Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications
- Francis D Sheski, MD
Francis D Sheski, MD
- Associate Professor of Clinical Medicine
- Indiana University School of Medicine
- Section Editors
- Praveen N Mathur, MB;BS
Praveen N Mathur, MB;BS
- Section Editor — Interventional Pulmonology
- Professor of Clinical Medicine
- Indiana University School of Medicine
- V Courtney Broaddus, MD
V Courtney Broaddus, MD
- Section Editor — Pleural Disease
- Professor of Medicine
- University of California San Francisco
Thoracoscopy (pleuroscopy) involves passage of an endoscope through the chest wall for direct visualization of the pleura. Medical thoracoscopy is most commonly used for pleural fluid drainage, pleural biopsy, and pleurodesis. Although the equipment and some applications are similar to those used in video-assisted thoracoscopic surgery (VATS), it is typically more limited in its diagnostic and therapeutic functions and performed by pulmonologists, thus the term "medical" thoracoscopy. While its use varies among clinicians and countries, this review is limited to its most common applications.
The indications and contraindications for medical thoracoscopy are discussed in this review while the technique, equipment, and complications are discussed separately. (See "Medical thoracoscopy (pleuroscopy): Equipment, procedure, and complications".)
Medical thoracoscopy is generally a second line tool for diagnostic or therapeutic procedures of the pleura. It should not replace preliminary diagnostic approaches, including thoracentesis for the evaluation of a pleural effusion or bronchoscopy for the evaluation of pulmonary parenchymal processes. For patients in whom parietal pleural biopsy is indicated, whether closed needle biopsy should be done before thoracoscopic biopsy is not clearly established. However, most experts prefer thoracoscopy given the higher diagnostic yield, ability to simultaneously perform additional procedures (eg, drainage and pleurodesis) and waning expertise in closed needle biopsy. However, closed needle biopsy may be preferred in cases where thoracoscopy is unavailable. Similarly, for those with pleural effusions in whom chemical pleurodesis is indicated, choosing whether to deliver sclerosant via a chest tube or a thoracoscope is unclear and usually depends upon the medical circumstances (eg, medical condition, physical performance status), goals and preferences of the patient, and institutional practice. (See "Management of malignant pleural effusions", section on 'Pleurodesis' and "Management of refractory nonmalignant pleural effusions", section on 'Pleurodesis'.)
Diagnostic evaluation of an exudative pleural effusion of unknown etiology — Medical thoracoscopy is most commonly performed when multiple attempts at thoracentesis (typically two to three) have failed to achieve a diagnosis in patients with an exudative pleural effusion of unclear etiology. This approach, which is supported by the 2010 British Thoracic Society Pleural Disease Guideline [1,2], is based upon the high diagnostic accuracy of thoracoscopic biopsy in this setting compared with closed needle or image-guided biopsy . Choosing among medical thoracoscopy or video-assisted thoracoscopic surgery (VATS) is dependent upon the complexity of the procedure, the possible need for concurrent minimally invasive surgery, as well as institutional expertise. Medical thoracoscopy can be safely performed in those who have an uncomplicated pleural space in whom no additional surgery (eg, lobectomy, wedge resection, decortication) is anticipated while VATS may be preferred in those with a complicated pleural space (eg, multiple adhesions), those in whom concurrent additional surgery is anticipated, or when medical thoracoscopy is not available. (See "Selection of modality for diagnosis and staging of patients with suspected non-small cell lung cancer", section on 'Pleural (T2, T3, M1a)' and "Procedures for tissue biopsy in patients with suspected non-small cell lung cancer", section on 'Suspected pleural metastases' and "Diagnostic evaluation of pleural effusion in adults: Additional tests for undetermined etiology".)
Parietal pleural biopsy is rarely needed for transudative effusions of unclear etiology but may be considered on a case-by-case basis (eg, borderline exudative effusions). (See "Management of refractory nonmalignant pleural effusions".)
- Rahman NM, Ali NJ, Brown G, et al. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii54.
- Hooper C, Lee YC, Maskell N, BTS Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii4.
- Agarwal R, Aggarwal AN, Gupta D. Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions: a meta-analysis. Chest 2013; 144:1857.
- Boutin C, Rey F, Viallat JR. Prevention of malignant seeding after invasive diagnostic procedures in patients with pleural mesothelioma. A randomized trial of local radiotherapy. Chest 1995; 108:754.
- Boutin C, Cargnino P, Viallat JR. Thoracoscopy in the early diagnosis of malignant pleural effusions. Endoscopy 1980; 12:155.
- Canto A, Rivas J, Saumench J, et al. Points to consider when choosing a biopsy method in cases of pleurisy of unknown origin. Chest 1983; 84:176.
- Cantó A, Ferrer G, Romagosa V, et al. Lung cancer and pleural effusion. Clinical significance and study of pleural metastatic locations. Chest 1985; 87:649.
- Meyer PC. Metastatic carcinoma of the pleura. Thorax 1966; 21:437.
- Breen D, Fraticelli A, Greillier L, et al. Redo medical thoracoscopy is feasible in patients with pleural diseases - a series. Interact Cardiovasc Thorac Surg 2009; 8:330.
- Wall CP, Gaensler EA, Carrington CB, Hayes JA. Comparison of transbronchial and open biopsies in chronic infiltrative lung diseases. Am Rev Respir Dis 1981; 123:280.
- Page RD, Jeffrey RR, Donnelly RJ. Thoracoscopy: a review of 121 consecutive surgical procedures. Ann Thorac Surg 1989; 48:66.
- Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 1991; 114:271.
- Davidson AC, George RJ, Sheldon CD, et al. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988; 43:327.
- Boutin C, Rey F. Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 consecutive patients. Part 1: Diagnosis. Cancer 1993; 72:389.
- Sasada S, Kawahara K, Kusunoki Y, et al. A new electrocautery pleural biopsy technique using an insulated-tip diathermic knife during semirigid pleuroscopy. Surg Endosc 2009; 23:1901.
- Thomas R, Karunarathne S, Jennings B, et al. Pleuroscopic cryoprobe biopsies of the pleura: a feasibility and safety study. Respirology 2015; 20:327.
- Loddenkemper R, Mai J, Scheffler N, Brandt HJ. Prospective individual comparison of blind needle biopsy and of thoracoscopy in the diagnosis and differential diagnosis of tuberculous pleurisy. Scand J Respir Dis Suppl 1978; 102:196.
- Diacon AH, Van de Wal BW, Wyser C, et al. Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J 2003; 22:589.
- Faurschou P, Francis D, Faarup P. Thoracoscopic, histological, and clinical findings in nine case of rheumatoid pleural effusion. Thorax 1985; 40:371.
- MacEachern P, Tremblay A. Pleural controversy: pleurodesis versus indwelling pleural catheters for malignant effusions. Respirology 2011; 16:747.
- Fysh ET, Waterer GW, Kendall PA, et al. Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion. Chest 2012; 142:394.
- Boutin C, Viallat JR, Cargnino P, Rey F. Thoracoscopic lung biopsy. Experimental and clinical preliminary study. Chest 1982; 82:44.
- Brandt HJ. [Pulmonary biopsy under visual control (author's transl)]. Poumon Coeur 1981; 37:307.
- Dijkman JH, van der Meer JW, Bakker W, et al. Transpleural lung biopsy by the thoracoscopic route in patients with diffuse interstitial pulmonary disease. Chest 1982; 82:76.
- Kapsenberg PD. Thoracoscopic biopsy under visual control. Poumon Coeur 1981; 37:313.
- Rodgers BM. Thoracoscopy in children. Poumon Coeur 1981; 37:301.
- Rodgers BM, Moazam F, Talbert JL. Thoracoscopy. Early diagnosis of interstitial pneumonitis in the immunologically suppressed child. Chest 1979; 75:126.
- Bonniot JP, Homasson JP, Roden SL, et al. Pleural and lung cryobiopsies during thoracoscopy. Chest 1989; 95:492.
- El-Hadidy TA, Rezk NA-S A. Diagnostic accuracy and safety of rigis medical thoracocospy in undiagnosed pleural effusion and ILD: Retrospective stidy of 100 patients. The Egyptian Journal of Chest Diseases and Tuberculosis 2015.
- Vansteenkiste J, Verbeken E, Thomeer M, et al. Medical thoracoscopic lung biopsy in interstitial lung disease: a prospective study of biopsy quality. Eur Respir J 1999; 14:585.
- Voellmy W. [Results of thoracoscopies in the diagnosis of diseases of the lungs and of the pleura (author's transl)]. Poumon Coeur 1981; 37:67.
- 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; 174:26.
- Torre M, Belloni P. Nd:YAG laser pleurodesis through thoracoscopy: new curative therapy in spontaneous pneumothorax. Ann Thorac Surg 1989; 47:887.
- Bridevaux PO, Tschopp JM, Cardillo G, et al.. Safety of large particle talc pleurodesis after talc poudrage under thoracoscopy for primary spontaneous pneumothorax. A European multicentre prospective study [Abstract]. Eur Respir J 2009; 34:375S.
- Brutsche MH, Tassi GF, Györik S, et al. Treatment of sonographically stratified multiloculated thoracic empyema by medical thoracoscopy. Chest 2005; 128:3303.
- Ohuchi M, Inoue S, Ozaki Y, et al. Single-trocar thoracoscopy under local anesthesia for pleural space infection. Gen Thorac Cardiovasc Surg 2014; 62:503.
- Ravaglia C, Gurioli C, Tomassetti S, et al. Is medical thoracoscopy efficient in the management of multiloculated and organized thoracic empyema?. Respiration 2012; 84:219.
- Narasimhan RL, Sehgal IS, Dhooria S, et al. Removal of Intrapleural Foreign Body by Medical Thoracoscopy: Report of Two Cases and a Systematic Review of the Literature. J Bronchology Interv Pulmonol 2016.
- Tassi GF, Marchetti GP, Aliprandi PL. Advanced medical thoracoscopy. Monaldi Arch Chest Dis 2011; 75:99.
- Michaud G, Berkowitz DM, Ernst A. Pleuroscopy for diagnosis and therapy for pleural effusions. Chest 2010; 138:1242.
- COMMON APPLICATIONS
- Diagnostic evaluation of an exudative pleural effusion of unknown etiology
- - Suspected malignant pleural disease
- Lung cancer
- - Suspected benign pleural disease
- Other benign pleural disorders
- Chemical pleurodesis for recurrent pleural effusion
- UNCOMMON APPLICATIONS
- Lung biopsy for parenchymal disease or peripheral nodules
- Blebectomy and/or pleurodesis for pneumothorax
- Drainage for complicated parapneumonic effusion and empyema
- Foreign body removal
- PROCEDURES NOT GENERALLY PERFORMED BY MEDICAL THORACOSCOPY
- SUMMARY AND RECOMMENDATIONS