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Medical ThoracoscopyMedical Thoracoscopy and Chest Ultrasound: The Green Shapes of Grey FREE TO VIEW

Marios E. Froudarakis, MD, PhD
Author and Funding Information

From the Department of Pneumonology, Medical School of Alexandroupolis, Democritus University of Thrace.

CORRESPONDENCE TO: Marios E. Froudarakis, MD, PhD, Department of Pneumonology, University Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece; e-mail: mfroud@med.duth.gr


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


Chest. 2015;147(4):869-871. doi:10.1378/chest.14-2406
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Medical thoracoscopy (or pleuroscopy) under local anesthesia is a technique known since the 18th century when the Swedish physician Christian Jackobeus treated his patients with TB by cutting the adhesions using a cystoscope.1 However, it is only in the last 20 years that the technique has been spread all over the world because of industrial development and more widespread access to sources of knowledge. The latter evidence was mainly attributed to pioneer physicians, educational courses launched from departments traditionally performing this technique, and, finally, the development of new tools, such as the mini-thoracoscope2 and the semirigid pleuroscope.3 Indeed, the semirigid thoracoscope, which was developed in the early 2000s,3,4 has revolutionized the application of the technique, since it resembles the fiber-optic bronchoscope, a device very familiar to respiratory physicians.5

In respiratory medicine, diagnosis of the cause of pleural effusion and pleurodesis in patients with malignant disease represents the two major indications of thoracoscopy (“green zone” of practice).6,7 In patients with malignant pleural effusion, its diagnostic accuracy is 95%, whereas the success rate in the same patient population of pleural talcage is 90%.6,7 The method may be performed safely when conditions are met in the outpatient setting of a highly active referral center.8 Furthermore, medical thoracoscopy is the principal tool to study the pathophysiology and pathogenesis of pleural disease9 by applying new modalities such as narrow-band imaging10 and fluorescence.11

Although authors have suggested that medical thoracoscopy is a safe and accurate procedure to investigate lung parenchyma disease12,13 by getting lung tissue of good quantity and quality,14 this technique is no longer performed by pulmonologists for various reasons, such as the increased diagnostic accuracy of high-resolution chest CT scanning, less invasive methods available when necessary (bronchoscopy with or without endobronchial ultrasonography), and, importantly, the lack of experience in the management of the technique and its complications—the “red zone” of practice.15 In addition, thoracoscopic sympathicolysis in patients with essential hyperhydration as well as pericardiolysis in patients with tamponade can be performed, but these techniques necessitate efficient training and general anesthesia with selective ventilation, for both patient comfort and treatment efficacy.15

There is a field of practice in thoracoscopy that represents a “grey zone” for physicians. Management of pneumothorax and empyema may be efficient with this method in the hands of experienced respiratory physicians. Indeed, a European randomized study of medical thoracoscopic talc pleurodesis vs chest tube drainage in pneumothorax showed significant lower recurrences, lower duration of hospitalization, and lower costs in patients treated with thoracoscopic pleurodesis.16 Rationale to spare lung parenchyma is that the presence or size of blebs, bullae, or both have never been proven to be real risk factors of primary spontaneous pneumothorax occurrence.17 A controlled study directly comparing surgical procedures to thoracoscopic pleurodesis should definitively answer this question.18,19

Regarding pleural infection, early medical thoracoscopy showed excellent results in treating patients, with an efficacy ranging from 85% to 92%.20-22 Treating these patients with medical thoracoscopy requires specific training to deal with difficulties such as recognition of different anatomic intracavitary structures when blurred by intense inflammation as well as lysis of loculations using the biopsy or the coagulation forceps. The method has not been compared with classic treatment or with video-assisted thoracoscopic surgery. Yet, overall, how many of the therapeutic interventions have been validated in empyema?15,23

Thoracoscopy in pleural disease without pleural effusion is another “grey zone” for respiratory physicians.24 In general, pulmonologists often choose to refer the patient with suspected pleural disease in the absence of pleural effusion for surgery rather than perform thoracoscopy.25 Concerns or relative inability to penetrate into the pleural space, due to the presence of adhesions, without harming the lung parenchyma represent the major explanation for this approach. Only skilled thoracoscopists may attempt extended thoracoscopy.25 Chest ultrasonography has dramatically changed our approach in pleural disease, since from the simple pleural tap to the minimally invasive pleuroscopy, its use provides higher diagnostic accuracy and comfort for both patient and physician.26 It is highly indicated in medical thoracoscopy to identify the right spot for trocar introduction, especially when empyema is suspected.27

The study by Marchetti and coworkers28 in this issue of CHEST (see page 1008) marks the dawn of a new era in medical thoracoscopy, where the usage of chest ultrasonography facilitates the approach to patients without pleural effusion. In particular, the presence of the “sliding sign,” defining the unrestricted movement of the visceral over the parietal pleura, supports the decision to perform diagnostic thoracoscopy regardless of the number of adhesions.28 The importance of applying thoracoscopy in this patient population is strengthened by the fact that 22 out of their 29 included patients (75.8%) had malignant disease. As expected, mesothelioma was diagnosed in the majority of these cases (13 patients out of 22 with malignancy), since this type of tumor may invade the pleura without effusion. It is hoped that this study will expand the indications of medical thoracoscopy and limit the number of patients referred for surgical procedures, thus sparing operation theaters and reducing hospital stay, costs, and morbidity. The study by Marchetti and coworkers28 definitely shifts the indication of medical thoracoscopy or pleuroscopy in patients with pleural disease without effusion from the “grey zone” to the “green zone” of everyday clinical practice in respiratory medicine.

References

Tassi GF, Tschopp JM. The centenary of medical thoracoscopy. Eur Respir J. 2010;36(6):1229-1231. [CrossRef] [PubMed]
 
Tassi G, Marchetti G. Minithoracoscopy: a less invasive approach to thoracoscopy. Chest. 2003;124(5):1975-1977. [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]
 
Munavvar M, Khan MA, Edwards J, Waqaruddin Z, Mills J. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J. 2007;29(3):571-574. [CrossRef] [PubMed]
 
Froudarakis ME. New challenges in medical thoracoscopy. Respiration. 2011;82(2):197-200. [CrossRef] [PubMed]
 
Rodríguez-Panadero F. Medical thoracoscopy. Respiration. 2008;76(4):363-372. [CrossRef] [PubMed]
 
Michaud G, Berkowitz DM, Ernst A. Pleuroscopy for diagnosis and therapy for pleural effusions. Chest. 2010;138(5):1242-1246. [CrossRef] [PubMed]
 
DePew ZS, Wigle D, Mullon JJ, Nichols FC, Deschamps C, Maldonado F. Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative. Chest. 2014;146(2):398-405. [CrossRef] [PubMed]
 
Froudarakis ME, Noppen M. Medical thoracoscopy: new tricks for an old trade. Respiration. 2009;78(4):373-374. [CrossRef] [PubMed]
 
Ishida A, Ishikawa F, Nakamura M, et al. Narrow band imaging applied to pleuroscopy for the assessment of vascular patterns of the pleura. Respiration. 2009;78(4):432-439. [CrossRef] [PubMed]
 
Noppen M, Dekeukeleire T, Hanon S, et al. Fluorescein-enhanced autofluorescence thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects. Am J Respir Crit Care Med. 2006;174(1):26-30. [CrossRef] [PubMed]
 
Colt HG, Russack V, Shanks TG, Moser KM. Comparison of wedge to forceps videothoracoscopic lung biopsy. Gross and histologic findings. Chest. 1995;107(2):546-550. [CrossRef] [PubMed]
 
Vansteenkiste J, Verbeken E, Thomeer M, Van Haecke P, Eeckhout AV, Demedts M. Medical thoracoscopic lung biopsy in interstitial lung disease: a prospective study of biopsy quality. Eur Respir J. 1999;14(3):585-590. [CrossRef] [PubMed]
 
Emam RH, Froudarakis ME, Refaat AI, Akl M, Maldonado F, Astoul P. Subpleural versus deep lung biopsies obtained during pleuroscopy for histological examination: an experimental animal study. Respiration. 2012;84(5):423-428. [CrossRef] [PubMed]
 
Froudarakis M. Thoracoscopy: advanced medical procedures.. In:Ernst A, Herth F., eds. Principles and Practice of Interventional Pulmonology. New York, NY: Springer-Verlag; 2013:631-638.
 
Tschopp JM, Boutin C, Astoul P, et al; ESMEVAT team. (European Study on Medical Video-Assisted Thoracoscopy). Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study. Eur Respir J. 2002;20(4):1003-1009. [CrossRef] [PubMed]
 
Astoul P. Editorial comment: management of primary spontaneous pneumothorax: a plea for a mini-invasive approach. Eur J Cardiothorac Surg. 2010;37(5):1135-1136. [CrossRef] [PubMed]
 
Tschopp JM, Schnyder JM, Froudarakis M, Astoul P. VATS or simple talc poudrage under medical thoracoscopy for recurrent spontaneous pneumothorax. Eur Respir J. 2009;33(2):442-443. [CrossRef] [PubMed]
 
Tschopp JM, Schnyder JM, Astoul P, et al. Pleurodesis by talc poudrage under simple medical thoracoscopy: an international opinion. Thorax. 2009;64(3):273-274. [CrossRef] [PubMed]
 
Ravaglia C, Gurioli C, Tomassetti S, et al. Is medical thoracoscopy efficient in the management of multiloculated and organized thoracic empyema? Respiration. 2012;84(3):219-224. [CrossRef] [PubMed]
 
Brutsche MH, Tassi GF, Györik S, et al. Treatment of sonographically stratified multiloculated thoracic empyema by medical thoracoscopy. Chest. 2005;128(5):3303-3309. [CrossRef] [PubMed]
 
Koulelidis A, Anevlavis S, Archontogiorgis K, et al. Evaluation of the efficacy of medical thoracoscopy in the treatment of pleural infection [abstract]. Eur Respir J. 2014;44(suppl 58):A491.
 
Froudarakis ME, Bouros D. Management of pleural empyema: don’t miss the point! Respiration. 2013;86(4):277-279. [CrossRef] [PubMed]
 
Rodriguez-Panadero F, Janssen JP, Astoul P. Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion. Eur Respir J. 2006;28(2):409-422. [CrossRef] [PubMed]
 
Janssen JP, Boutin C. Extended thoracoscopy: a biopsy method to be used in case of pleural adhesions. Eur Respir J. 1992;5(6):763-766. [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [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]
 
Marchetti G, Valsecchi A, Indellicati D, Arondi S, Trigiani M, Pinelli V. Ultrasound-guided medical thoracoscopy in the absence of pleural effusion. Chest. 2015;147(4):1008-1012.
 

Figures

Tables

References

Tassi GF, Tschopp JM. The centenary of medical thoracoscopy. Eur Respir J. 2010;36(6):1229-1231. [CrossRef] [PubMed]
 
Tassi G, Marchetti G. Minithoracoscopy: a less invasive approach to thoracoscopy. Chest. 2003;124(5):1975-1977. [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]
 
Munavvar M, Khan MA, Edwards J, Waqaruddin Z, Mills J. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J. 2007;29(3):571-574. [CrossRef] [PubMed]
 
Froudarakis ME. New challenges in medical thoracoscopy. Respiration. 2011;82(2):197-200. [CrossRef] [PubMed]
 
Rodríguez-Panadero F. Medical thoracoscopy. Respiration. 2008;76(4):363-372. [CrossRef] [PubMed]
 
Michaud G, Berkowitz DM, Ernst A. Pleuroscopy for diagnosis and therapy for pleural effusions. Chest. 2010;138(5):1242-1246. [CrossRef] [PubMed]
 
DePew ZS, Wigle D, Mullon JJ, Nichols FC, Deschamps C, Maldonado F. Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative. Chest. 2014;146(2):398-405. [CrossRef] [PubMed]
 
Froudarakis ME, Noppen M. Medical thoracoscopy: new tricks for an old trade. Respiration. 2009;78(4):373-374. [CrossRef] [PubMed]
 
Ishida A, Ishikawa F, Nakamura M, et al. Narrow band imaging applied to pleuroscopy for the assessment of vascular patterns of the pleura. Respiration. 2009;78(4):432-439. [CrossRef] [PubMed]
 
Noppen M, Dekeukeleire T, Hanon S, et al. Fluorescein-enhanced autofluorescence thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects. Am J Respir Crit Care Med. 2006;174(1):26-30. [CrossRef] [PubMed]
 
Colt HG, Russack V, Shanks TG, Moser KM. Comparison of wedge to forceps videothoracoscopic lung biopsy. Gross and histologic findings. Chest. 1995;107(2):546-550. [CrossRef] [PubMed]
 
Vansteenkiste J, Verbeken E, Thomeer M, Van Haecke P, Eeckhout AV, Demedts M. Medical thoracoscopic lung biopsy in interstitial lung disease: a prospective study of biopsy quality. Eur Respir J. 1999;14(3):585-590. [CrossRef] [PubMed]
 
Emam RH, Froudarakis ME, Refaat AI, Akl M, Maldonado F, Astoul P. Subpleural versus deep lung biopsies obtained during pleuroscopy for histological examination: an experimental animal study. Respiration. 2012;84(5):423-428. [CrossRef] [PubMed]
 
Froudarakis M. Thoracoscopy: advanced medical procedures.. In:Ernst A, Herth F., eds. Principles and Practice of Interventional Pulmonology. New York, NY: Springer-Verlag; 2013:631-638.
 
Tschopp JM, Boutin C, Astoul P, et al; ESMEVAT team. (European Study on Medical Video-Assisted Thoracoscopy). Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study. Eur Respir J. 2002;20(4):1003-1009. [CrossRef] [PubMed]
 
Astoul P. Editorial comment: management of primary spontaneous pneumothorax: a plea for a mini-invasive approach. Eur J Cardiothorac Surg. 2010;37(5):1135-1136. [CrossRef] [PubMed]
 
Tschopp JM, Schnyder JM, Froudarakis M, Astoul P. VATS or simple talc poudrage under medical thoracoscopy for recurrent spontaneous pneumothorax. Eur Respir J. 2009;33(2):442-443. [CrossRef] [PubMed]
 
Tschopp JM, Schnyder JM, Astoul P, et al. Pleurodesis by talc poudrage under simple medical thoracoscopy: an international opinion. Thorax. 2009;64(3):273-274. [CrossRef] [PubMed]
 
Ravaglia C, Gurioli C, Tomassetti S, et al. Is medical thoracoscopy efficient in the management of multiloculated and organized thoracic empyema? Respiration. 2012;84(3):219-224. [CrossRef] [PubMed]
 
Brutsche MH, Tassi GF, Györik S, et al. Treatment of sonographically stratified multiloculated thoracic empyema by medical thoracoscopy. Chest. 2005;128(5):3303-3309. [CrossRef] [PubMed]
 
Koulelidis A, Anevlavis S, Archontogiorgis K, et al. Evaluation of the efficacy of medical thoracoscopy in the treatment of pleural infection [abstract]. Eur Respir J. 2014;44(suppl 58):A491.
 
Froudarakis ME, Bouros D. Management of pleural empyema: don’t miss the point! Respiration. 2013;86(4):277-279. [CrossRef] [PubMed]
 
Rodriguez-Panadero F, Janssen JP, Astoul P. Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion. Eur Respir J. 2006;28(2):409-422. [CrossRef] [PubMed]
 
Janssen JP, Boutin C. Extended thoracoscopy: a biopsy method to be used in case of pleural adhesions. Eur Respir J. 1992;5(6):763-766. [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [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]
 
Marchetti G, Valsecchi A, Indellicati D, Arondi S, Trigiani M, Pinelli V. Ultrasound-guided medical thoracoscopy in the absence of pleural effusion. Chest. 2015;147(4):1008-1012.
 
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