Medical Thoracoscopy | Jindal Chest Clinic

Presentation on the topic "Medical thoracoscopy"

1. Medical thoracoscopy
Dr. Aditya Jindal
Interventional Pulmonologist & Intensivist
Jindal Clinics
SCO 21, Sec 20D, Chandigarh
DM Pulmonary and Critical Care Medicine (PGI Chandigarh),
FCCP

2. Interventional Pulmonology
“Art & science of medicine related to
performance of invasive diagnostic &
therapeutic procedures that require additional
training and expertise beyond within a
standard pulmonary program.”
ERS & ATS Task Force, 2002
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3. History
• Excellent results of laparoscopic surgery and the
tremendous advances in endoscopic technology
stimulated many thoracic surgeons to develop minimally
invasive techniques, which were termed therapeutic or
surgical thoracoscopy, as well as video-controlled or
video-thoracoscopic surgery, or video-assisted thoracic
surgery (VATS).
•Pleuroscopy (medical thoracoscopy) is considered as a
part of the field of interventional pulmonology.

4. History and evolution
Jacobacus Hans-Christian, a Swedish internist
explored thoracic cavity in 1910
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PROFESSOR OF
MEDICINE

5. Pleuroscopy
An intervention for:
•Diagnostic evaluation and therapy of pleural
pathologies such as:
–Pleural effusion
–Pleural carcinomatosis
–Pneumothorax
•Examination of pleural space by a trained
individual
Can be performed in Endoscopy suit or an OT

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7. MT vs. VATS
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MT VATS
Main Indications
Diagnosis of
pleural diseases
Treatment
Anaesthesia LA/Sedation GA
Intubation No Yes
Procedure site Suite/Room OT
Ports of entry Single-Double Multiple(>3)
Instruments Non-disposable Disposable
Invasiveness + ++
Safety ++ +
Cost + ++

8. Techniques
•The technique is actually very similar to chest tube insertion
by means of a trocar.
•There are two different techniques of diagnostic and
therapeutic pleuroscopy.
1.Single entry site: The method uses a 9-mm trocar, for a
thoracoscope with a working channel for accessory
instruments and optical biopsy forceps that is employed
under local anesthesia.
2.Two entry sites: As used by Jacobaeus for lysis of
adhesions, one entry (with a 7-mm trocar) is used for the
examination telescope and the other (with a 5-mm trocar)
for accessory instruments, including the biopsy forceps.

9. Semi-rigid pleuroscopy
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SEMI-RIGID PLEUROSCOPE WITH BIOPSY FORCEPS
However, the flexible tip allows very homogeneous
distribution of talc on all pleural surfaces

10. Indications
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11. Tubercular Pleural Effusion
Advantages of MT:
–Visualization of grayish-white granuloma (parietal &
diaphragmatic pleura).
–Multiple biopsies from selected sites.
–TB cultures more frequently positive.
–Complete drainage of pleural effusion during MT →
greater symptomatic improvement.
–Lysis of adhesions in multi-loculated pleural effusion
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12. Tubercular Pleural Effusion
Sensitivity of different biopsy
methods (histologic and
bacteriologic results
combined) for the diagnosis
of M.Tb infection.
Note the numerous small whitish
nodules on the parietal (chest
wall) pleura. The histology
revealed florid necrotizing
granuloma.
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13. Malignant Pleural Effusions
Indications of MT:
• Staging lung cancer
• Diffuse malignant mesothelioma.
• Metastatic cancer.
Advantages of MT:
• Complete evacuation of pleural fluid.
• Maximization of lung expandability by
removing adhesions.
• Talc pleurodesis.
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14. Malignant Pleural Effusions
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15. Mesothelioma
Advantage of Medical Thoracoscopy:
1.Specimens are large & full-thickness from several areas (no need
for open pleural biopsy) → Early diagnosis (accuracy by HPE up
to 98%) and better H/P classification
2.If intra-pleural chemotherapy or surgical treatment not under
consideration, diagnosis and pleurodesis done simultaneously
3.Benign asbestos-related Pleural effusion
•Fibro-hyaline/calcified, thick, pearly white pleural
plaques.
•Pleural and pulmonary biopsy→ demonstration of
asbestos fibers
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16. Empyema (Loculated)
Empyema :
Chest tube within
locule of pus after
adhesiolysis

17. Empyema
•Pleuroscopy can be used in the management of
early empyema
•In patients with multiple loculations, it is possible to open these
spaces, and to create a single cavity, which can then be
successfully drained and irrigated.
•This treatment should be carried out early in the course of
empyema before the adhesions become too fibrous and adherent to
perform pleuroscopy
•Pleuroscopy is a procedure similar to chest tube placement, but
enables the creation of a single pleural cavity, allowing much better
local treatment
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18. Pleural effusion of unknown etiology
•>20–25% of pleural effusion remain undiagnosed even after
extensive diagnostic work-up of pleural fluid.
•Pleuroscopy may give visual clues to the etiology (e.g., thick
white fibrin deposits in rheumatoid effusions, calcifications in
effusions following pancreatitis, dilated veins in liver cirrhosis).
•In some cases of recurrent pleural effusions of nonmalignant
etiology, such as hepatic and renal hydrothorax, chylothorax
and SLE that do not respond appropriately to medical therapy,
the recurrent effusion can be treated successfully by talc
pleurodesis.
•By medical thoracoscopy → The proportion of idiopathic
pleural effusions usually falls below 10%.
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19. Pneumothorax

20. Pneumothorax- Classification

21. Treatment options for PSP

22. Spontaneous Pneumothorax
•Pts. with recurrent/prolonged (> 5 days)
pneumothorax– Treatment with MT/VATS
better then repeated ICD
•Thoracoscopic findings in PSP :
–Type I (‘Normal appearance’)
–Type II (Pleuro-Pulmonary adhesions)
–Type III (Small blebs or bullae < 2 cm)
–Type IV (Large bullae > 2 cm)
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23. Spontaneous Pneumothorax
Advantages of Pleuroscopy
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24. A typical apical bleb
•Blebs /bullae(>2 cms) :
ligated/removed by APC,
electrocautery, Nd: YAG
laser after Endo Loop
application
•Wedge resection of
blebs/bulla with stapling
device possible

25. Secondary Spontaneous Pneumothorax
Underlying Lung Disease
– COPD and other bullous lung diseases
– Fibrocavitary tuberculosis
– Bronchiectasis, Cystic fibrosis
– Interstitial lung diseases
– Lymphangioleiomyomatosis
– Histiocytosis
– Malignancies
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26. LAM with Bilateral Pneumothorax
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27. Pleurodesis
•Definition: Obliteration of pleural cavity through
adhesions of visceral and parietal pleurae
•Indication: Recurrent pleural
effusion/ pneumothorax
•Method: Instillation of
sclerosants
•Side effects: Chest pain, Fever,
ARDS
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29. Therapeutic pleuroscopy
Talc poudrage
Talc is evenly distributed
over both pleural surface
Talc poudrage followed
by chest tube placement
in optimal position
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30. Sclerosants for Pleurodesis
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Sclerosant Dose
Success
rate
Adverse
events
Tetracyclin 20 mg/kg67% CP and fever
Bleomycin 60 IU 61%
CP and fever
Talk slurry via ICD2-5 gms 90%
CP, fever and
ARDS
Talk poudrage via
pleuroscopy
2-5 gms >90% CP and fever

31. TALC IS NOT GLUE !!!
Even spread over pleura not essential
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32. Failed VATS Pleurodesis
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33. Other Indications for thoracoscopy
Diffuse pulmonary diseases
1. Evaluation of single/multiple peripheral
pulmonary opacities where TBLB/Percutaneous
lung biopsy non-diagnostic.
2. Biopsy of visceral pleura and lung surface in
patients with proven or suspected pleural
malignancy (metastasis/ malignant
mesothelioma) for staging.
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34. Advantage over TBLB:
1. Ability to choose biopsy site (direct visualization).
2. Larger biopsy size.
3. Bleeding can be controlled with
electrocoagulation /laser.
•Sensitivity – overall > 90%
1. Sarcoidosis stage II/III → ~ 98%
2. Diffuse malignant lung diseases → ~ 90%
3. Fibrotic lung disease → ~ 85%
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Diffuse pulmonary Diseases

35. Localized Diseases
•Localized diseases in the region of the chest wall,
diaphragm, thoracic spine, and lung, and pathologic
changes in the chest cage close to the pleura
(provided the pleural space is not obliterated).
•Currently, the application of pleuroscopy has
decreased substantially for these indications due to
better imaging techniques such as CT, magnetic
resonance imaging, and ultrasound, which allow the
diagnosis of pleural plaques, lipomas, and cysts,
usually without difficulty.
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36. Contraindications
Absolute
•Size of free pleural space <6-10 cm usually due to
extensive adhesions.
•Respiratory insufficiency; on ventilatory support.
•Pulmonary arterial hypertension
•Uncorrectable bleeding disorders.
Relative
• Intractable cough.
• Hypoxemia.
• Bleeding and coagulation disorders.
• Unstable cardiovascular status.
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37. Complications
Mortality - 0.01-0.25 %
Morbidity
•Desaturation during procedure (↓ LA) <2%
•Persistent post-operative air leak (>7d)
<2% (pts with spontaneous pneumothorax).
•Subcutaneous emphysema ~ 0.5%
•Rare – benign cardiac arrythmias, transient hypotension
and seeding of pathology in patients with malignant
mesothelioma.
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38. Summary
•The advances in endoscopic technology, with
sophisticated endoscopic instruments and endoscopic
telescopes, allow the replacement of standard
management with thoracoscopy in many indications.
•Just as there is an overlap between pleuroscopy and
VATS procedures, there is also an overlap between
VATS and open surgical procedures.
•The decision to undertake a procedure depends on the
particular situation, the performance status and
prognosis, and on the expertise of the performer.

39. If only we were elephants…
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Elephant are auto-pleurodesed and live happily Elephant are auto-pleurodesed and live happily
without a pleural cavity, and never have to worry without a pleural cavity, and never have to worry
about effusions and pneumothorax!about effusions and pneumothorax!
West J. International Pleural Newsletter 2004

40. THANKS