Medical thoracoscopy (pleuroscopy): Equipment, procedure, and complications
- Francis D Sheski, MD
Francis D Sheski, MD
- Associate Professor of Clinical Medicine
- Indiana University School of Medicine
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.
The technique, instruments used, and complications of medical thoracoscopy are reviewed here. The diagnostic and therapeutic uses are discussed separately. (See "Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications".)
Rigid and semirigid thoracoscopes are commonly used; choosing among them is typically operator-dependent.
Rigid instruments — The rigid thoracoscope is probably still the most common instrument used for medical thoracoscopy. It is cheap and provides both excellent optical quality and maneuverability within the pleural space [1-5]. Multiple diameter and angle-viewing instruments are available :
●Most instruments contain a light source, working channel, and video port all in a single device, allowing for a single point of entry procedure. Other instruments fulfill just one of these needs which necessitates a multi-port procedure. (See 'Choosing a point of entry' below.)
- Boutin C, Viallat JR, Cargnino P, Farisse P. Thoracoscopy in malignant pleural effusions. Am Rev Respir Dis 1981; 124:588.
- Boutin C, Cargnino P, Viallat JR. Thoracoscopy in the early diagnosis of malignant pleural effusions. Endoscopy 1980; 12:155.
- Feinsilver SH, Barrows AA, Braman SS. Fiberoptic bronchoscopy and pleural effusion of unknown origin. Chest 1986; 90:516.
- Cantó A, Blasco E, Casillas M, et al. Thoracoscopy in the diagnosis of pleural effusion. Thorax 1977; 32:550.
- Enk B, Viskum K. Diagnostic thoracoscopy. Eur J Respir Dis 1981; 62:344.
- Lee P, Colt HG. Pleuroscopy in 2013. Clin Chest Med 2013; 34:81.
- Ernst A, Hersh CP, Herth F, et al. A novel instrument for the evaluation of the pleural space: an experience in 34 patients. Chest 2002; 122:1530.
- Munavvar M, Khan MA, Edwards J, et al. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J 2007; 29:571.
- Khan MA, Ambalavanan S, Thomson D, et al. A comparison of the diagnostic yield of rigid and semirigid thoracoscopes. J Bronchology Interv Pulmonol 2012; 19:98.
- Thangakunam B, Christopher DJ, James P, Gupta R. Semi-rigid thoracoscopy: initial experience from a tertiary care hospital. Indian J Chest Dis Allied Sci 2010; 52:25.
- Wang Z, Tong ZH, Li HJ, et al. Semi-rigid thoracoscopy for undiagnosed exudative pleural effusions: a comparative study. Chin Med J (Engl) 2008; 121:1384.
- Agarwal R, Aggarwal AN, Gupta D. Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions: a meta-analysis. Chest 2013; 144:1857.
- Dhooria S, Singh N, Aggarwal AN, et al. A randomized trial comparing the diagnostic yield of rigid and semirigid thoracoscopy in undiagnosed pleural effusions. Respir Care 2014; 59:756.
- Yap KH, Phillips MJ, Lee YC. Medical thoracoscopy: rigid thoracoscopy or flexi-rigid pleuroscopy? Curr Opin Pulm Med 2014; 20:358.
- Senno A, Moallem S, Quijano ER, et al. Thoracoscopy with the fiberoptic bronchoscope. A simple method in diagnosing pleuropulmonary diseases. J Thorac Cardiovasc Surg 1974; 67:606.
- Ooi H. Bedside pleuroscopy in Taiwan : a great vision for critically-ill patients and intensivists. Biomedicine (Taipei) 2016; 6:13.
- Arias S, Semaan R, Lee H, et al. Tridimensional Medical Thoracoscopy. Ann Am Thorac Soc 2015; 12:945.
- Medford AR, Agrawal S, Bennett JA, et al. Thoracic ultrasound prior to medical thoracoscopy improves pleural access and predicts fibrous septation. Respirology 2010; 15:804.
- Watanabe Y, Sasada S, Chavez C, et al. Flex-rigid pleuroscopy under local anesthesia in patients with dry pleural dissemination on radiography. Jpn J Clin Oncol 2014; 44:749.
- Marchetti G, Valsecchi A, Indellicati D, et al. Ultrasound-guided medical thoracoscopy in the absence of pleural effusion. Chest 2015; 147:1008.
- 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-Armengod A. Macroscopic characteristics of pleural metastases arising from the breast and observed by diagnostic thoracoscopy. Am Rev Respir Dis 1990; 142:616.
- Rodrîguez-Panadero F, Borderas Naranjo F, López Mejîas J. Pleural metastatic tumours and effusions. Frequency and pathogenic mechanisms in a post-mortem series. Eur Respir J 1989; 2:366.
- Oldenburg FA Jr, Newhouse MT. Thoracoscopy. A safe, accurate diagnostic procedure using the rigid thoracoscope and local anesthesia. Chest 1979; 75:45.
- Loddenkemper R. Thoracoscopy: results in non cancerous and idiopathic pleural effusions. Poumon Coeur 1981; 37:261.
- 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.
- Pepper JR. Thoracoscopy in the diagnosis of pleural effusions and tumours. Br J Dis Chest 1978; 72:74.
- Boutin C, Viallat JR, Cargnino P, Rey F. Thoracoscopic lung biopsy. Experimental and clinical preliminary study. Chest 1982; 82:44.
- Lee P, Colt HG. A spray catheter technique for pleural anesthesia: a novel method for pain control before talc poudrage. Anesth Analg 2007; 104:198.
- 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.
- DePew ZS, Wigle D, Mullon JJ, et al. Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative. Chest 2014; 146:398.
- Psallidas I, Corcoran JP, Fallon J, et al. Provision of Day-Case Local Anesthetic Thoracoscopy: A Multicenter Review of Practice. Chest 2017; 151:511.
- Kern RM, DePew ZS, Maldonado F. Outpatient thoracoscopy: safety and practical considerations. Curr Opin Pulm Med 2015; 21:357.
- Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 1991; 114:271.
- Brims FJ, Arif M, Chauhan AJ. Outcomes and complications following medical thoracoscopy. Clin Respir J 2012; 6:144.
- Colt HG. Thoracoscopy. A prospective study of safety and outcome. Chest 1995; 108:324.
- Lee P, Hsu A, Lo C, Colt HG. Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome. Respirology 2007; 12:881.
- Nour Moursi Ahmed S, Saka H, Mohammadien HA, et al. Safety and Complications of Medical Thoracoscopy. Adv Med 2016; 2016:3794791.
- Viskum K, Enk B. Complications of thoracoscopy. Poumon Coeur 1981; 37:25.
- Hansen M, Faurschou P, Clementsen P. Medical thoracoscopy, results and complications in 146 patients: a retrospective study. Respir Med 1998; 92:228.
- Rahman NM, Ali NJ, Brown G, et al. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii54.
- Andersen HA, Fontana RS. Transbronchoscopic lung biopsy for diffuse pulmonary diseases: technique and results in 450 cases. Chest 1972; 62:125.
- Zavala DC. Pulmonary hemorrhage in fiberoptic transbronchial biopsy. Chest 1976; 70:584.
- 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.
- 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.
- Rigid instruments
- Semi-rigid instruments
- - Flexible fiberoptic instruments
- - Autofluorescent instruments
- - Three dimensional instruments
- Choosing a point of entry
- - Local anesthesia plus procedural sedation
- - General anesthesia
- Intercostal dissection and lung deflation
- Sedation or anesthesia-related
- SUMMARY AND RECOMMENDATIONS