Therapeutic uses of medical thoracoscopy
- Francis D Sheski, MD
Francis D Sheski, MD
- Associate Professor of Clinical Medicine
- Indiana University School of Medicine
Thoracoscopy involves a percutaneous approach to placement of an endoscopic instrument within the pleural space, allowing direct visualization and sampling of the pleura. Unlike video-assisted thoracic surgery (VATS), in which the surgeon uses a thoracoscope to assist with performance of minimally invasive surgery, the purpose of "medical thoracoscopy" is to provide access to the pleura and the pleural space for evaluation and, in some cases, management of pleural disease.
This topic will review the therapeutic uses of medical thoracoscopy. An overview of thoracoscopy and the diagnostic indications for thoracoscopy are discussed separately. (See "An overview of medical thoracoscopy" and "Indications for diagnostic thoracoscopy".)
The most widely employed therapy for treatment of malignant pleural effusion or recurrent benign pleural effusion involves drainage by tube thoracostomy followed by instillation of sclerosing agents to achieve chemical pleurodesis. Numerous sclerosing agents have been used to induce pleurodesis including talc, tetracycline, minocycline, doxycycline, silver nitrate, iodopovidone, bleomycin, Corynebacterium parvum with parenteral methylprednisolone acetate, erythromycin, fluorouracil, interferon beta, mitomycin C, cisplatin, cytarabine, doxorubicin, etoposide, and Streptococcus pyogenes A3 [1-6]. Chemical pleurodesis is discussed in general separately (see "Chemical pleurodesis" and "Talc pleurodesis"). This section focuses on the use of thoracoscopic talc poudrage (ie, insufflation) to achieve pleurodesis.
Efficacy — Requirements for successful pleurodesis include even distribution of the sclerosing agent over all pleural surfaces and expansion of the lung to the chest wall. Pleurodesis may fail if there is uneven distribution of agents, if the lung cannot re-expand following fluid removal, or if there is a large tumor burden with a low pleural pH . In theory, thoracoscopic talc poudrage (ie, insufflation) may increase the likelihood of successful pleurodesis in difficult cases by improving talc distribution over the pleural surfaces. This is supported by a series of 25 patients who had malignant effusions with a pH <7.30, which found that 22 patients (88 percent) had successful pleurodesis via thoracoscopic talc poudrage.
Historically, use of talc in its powder form for pleurodesis required a thoracotomy and had reported success rates greater than 90 percent accompanied by operative mortality of approximately two percent. However, talc pleurodesis has since been shown to be equally effective when used in conjunction with thoracoscopy, but with lower morbidity and mortality rates. As an example, one study achieved successful pleurodesis with talc via thoracoscopy in 90 percent, with a mortality rate of only 0.25 percent . Other studies have similarly reported a pleurodesis success rate greater than 90 percent . (See "Talc pleurodesis", section on 'Indications and efficacy'.)
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