Thoracoscopy In Undiagnosed Pleural Effusion Research Articles

Diagnostic value and safety of medical thoracoscopy in undiagnosed pleural effusions-a prospective observational cohort study.

With the need for "actionable histology" in the current era of targeted cancer treatment, and the increasing practice of upfront thoracoscopy (without a prior diagnostic thoracentesis) or a "biopsy first" approach in suspected malignant pleural effusions (MPEs), we sought to prospectively evaluate the diagnostic accuracy, including full molecular profiling of cancer, and safety of medical thoracoscopy (MT) at a tertiary referral hospital. Patients with MT performed for an undiagnosed pleural effusion between January 2020 and December 2022 were included in this observational cohort study. All procedures were performed with a semirigid thoracoscope under conscious sedation. Clinical outcomes and adverse events were recorded prospectively. We evaluated 141 patients, with a mean age of 67±12 years. Talc poudrage was performed in 67 (47.5%) patients with a median of 2 [interquartile range (IQR), 1-4] hospitalisation days after MT. Upfront thoracoscopy was performed in approximately half (55.3%) of patients. The overall diagnostic accuracy of MT was 95.7% in our cohort. A final diagnosis of cancer was made in 116 (82.3%) patients, with lung (67.2%) and breast cancer (8.6%) the most common. The diagnostic sensitivity of MT for malignancy was 94.8%, and molecular profiling of relevant cancer types for oncogenic mutations was achieved in all patients with malignancy seen on histopathology. The most common non-malignant diagnosis was tuberculous pleuritis in 14 patients (9.9%). Major complications occurred in 3 (2.1%) patients. Two patients had re-expansion pulmonary edema that resolved with low flow oxygen supplementation in the general ward, and one patient required intensive care unit admission for cardiac tamponade from a malignant pericardial effusion. There were no cases of mortality, bleeding complications or persistent air leaks. MT is a well-tolerated and effective option for the evaluation of undiagnosed pleural effusions. With expanding utility and expertise with MT and other pleural interventions, the challenge for respiratory physicians is integrating these into expeditious diagnostic and effective therapeutic pathways, individualised to patients' needs.

Role of Single Port Rigid Thoracoscopy in Undiagnosed Pleural Effusion.

In recent years, medical thoracoscopy has been well established to play an important role in undiagnosed pleural effusion; however, this procedure is underutilized due to limited availability of the instruments it requires. This study analysed the outcome of single port rigid thoracoscopy in patients with undiagnosed pleural effusions. This study retrospectively analysed the outcomes of all patients with undiagnosed pleural effusion presenting to our centre between 2016 to 2020 who underwent single port rigid medical thoracoscopy as a diagnostic procedure. In total, 92 patients underwent single port rigid medical thoracoscopy. The most common presenting symptom was shortness of breath. A majority of the patients had lymphocytic exudative pleural effusion. The average biopsy sample size was 18 mm, and no major complication was reported in any of the patients. Single port rigid thoracoscopy is a safe and well-tolerated procedure that yields a biopsy of a larger size with high diagnostic yield. Moreover, the low cost of the instruments required by this procedure makes it particularly suited for use in developing countries.

A Study of Role of Medical Thoracoscopy in Undiagnosed Pleural Effusion.

b/pulli>To know the diagnostic yield of pleuroscopy (medical thoracoscopy) in cases of pleural effusions which remain undiagnosed after routine initial investigations.lili>To notice the different gross pleuroscopic findings during the procedure.lili>To observe various histopathological reports of pleural biopsy taken through medical thoracoscopy.lili>To know the various complications of pleuroscopy in patients undergoing this procedure.li/ulp! A total of 56 patients having undiagnosed pleural effusion were taken for study after informed written consent. All patients underwent medical thoracoscopy. The clinical, demographic, and radiological profile of patients was recorded. Gross pleuroscopic findings and histopathological reports of the pleural biopsy were noted. All patients were observed for any complications that occurred during or after the procedure. Diagnostic yield of thoracoscopy in the present study was 91.07% (malignant pleural effusion 75% and tuberculous pleuritis 12.5%). Adenocarcinoma was the commonest malignancy in 60.71% of patients amongst malignant pleural effusion in the present study. Very few complications were recorded. The most common postprocedure complication was subcutaneous emphysema (12.5%) followed by pneumothorax (10.78%). Thoracoscopy gives excellent diagnostic yield in undiagnosed pleural effusion without major complications, and should be utilized wherever feasible.

Role for Video-Assisted Thoracoscopy in Undiagnosed Pleural Effusion: An Audit to Represent our Clinical Experience?

Background: Undiagnosed pleural effusion represents a health challenge. To discover possible causes, there were a number of invasive and non-invasive modalities. Each modality had its own accuracy. The aim of the work: The current work aimed to evaluate the role of video-assisted thoracoscopy (VATS) in the undiagnosed intermediate pleural effusion. Materials and Methods: The current work included forty patients with undiagnosed intermediate pleural effusion. All underwent preoperative assessment [history, physical examination, laboratory and radiological investigation]. Then, all submitted to VATS, pleurocentesis had been completed, and pleural aspirates were sent for culture and sensitivity. Also, the aspirate was subjected to biochemical investigation]. Operative data related to VATS included time of the whole procedure, intraoperative complications, amount of drained pleural fluid, the ability to obtain multiple biopsies, field exposure and degree of lung expansion. The visual analogue scale [VAS] was used to assess postoperative pain. Any postoperative complications were documented. Results: The mean operative time was 54.37±7.63 minutes, and no intraoperative complications had been recorded. The field exposure was adequate among the majority (77.5%). The VATS was able to provide a diagnosis for all studied patients. The mean duration of hospital stay was 5.90±1.53 days; the mean chest tube duration was 5.65±1.27 days. Finally, recurrent effusion was reported in 7 patients (17.5%) (5 males and two females). All patients need postoperative analgesia with great variability and postoperative pain showed significant variance across time (during the first 24 hours). 60% need no further intervention, while 32.5% need pleurodesis, and 7.5% need decortication. Malignant effusion was reported in 9 patients (22.5%). Conclusions: VATS as a diagnostic and therapeutic tool for undiagnosed pleural effusions, is an effective and safe intervention. Thus, it is advocated to be used as the standard and first intervention in such patients.

Role of flexi-rigid thoracoscopy in undiagnosed pleural effusions and correlation of visual appearance of pleura on thoracoscopy with the final diagnosis

Role of flexi-rigid thoracoscopy in undiagnosed pleural effusions and correlation of visual appearance of pleura on thoracoscopy with the final diagnosis

ES19.02 Best Endoscopic Tools for the Best Results

Undiagnosed pleural effusion is an increasingly common clinical problem and represents significant burden of disease both to patients and healthcare resources. With the increase in annual incidence of both primary and secondary pleural malignancies, better diagnostics and treatment options are very much needed. Medical thoracoscopy, also known as local anaesthetic thoracoscopy [2], is a procedure where a rigid or semi-rigid scope is inserted into the pleural cavity via a port for direct visualisation of the pleura and biopsy of abnormal areas, besides completion of talc poudrage, where appropriate. It is usually performed under conscious sedation and local anaesthesia. This procedure avoids risks of general anaesthesia and single lung ventilation, required for video-assisted thoracoscopic surgery (VATS) and therefore can be performed in patients who are unfit for anaesthesia/surgery. The procedure of thoracoscopy is performed in a controlled environment such as in an operating theatre setting, endoscopy suite or treatment room with adequate staffing. Diagnostic advantage A significant number of cases of pleural effusion are undiagnosed after a single diagnostic pleural aspiration and the diagnostic yield of pleural fluid cytology is only approximately 60% [3]. A second aspiration only modestly increases diagnostic yield by 15% and a third sample is non-contributory [3]. A blind pleural biopsy (also known as closed pleural biopsy) increases the diagnostic yield above pleural fluid cytology by only 7-27% [3]. In mesothelioma however, the diagnostic yield of pleural fluid cytology is even lower, at around 32% [4]. A blind pleural biopsy only increases sensitivity to around 50% [5]. Medical thoracoscopy is substantially superior in diagnostic power compared to pleural fluid cytology and blind pleural biopsy. As it allows direct visual assessment of the pleura and subsequent biopsy of the abnormal areas, it maximises diagnostic yield to >90% in malignant pleural diseases [5,6]. Rigid thoracoscopy generates similar diagnostic yield compared to semirigid thoracoscopy in exudative pleural effusions but larger biopsy samples can be obtained during rigid thoracoscopy [5,6]. The sensitivity of medical thoracoscopy in malignant mesothelioma appears to be equally good and the efficacy of rigid medical thoracoscopy in regards to diagnosis in pleural malignancy is as high as VATS [2]. With the increasing need to secure an accurate diagnosis and plan optimal treatment in possible pleural malignancy, medical thoracoscopy offers a high diagnostic yield earlier in the patient journey. Therefore, this is the preferred procedure where the option exists and helps to reduce the need for repeated diagnostic procedures and reduces the time taken to establish diagnosis and commence appropriate treatment. Medical thoracoscopy as a therapeutic procedure Another advantage of medical thoracoscopy is that it is a diagnostic and therapeutic procedure in the same setting. Complete drainage of pleural fluid can be achieved during the procedure and talc poudrage can also be performed during medical thoracoscopy. It is a highly effective method of pleurodesis with an efficacy of 84% at 1 month, which is at least equivalent to talc slurry via a seldinger chest drain, with possibly increased efficacy in the subgroup of patients who have breast or lung carcinoma and without trapped lung [2]. Medical thoracoscopy is also effective in the management of TB pleurisy and empyema. Septations and adhesions in complex infected effusions can be divided during thoracoscopy which can facilitate accurate chest tube placement and drainage. Advanced Thoracoscopy Techniques Narrow Band Imaging- using Semirigid Thoracoscope Autofluorescence Rigid Thoracoscopy Biopsy- with Insulated Tip Diathermy Knife Cryobiopsy- using Semirigid Thoracoscope Rigid Thoracoscope Semi-rigid Thoracoscope Diacon AH, Van de Wal BW, Wyser C, et al. Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J 2003;22:589e91. Rahman NM, Ali NJ, Brown G, Chapman SJ, O’Davies RJ, Downer NJ, Gleeson FV, Howes TQ, Treasure T, SinghS and Phillips GD Local anaesthetics thoracoscopy: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii54-ii60 Mohan A, Chandra S, Agarwal D, Naik S and Munavvar M. Utility of semirigid thoracoscopy in the diagnosis of pleural effusions: a systematic review. Journal of Bronchology and Interventional Pulmonology 17 (3), 195-201 Munavvar M, Khan MAI, Edwards J, Waqaruddin Z and Mills J. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J 2007; 29: 571-574 Dhooria S, Singh N, Agarwal AN, Gupta D and Agarwal R. A randomized trial comparing the diagnostic yield of rigid and semirigid thoracoscopy in undiagnosed pleural effusion. Respir Care 2014:59 (5), 756-764 Rozman A, Camlek L, Marc-Malovrh M, Triller N, Kern I. Rigid versus semi-rigid thoracoscopy for diagnosis of pleural disease: a randomized pilot study. Respirology, 2013 May;18(4):704-10. Loddenkemper R, Lee P, Noppen M, Mathur PN. Medical thoracoscopy/pleuroscopy: step by step. Breathe. 2011;8(2):156-67. Rigid Thoracoscopy, Semi-rigid Thoracoscopy, Advanced Techniques

Thoracoscopic pleural cryobiopsy versus conventional forceps biopsy in diagnosis of exudative pleural effusion of unknown etiology

BackgroundRigid forceps is commonly used for pleural biopsies during medical thoracoscopy in undiagnosed pleural effusion, and recently, the use of cryoprobe for pleural biopsies was encouraged, as the procedure is effective and safe.ObjectiveThis study compared between rigid forceps and cryoprobe pleural biopsies regarding biopsy characteristics, diagnostic yield, and tissue viability in patients with undiagnosed exudative pleural effusion who underwent medical thoracoscopy.Patients and methodsA total of 30 patients with undiagnosed exudative pleural effusion were selected for medical thoracoscopy, and pleural biopsies were taken by rigid forceps and cryoprobe in the same setting. All biopsies were processed for histopathology examination.ResultsOf the 30 patients, 18 (60%) were males and 12 (40%) were females, with mean age of 51.03 years. The most frequent diagnosis was mesothelioma (43.3%) followed by chronic nonspecific inflammation (23.3%), metastatic carcinoma (16.6%) and tuberculosis (16.6%). Biopsies of rigid forceps (mean: 0.8193 cm2) were larger than cryoprobe (mean: 0.3377 cm2) but with less depth. Tissue viability of cryoprobe biopsies was better than rigid forceps biopsies, and the diagnostic yield of both techniques was the same.ConclusionCryobiopsies obtained during medical thoracoscopy is technically feasible and safe with high diagnostic value. Biopsies of cryoprobe were smaller than that of rigid forceps but were deeper and with better preserved cellular architecture. These results will encourage the use of cryotechnique for diagnosis of undiagnosed exudative pleural effusion.

Role of Rigid Thoracoscopy in Undiagnosed Pleural Effusion: A Prospective Study

Role of Rigid Thoracoscopy in Undiagnosed Pleural Effusion: A Prospective Study

Outcomes and complications of medical thoracoscopy in undiagnosed exudative pleural effusion

Thoracoscopy has long been established as the procedure of choice for various chest diseases, among which is undiagnosed pleural effusions. Thoracoscopy does not only visualizes the extent of the disease but allows adequate tissue biopsy sampling. The aim of the present study was to detect outcomes and complications of medical thoracoscopy in undiagnosed pleural effusion. This study was conducted on 50 patients with unexplained exudative pleural effusion referred for medical thoracoscopy at Abbassia Chest Hospital. Medical thoracoscopy is a safe and valuable tool for the diagnosis of pleural effusion, particularly for patients with suspected malignancy. Overall cost-effectiveness of thoracoscopy is better due to its better yield and lesser duration of hospital stay. Medical thoracoscopy gave a definitive diagnosis with a diagnostic yield of 96%. Histopathological results of thoracoscopic pleural biopsy revealed that the most common diagnosis was malignancy (92%), followed by tuberculous pleurisy (2%), and fibrotic pleurisy (2%); only 4% of the patients remained undiagnosed. The most common malignant pathological type was malignant pleural mesothelioma (60%), followed by metastatic adenocarcinoma (12%). According to the residence of studied patients, we found that environmental exposure to asbestos has a relationship with mesothelioma in patients living in Shoubra El-Kheima and Helwan. Medical thoracoscopy is a safe tool for diagnosing pleural effusion; although no major complications were found in the present study, minor complications occurred only in 10% of the patients. Medical thoracoscopy is a valuable tool in the diagnosis of undiagnosed pleural effusion. It is a simple and safe method with a high diagnostic yield and low complication rates.

Thoracoscopic evaluation of 129 cases having undiagnosed exudative pleural effusions.

Background:Medical thoracoscopy is a minimally invasive procedure used in diagnostic and therapeutic applications for pleural diseases. In this study, we describe our experience in the outcome and analysis of thoracoscopy in undiagnosed pleural effusion presenting to our center.Materials and Methods:This is a prospective study conducted over last 2 years. We performed thoracoscopy in 129 cases of undiagnosed exudative pleural effusions using rigid thoracoscope. Clinical, radiological, cyto and histopathological data of the patients were collected prospectively and analyzed.Results:The overall diagnostic yield of thoracoscopic pleural biopsy was 110/129 (85.2%) in patients with undiagnosed pleural effusion, and 19/129 (14.8%) patients remained unexplained. Histopathological diagnosis confirmed malignancy in 66.4% patients (both primary and metastatic pleural carcinoma), tuberculosis in 28.2%, others including parapneumonic effusion in 4 cases followed by multiple myeloma, lupus pleuritis, and pulmonary langerhans cell histiocytosis in one case each. Procedure-related mortality was nil. Minor complications related to the procedure include hemorrhage, subcutaneous emphysema, etc.Conclusion:Thoracoscopy is relatively a safe and well-tolerated procedure with high diagnostic accuracy in undiagnosed pleural effusions, decreasing the need of formal diagnostic thoracotomy. Every chest physician must, therefore, consider this procedure to decrease the time lag in achieving the final diagnosis and to initiate the treatment as early as possible.

Diagnostic accuracy and safety of rigid medical thoracoscopy in undiagnosed pleural effusion and ILD: Retrospective study of 100 patients

Aim of studyA retrospective study of diagnostic evaluation, safety and thoracoscopic findings in 100 cases was done at thoracoscopy unit of Chest Department Mansoura University Hospitals in the last two years. ResultsWe studied 100 patients in two groups, first group (G1) consisted of 85 male patients (67.1%) with undiagnosed pleural effusion and the second group (G2) consisted of 15 undiagnosed ILD female patients (60%).Final histopathologic diagnosis in the first group revealed metastatic adenocarcinoma in 35.3%, para-pneumonic 44.7%, TB 10.6%, NHL7.1% and mesothelioma 2.4%, while in the second group it was metastatic adenocarcinoma 6.7%, UIP 46.7%, NSIP 13.3%, TB 6.7%, BAC 13.3%, silicosis 6.7% and lastly LIP in 6.7%.We found that time of ICT removal was significantly lower in the first group with p value 0.001 and complication incidences were variants; fistula was significantly lower in the first group while empyema and surgical emphysema were significantly higher in the first group with p value 0.001. ConclusionVAMT is a good tool for the diagnosis of undiagnosed pleural diseases and is promising in ILDs, safe, and inexpensive with minimally tolerable complications.

Efficacy and Safety of Diagnostic Thoracoscopy in Undiagnosed Pleural Effusions

Background: The differential diagnosis of pleural effusions can present a considerable challenge, and the etiology of pleural effusions varies depending on the population studied. Objective: This study aimed to assess the efficacy and safety of medical thoracoscopy in the diagnosis of patients with undiagnosed pleural effusions in a Chinese population. Methods: Between July 2005 and June 2014, medical thoracoscopy (MT) using the semirigid instrument was performed in 833 patients with pleural effusions of unknown etiology in our Institute, where diagnostic thoracocentesis or/and blind pleural biopsy had failed to yield an answer. Demographic, radiographic, procedural, and histological data were recorded and analyzed. Results: During this 9-year study, satisfactory pleural biopsy samples were obtained in 833 patients, and MT revealed malignant pleural effusion in 342 (41.1%) patients, benign pleural effusion in 429 (51.5%) patients, and 62 (7.4%) patients could not get definite diagnoses. The overall diagnostic efficiency of MT was 92.6% (771/833). After MT, the only severe complication was empyema, seen in 3 patients (0.4%). The most common minor complication was transient chest pain (44.1%) from the indwelling chest tube. Conclusions: MT is an effective and safe procedure for diagnosing pleural effusions of undetermined causes. In areas with high tuberculosis prevalence, MT should be particularly helpful in the differential diagnosis of tuberculous pleural effusion.

Yield of Video Assisted Thoracoscopy in Undiagnosed Pleural Effusions in South Indian Population

Yield of Video Assisted Thoracoscopy in Undiagnosed Pleural Effusions in South Indian Population

Diagnostic thoracoscopy in undiagnosed pleural effusion: Our experience in Manmohan cardio-thoracic vascular and transplant Center

Introduction: Diagnosis of exudative pleural effusions can often be elusive leading to delayed or misdirected treatment. Pleural biopsy remains the gold standard in the diagnosis but blind biopsy have historically low yields while thoracoscopic biopsies give ≥90% results. We reviewed our experience with thoracoscopic pleural biopsy.
 Methods: A retrospective observational study of patients with exudative pleural effusions which had Adenosinedeaminase (ADA) values ≤ 60 and ≥ three cytology samples negative for malignancy was conducted. These patients were subjected to thoracoscopy and pleural biopsy. The concordance of pre and post operative diagnosis and morbidity of the procedure were studied.
 Results: Seventeen such patients with mean age of 39.3±19.8 years (11 to 70 years) and Male to Female ratio of 10:7 underwent thoracoscopic pleural biopsy between Jan 2012 – Jan 2013. The average duration of effusion was 11.05 ±2.34weeks. Seven patients had either taken or were currently on a course of antitubercular treatment at the time of pleural biopsy. The presumptive clinical diagnosis was tuberculosis in nine patients, malignancy in three and unsure in five. The final histopathology confirmed pleural tuberculosis in only two while metastatic adenocarcinoma was found in six patients and non-specific pleural inflammation in nine. Pleurodesis was done in six and decortication in five patients.
 Conclusion: Thoracoscopy should be considered when the cause of pleural effusion is elusive. Judicious use of this diagnostic modality may avoid delayed or misdirected treatment in people with pleural effusions and also offer opportunity of therapeutic intervention when needed.

A Randomized Trial Comparing the Diagnostic Yield of Rigid and Semirigid Thoracoscopy in Undiagnosed Pleural Effusions

Thoracoscopic pleural biopsy increases the diagnostic yield of pleural effusions undiagnosed after thoracentesis and is superior to closed pleural biopsy. Medical thoracoscopy can be performed using the rigid thoracoscope or the semirigid thoracoscope (pleuroscope). In this randomized trial, we compare the efficacy and safety of the 2 thoracoscopes. Subjects with undiagnosed exudative pleural effusions were randomly assigned to undergo pleural biopsy with either the rigid or the semirigid thoracoscope. The primary outcome was the diagnostic yield of the procedure, while the secondary outcomes were requirement of sedative/analgesic agents, scar size, biopsy sample size, and the operator's view of the procedure. Of the 145 screened subjects with exudative pleural effusions, 90 were randomized to undergo thoracoscopy with the 2 thoracoscopes (n = 45 each). The diagnostic yield of rigid thoracoscopy was superior to semirigid thoracoscopy (97.8% vs 73.3%, P = .002) on an intention-to-treat analysis but was similar (100% vs 94.3%, P = .18) in those with successful biopsy. The requirement of sedative/analgesic agents was higher in the rigid thoracoscopy arm. The scar size was slightly larger (mean ± SD, 23.1 ± 4 vs 18.7 ± 3.2 mm, P = .0001), whereas the biopsy sample size was distinctly larger in the rigid arm (mean ± SD, 13.9 ± 4.4 vs 4.4 ± 1.4 mm, P = .001). The operator-rated visual analog scale score for the ease of taking a biopsy sample was significantly higher with the rigid instrument (mean ± SD, visual analog scale 86 ± 12 vs 79 ± 12 mm, P = .01), while the quality of image was superior in the semirigid arm (mean ± SD, visual analog scale 88 ± 7 vs 92 ± 5 mm, P = .002). The number of complications were similar in the 2 groups. Rigid thoracoscopy was found to be superior to semirigid thoracoscopy overall, but the diagnostic yield was similar if pleural biopsy could be successfully performed. Due to the small sample size, a larger study is required to define the usefulness and choice between the 2 procedures. (ClinicalTrials.gov registration NCT01726556).

Performance Characteristics of Semirigid Thoracoscopy in Pleural Effusions of Undetermined Etiology

The utility of the recently introduced semirigid thoracoscopy in undiagnosed pleural effusions is still unclear. A single-center, 4-year retrospective analysis of all semirigid medical thoracoscopy procedures was done. The diagnostic accuracy of thoracoscopy was calculated as the number of positive diagnoses achieved by thoracoscopy in relation to the end-diagnosis achieved in the patient group by any means. One hundred fifty procedures were analyzed. Ninety-two patients (62.3%) were diagnosed as having a malignant disorder, of which mesothelioma was the most common (26%). Pleural thickening and nodularity were the most common abnormalities noted. The combined presence of nodules and hemorrhagic fluid increased the likelihood of malignancy 9-fold. Thirteen patients with a high clinical suspicion of malignancy but negative by thoracoscopy underwent mediastinoscopy, computed tomography-guided biopsy, or open thoracotomy. A malignant etiology was confirmed in all of them. Overall, thoracoscopy provided a diagnostic accuracy of 91.3%, sensitivity of 87%, and specificity of 100%. The addition of a second procedure in selected patients improved the diagnostic accuracy for malignancy by 8.7%. The procedures were well tolerated and only 6 patients developed minor and transient complications such as pain, hypoxia, and bradycardia. Semirigid thoracoscopy is a safe, well-tolerated, and efficacious procedure for establishing the diagnosis in pleural effusions of undetermined etiology.