Thoracoscopy: Advances and Increasing Role for Interventional Pulmonologists

Abstract

Thoracoscopy is an increasingly common procedure that provides significant clinical information and therapeutic applications. The procedure allows the physician to biopsy the parietal pleura under direct visualization with high accuracy. In addition, one can drain pleural fluid, place a chest tube in a precise location, and perform poudrage pleurodesis. Medical thoracoscopy (MT) is carried out in the operating room or procedure suite under moderate sedation with spontaneous ventilation. In comparison, video-assisted thoracoscopic surgery (VATS) is performed under general anesthesia with single lung ventilation and through multiple ports in the operating room. MT is less invasive, has a comparable diagnostic yield, and may be better tolerated in high-risk patients. The indications, complications, and advances in thoracoscopy will be discussed in this article. In the era of rapidly evolving therapeutics for lung cancer, immune-modulation and ever-increasing risks of immunosuppression, MT will evolve and continue to play a pivotal role in the evaluation and research of pleuropulmonary diseases.

Pleural Cryobiopsy

“…Given the growing interest in use of cryotechnology across areas relevant to interventional pulmonology and thoracic surgery, and given the current absence of multicenter randomized trial data on this subject, this study is both timely and crucial in advancing our understanding of the role of cryobiopsy in pleural tissue sampling. 6,7,22 The ability of cryobiopsy to yield comparatively larger tissue specimens is intuitively obvious. The flexible forceps have fairly limited jaw opening (available sizes include 2.0 and 2.8 mm) and can therefore only be expected to provide modest biopsy sizes.…”

“…Endoscopic pleural tissue sampling is typically accomplished using rigid or flexible forceps; rigid forceps are used in conjunction with standard rigid thoracoscopic instruments used for VATS that may also be used for MP, whereas flexible forceps are passed through the working channel of a semi-rigid thoracoscope with a flexible distal tip resembling that of a flexible video bronchoscope that is frequently (but not exclusively) used for MP. 6 Endoscopic pleural biopsy (via MP or VATS) has the highest diagnostic yield among all available sampling modalities, with estimates approximating 90% when pooled from multiple studies. 7 Why is there an imperfect rate of successful diagnosis despite pleural sampling under direct endoscopic vision, and how could this yield be improved on?…”

Pleurodesis

“…5,6 While there are no absolute contraindications to pleurodesis, patients who are critically ill with high oxygen requirements are unsuitable candidates for pleurodesis as they may not tolerate the systemic inflammatory response or impaired gas exchange induced by chemical pleurodesis. 7…”

“…The advent of the flexi-rigid thoracoscope fashioned like the bronchoscope and interfaces well with existing light sources and processors found in a regular endoscopy suite and it has garnered its widespread adoption as a diagnostic and therapeutic tool that facilitates pleurodesis. 7 Talc is the most commonly used agent and is applied as poudrage using an atomizer or a bulb syringe during thoracoscopy. 60 TTP is extremely effective with 90 to 100% success rates.…”

Twenty‐five years of Respirology: Advances in pleural disease

“…3 Imaging-guided pleural biopsy provided better diagnostic accuracy than 'blind' closed pleural biopsy in a randomized study on suspected malignant pleural effusion (MPE) 4 and significantly reduced the need of thoracoscopic biopsies. If imaging-guided biopsy is unavailable or has failed, medical thoracoscopy (pleuroscopy) is preferred over video-assisted thoracoscopic surgery (VATS) 5 as the former can be performed under sedation and spontaneous ventilation, avoid risks of general anaesthesia and shorten recovery time.…”