Thoracoscopy: A review of 121 consecutive surgical procedures

doi:10.1016/0003-4975(89)90179-3

The Annals of Thoracic Surgery

Volume 48, Issue 1, July 1989, Pages 66-68

https://doi.org/10.1016/0003-4975(89)90179-3 Get rights and content

Abstract

The records of 121 patients who underwent surgical thoracoscopy between 1976 and 1987 were reviewed. The indications for thoracosopy were pleural effusion (38%), pleural thickening (7.4%), and a mass on the chest roentgenogram (15%). All procedure were performed under general anesthesia with a rigid thoracoscope and 91 patients (75%) were diagnosed as having a malignant process. Although thoracotomy was undertaken in 20 patients (16.5%), no patient with benign disease underwent diagnostic thoracotnmy. Thoracoscopy had a 98.9% sensitivity and a 93.3% specificity in this series. One patient died of a myocardial infarction after the procedure, and 11 patients (9.1%) had other, predominantly respiratory, complications. We confirm that surgical thoracoscopy is a useful procedure in the diagnosis of pleural processes.

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Cited by (119)

Efficacy and Cost of Awake Thoracoscopy and Video-Assisted Thoracoscopic Surgery in the Undiagnosed Pleural Effusion
2018, Annals of Thoracic Surgery
Citation Excerpt :
The diagnostic yield of AT and VATS for undiagnosed exudative pleural effusion in our study is similar to a recent meta-analysis, with a quoted sensitivity of 91% and specificity of 100% for AT [12]. A case series described a sensitivity of 98.9% and specificity of 93.3% for VATS [13] in undiagnosed pleural disease. In addition, major and minor complications in our study for both VATS and AT are comparable with other studies, with major complications being infrequent [5, 7–10, 12, 14–17].
The study aim is to compare the diagnostic yield, safety, and cost of outpatient awake thoracoscopy (AT) with video-assisted thoracoscopic surgery (VATS) pleural biopsy in undiagnosed pleural effusions.
The diagnostic yield of pleural biopsy performed by AT or VATS in patients with undiagnosed exudative pleural effusions at a tertiary thoracic surgery center in Canada between 2011 and 2015 was retrospectively evaluated. Test sensitivity, specificity, positive predictive value, and negative predictive value were compared. Procedure safety, hospital length of stay, additional pleural-based interventions, and procedure-related costs were compared.
Patients underwent either AT (n = 78) or VATS (n = 99) during the study period. Sensitivity, specificity, positive predictive value, and negative predictive value were 85%, 100%, 100%, and 79% for AT and 93%, 94%, 99%, and 76% for VATS, with no significant difference in diagnostic test performance. There was no difference in the rate of major complications (2 AT [2.6%] versus 4 VATS [4.0%], p = 0.696), minor complications (14 AT [17.9%] versus 16 VATS [16.2%], p = 0.841) or need for additional pleural-based procedures (20 AT [25.6%] versus 18 VATS [18.2%], p = 0.270). The VATS was associated with longer median hospital stay (VATS 3 days [interquartile range: 1 to 4] versus AT 0 days [interquartile range: 0 to 1], z = 6.98, p < 0.001) and a higher procedure-related average cost (VATS Canadian dollars $7,962 [95% confidence interval: $7,134 to $8,790] versus AT Canadian dollars $2,815 [95% confidence interval: $2,010 to $3,620], p < 0.001).
Awake thoracoscopy and VATS have similar diagnostic yield and safety profiles in the assessment of undiagnosed pleural effusions; however, AT is associated with shorter length of stay and lower average per-procedure cost. In the appropriate clinical setting, AT may be the diagnostic test of choice.
Nonspecific pleuritis: Optimal duration of follow-up
2014, Annals of Thoracic Surgery
Citation Excerpt :
Our cohort had a mean follow-up time of 5 years, and the maximum time to diagnosis of mesothelioma was approximately 10 months (306 days). Consistent with our data, both Ryan and associates [15] and Page and coworkers [13] reported a time to diagnosis of mesothelioma among their NSP cohorts of less than 1 year at 6 and 8.7 months, respectively. Davies and colleages [20] reported a wider interval with 5 cases of mesothelioma established between 3 and 39 months from the initial biopsy showing NSP, although 4 of these cases were diagnosed at approximately a year or less with one single outlier.
Nonspecific pleuritis (NSP) is a frequent diagnosis after parietal pleural biopsy, but the clinical significance of this finding and need for further follow-up have not been firmly established. Previous reports suggest that 5% to 25% of patients with NSP are subsequently diagnosed with pleural malignancy.
Our pathology database was queried for patients with histologic evidence of NSP from January 01, 2001, to December 31, 2012 (n = 413). Patients with less than 1 year of follow-up after biopsy, diagnosis of empyema, tuberculous pleuritis, active systemic connective tissue disease or vasculitis, or active malignancy were excluded (n = 327). The remaining patients were included and their medical records were reviewed.
Eighty-six patients were included. Mean follow up was 1,824 ± 1,032 days (range, 409 to 4,599 days). Three of the 86 patients with NSP (3.5%) were subsequently diagnosed with pleural malignancy. All 3 patients were found to have mesothelioma with a mean time from biopsies to diagnosis of 205 ± 126 days (range, 64 to 306 days). Twenty-two of 86 patients (25.5%) had a possible identifiable cause of pleural inflammation (benign disease). After exclusion of these 22 patients, the incidence of malignancy was 3 of 64 (4.7%).
The incidence of subsequent pleural malignancy (mesothelioma) among patients found to have NSP based on pleural biopsy was 3.5%. Occult mesothelioma in patients with NSP will most likely be diagnosed within 1 year of the initial pleural biopsy; therefore, these patients should be followed for a minimum of 1 year to allow for timely detection of occult pleural malignancy.
Pulmonary resection using video-assisted thoracoscopic surgery - 20 years experience
2014, Revue des Maladies Respiratoires
La chirurgie mini-invasive pour les exérèses pulmonaires majeures existe maintenant depuis 20 ans, mais son développement reste encore controversé en France. Les différentes techniques utilisées ainsi que les définitions multiples ont prêté à confusion chez les médecins et les chirurgiens. Le bénéfice de ces chirurgies « mini-invasives » n’a pas toujours été très clair, avec une sécurité opératoire souvent remise en cause. Les avancées technologiques récentes (imagerie, colonne vidéo HD, instrumentations) ont apporté une aide essentielle pour assurer la sécurité optimale des patients. L’objectif principal de cette revue est de préciser la définition actuelle de la chirurgie mini-invasive ou vidéothoracoscopique (VTC), les techniques, les résultats mais aussi les écueils. Cependant cette chirurgie présente des atouts multiples à la fois sur le plan clinique mais aussi universitaire. La chirurgie thoracique mini-invasive s’inscrit dans l’histoire naturelle de la chirurgie mais les différences cliniques entre ces deux grands types de chirurgie d’exérèse sont faibles. La VTC n’est pas une révolution chirurgicale mais une évolution qu’il faut maîtriser au même titre que les évolutions en radiothérapie et radiologie interventionnelle. Elle s’inscrit en complément des stratégies de dépistage précoce du cancer qui ont fait la preuve récente de leur efficacité.
Major lung resection using minimally invasive techniques – video-assisted thoracoscopic surgery (VATS) – was first described 20 years ago. However, its development has been slow in many countries because the value of this approach has been questioned. Different techniques and definitions of VATS are used and this can be confusing for physicians and surgeons. The benefit of minimally invasive thoracic surgery was not always apparent, while many surgeons pointed to suboptimal operative outcomes. Recently, technological advances (radiology, full HD monitor and new stapler devices) have improved VATS outcomes. The objectives of this review are to emphasize the accepted definition of VATS resection, outline the different techniques developed and their results including morbidity and mortality compared to conventional approaches. Minimally invasive thoracic surgery has not been proven to give superior survival (level one evidence) compared to thoracotomy. A slight advantage has been demonstrated for short-term outcomes. VATS is not a surgical revolution but rather an evolution of surgery. It should be considered together with the new medical environment including stereotactic radiotherapy and radiofrequency. VATS seems to be more accurate in the treatment of small lung lesions diagnosed with screening CT scan. In the academic field, VATS allows easier teaching and diffusion of techniques.
Medical Pleuroscopy
2013, Clinics in Chest Medicine
Citation Excerpt :
Pooling results from all of these gives a combined diagnostic rate of 92.6%, based on a total sample of 1369 patients,33 which is certainly comparable to rates achieved using VATS.34 Some disparity in diagnostic values also seems to exist when pleural mesothelioma is analyzed separately, with a series by Boutin and Rey35 reporting a 98% success rate compared with 60% in another, marginally smaller, series.30 Separate to diagnostic ability, however, is the appeal of the one-stop thoracoscopic approach, which is especially strong in mesothelioma given the extremely high rates of recurrent pleural effusion in this condition.36
Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American college of chest physicians evidence-based clinical practice guidelines
2013, Chest
Citation Excerpt :
Thoracoscopic biopsy of the pleura, which can be performed with a semirigid instrument under local anesthesia (medical thoracoscopy) or by video-assisted thoracoscopic surgery, is safe and can provide a definitive diagnosis with a high degree of accuracy and minimal risk to the patient. The reported sensitivity rate ranges from 80% to 99%, the specificity rate ranges from 93% to 100% and the negative predictive value ranges from 93% to 96%.45–51 False-negative (FN) results are more common in cases of mesothelioma than in cases of primary lung carcinoma.47
Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.
To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article “Methodology for Development of Guidelines for Lung Cancer” in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.
Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions < 2 or > 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.
The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.
Diagnostic Workup of Lung Cancer
2011, Surgical Oncology Clinics of North America

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Original articleThoracoscopy: A review of 121 consecutive surgical procedures

Abstract

Am J Cardiol

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Surg

The practical importance of thoracoscopy in surgery of the chest

Surg Gynecol Obstet

Original article
Thoracoscopy: A review of 121 consecutive surgical procedures