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Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications

Author
Francis D Sheski, MD
Section Editors
Praveen N Mathur, MB;BS
V Courtney Broaddus, MD
Deputy Editor
Geraldine Finlay, MD

INTRODUCTION

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".)

COMMON APPLICATIONS

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 [3]. 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".)

                
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Literature review current through: Nov 2017. | This topic last updated: Jul 07, 2017.
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