1992;86(5):437-440. [CrossRef] [PubMed]
 
Davies HE, Nicholson JE, Rahman NM, Wilkinson EM, Davies RJ, Lee YC. Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies. Eur J Cardiothorac Surg. 2010;38(4):472-477. [CrossRef] [PubMed]
 
Venekamp LN, Velkeniers B, Noppen M. Does ‘idiopathic pleuritis’ exist? Natural history of non-specific pleuritis diagnosed after thoracoscopy. Respiration. 2005;72(1):74-78. [CrossRef] [PubMed]
 
Wrightson JM, Davies HE. Outcome of patients with nonspecific pleuritis at thoracoscopy. Curr Opin Pulm Med. 2011;17(4):242-246. [CrossRef] [PubMed]
 
Tschopp JM, Purek L, Frey JG, et al. Titrated sedation with propofol for medical thoracoscopy: a feasibility and safety study. Respiration. 2011;82(5):451-457. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
TABLE 1  ] Patient Characteristics

Data are presented as mean ± SD or No. (%). ECOG = Eastern Cooperative Oncology Group; FDG = fluorodeoxyglucose.

Table Graphic Jump Location
TABLE 2  ] Procedural Details for Total Cohort

Data are presented as mean ± SD or No. (%). TIPC = tunneled indwelling pleural catheter.

Table Graphic Jump Location
TABLE 3  ] Procedural Details by Thoracostomy Tube Type

Data are presented as mean ± SD or No. (%). See Table 2 legend for expansion of abbreviations.

a 

Interventional Pulmonology.

b 

Thoracic Surgery.

c 

Interventional Radiology.

Table Graphic Jump Location
TABLE 4  ] Results

Data are presented as No. or No. (%).

References

Light RW. Pleural effusions. Med Clin North Am. 2011;95(6):1055-1070. [CrossRef] [PubMed]
 
Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States, 1996. Vital Health Stat 13. 1998;;(139):1-119.
 
Maskell NA, Butland RJ; Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax. 2003;58(suppl 2):ii8-ii17. [CrossRef] [PubMed]
 
McLean AN, Bicknell SR, McAlpine LG, Peacock AJ. Investigation of pleural effusion: an evaluation of the new Olympus LTF semiflexible thoracofiberscope and comparison with Abram’s needle biopsy. Chest. 1998;114(1):150-153. [CrossRef] [PubMed]
 
Pastis NJ, Nietert PJ, Silvestri GA; American College of Chest Physicians Interventional Chest/Diagnostic Procedures Network Steering Committee. Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors. Chest. 2005;127(5):1614-1621. [CrossRef] [PubMed]
 
Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society Pleural Disease Guideline Group. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60. [PubMed]
 
Colt HG. Thoracoscopy. A prospective study of safety and outcome. Chest. 1995;108(2):324-329. [CrossRef] [PubMed]
 
Breen DP, Mallawathantri S, Fraticelli A, Greillier L, Astoul P. Feasibility of short term drainage for diagnostic thoracoscopy. Monaldi Arch Chest Dis. 2009;71(2):54-58. [PubMed]
 
Agarwal R, Aggarwal AN, Gupta D. Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions: a meta-analysis. Chest. 2013;144(6):1857-1867. [CrossRef] [PubMed]
 
Blanc FX, Atassi K, Bignon J, Housset B. Diagnostic value of medical thoracoscopy in pleural disease: a 6-year retrospective study. Chest. 2002;121(5):1677-1683. [CrossRef] [PubMed]
 
Boutin C, Rey F. Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 consecutive patients. Part 1: diagnosis. Cancer. 1993;72(2):389-393. [CrossRef] [PubMed]
 
Hansen M, Faurschou P, Clementsen P. Medical thoracoscopy, results and complications in 146 patients: a retrospective study. Respir Med. 1998;92(2):228-232. [CrossRef] [PubMed]
 
Lee P, Hsu A, Lo C, Colt HG. Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome. Respirology. 2007;12(6):881-886. [CrossRef] [PubMed]
 
Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med. 1991;114(4):271-276. [CrossRef] [PubMed]
 
Wilsher ML, Veale AG. Medical thoracoscopy in the diagnosis of unexplained pleural effusion. Respirology. 1998;3(2):77-80. [CrossRef] [PubMed]
 
Kendall SW, Bryan AJ, Large SR, Wells FC. Pleural effusions: is thoracoscopy a reliable investigation? A retrospective review. Respir Med. 1992;86(5):437-440. [CrossRef] [PubMed]
 
Davies HE, Nicholson JE, Rahman NM, Wilkinson EM, Davies RJ, Lee YC. Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies. Eur J Cardiothorac Surg. 2010;38(4):472-477. [CrossRef] [PubMed]
 
Venekamp LN, Velkeniers B, Noppen M. Does ‘idiopathic pleuritis’ exist? Natural history of non-specific pleuritis diagnosed after thoracoscopy. Respiration. 2005;72(1):74-78. [CrossRef] [PubMed]
 
Wrightson JM, Davies HE. Outcome of patients with nonspecific pleuritis at thoracoscopy. Curr Opin Pulm Med. 2011;17(4):242-246. [CrossRef] [PubMed]
 
Tschopp JM, Purek L, Frey JG, et al. Titrated sedation with propofol for medical thoracoscopy: a feasibility and safety study. Respiration. 2011;82(5):451-457. [CrossRef] [PubMed]
 
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