medical thorcoscopy

1. Current practices and
evolving trends in
Medical Thoracoscopy
Dr Sushant Kumar Nanda
1st yr DM Resident
SCB MCH, Cuttack

2. Outline
– Introduction
– Medical vs surgical thoracoscopy
– Historical background and Indian scenario
– Pleural biopsy methods- pros and cons
– Types, indications, contraindications of MT
– Preparation, procedure and complications
– Innovations and future directions
– Conclusion

3. Introduction

4. Medical
Thoracoscopy
MT also termed “local anesthetic thoracoscopy” and
“pleuroscopy,” is a minimally invasive single-port
endoscopic technique using rigid and semi-rigid
thoracoscopes that offers direct visualization of pleural
surfaces, as well as channels to perform diagnostic and
therapeutic procedures.
Murthy and Bessich. MT: its evolving role
J Thorac Dis 2017;9(Suppl 10):S1011- S1021

6. https://doi.org/10.1183/2312508X.10003417

7. • 659 respondents
• 47.8% practiced in corporate/private hospitals
• 47.2% performed MT
• 61.1% used flex-rigid/semi-rigid thoracoscopes
• Undiagnosed pleural effusions and recurrent pleural effusions were the
most common indications
• Majority of the thoracoscopists (71.4%) used conscious sedation and a
combination of Midazolam and Fentanyl was the most preferred
combination

8. • Rigid thoracoscope was the most commonly used instrument.
• The common indications of procedure included undiagnosed pleural effusion,
talc pleurodesis, and adhesiolysis.
• Local anesthesia with conscious sedation was the preferred anesthetic
modality. Midazolam, along with fentanyl, was the most widely used sedation
combination. 2% lignocaine was the most commonly used concentration for
local infiltrative anesthesia.
• Nearly 2/3 of the respondents reported having encountered any complication
of thoracoscopy. Significant reported complications included empyema,
incision/port-site infection, re-expansion pulmonary edema, and
procedure-related mortality.

9. Training in MT
• The American College of Chest Physicians (ACCP)
recommends that
20 supervised procedures are performed before
operators are considered competent
AND
10 procedures should be performed each year to
maintain competency
Ernst A, Silvestri GA, Johnstone D, et al. Interventional pulmonary procedures: guidelines from
the American College of Chest Physicians. Chest 2003; 123: 1693–1717.

10. Levels of competence in
medical thoracoscopy
3 levels of medical thoracoscopic practice in European countries
• Level I
includes basic diagnostic and therapeutic techniques, manage large pleural effusions,
biopsy the parietal but not the visceral pleura; undertake therapeutic talc insufflation
• Level II
small/no pleural effusion (pneumothorax induction); visceral pleural biopsy; pinch lung
biopsy; lysis of adhesions
• Level III
This level covers all VATS techniques (eg, lung resection) and is currently the province of
the thoracic surgeon.
Thorax 2010;65(Suppl 2):ii54eii60. doi:10.1136/thx.2010.137018

12. • Pleural fluid cytology for malignancy has a varying sensitivity, with a
maximum of only 60% and it may increase with subsequent tapping.
• Closed pleural biopsy using a Cope or Abrams needle has a sensitivity up to
80% in cases of tuberculous effusion and 40% to73% in cases of
Malignancies.
• Drawback of closed pleural biopsy is false negative results. The sample
obtained may not be representative of the tumor due to localized seeding
of the cells.
• In TB endemic areas, diagnostic yield in a pleuroscopic guided biopsy for TB
is very high (98%) although a closed pleural biopsy which has a diagnostic
yield of 80% should suffice. But in view of increasing incidence of drug
resistant TB, it's wise to obtain a pleuroscopy guided biopsy for better
culture of organism for drug sensitivity
• Semi-rigid thoracoscopy is simple, safe procedure with a very high
sensitivity of 93-95% in cases of malignancies

13. CLOSED PLEURAL BIOPSY VS MEDICAL THORACOSCOPY

16. Rigid or Semi-rigid ?
• Small-scale trials of both approaches suggest they
have a comparable diagnostic yield, despite the
generally larger biopsy specimens obtained via rigid
thoracoscopy.
• RCT comparing the two techniques by Dhooria et al
suggests that when biopsies are obtained, there is
little difference in the procedural approach selected,
but rigid thoracoscopy remains superior in the
setting of difficult-to-biopsy lesions.

18. https://doi.org/10.1183/2312508X.10003417
ERS MONOGRAPH | INTERVENTIONAL PULMONOLOGY

20. Rigid thoracoscopy

22. Semi-rigid thoracoscope
Angled range:
up 160/down 130.
operating part is the
same as the
flexible
bronchoscope
Insertion section outer
diameter of 7 mm and a
working channel 2.8-mm
diameter

24. Mini-thoracoscopy
currently defined as endoscopy using small instruments with
a diameter from 2-5 mm
Indications:
• Endoscopy of a small loculated effusion
• Evaluation for drainage of a loculated empyema
• Complete endoscopic examination of pleural cavity
• Pre-standard thoracoscopic evaluation in complex cases
Thoracoscopy for Pulmonologists: A Didactic Approach
DOI 10.1007/978-3-642-38351-9

25. Forceps ( below ) and optic ( above )
during minithoracoscopy

26. Minithoracoscopy

29. Rodriguez-Panadero F, Janssen JP, Astoul P (2006) Thoracoscopy: general overview and
place in the diagnosis and management of pleural effusion. Eur Respir J 28:409–421

30. Thoracoscopy procedure steps
• Place the patient in lateral decubitus positions (healthy lung down)
• Identify entry site (preferably using ultrasound guidance)
• Sterile prep of patient and proceduralist
• Give systemic and local anesthesia
• Skin incision
• Blunt dissection down to the parietal pleura
• Entry into the pleural space with measurement of the chest wall thickness
• Insertion of the trocar (care taken regarding depth of insertion)
• Trocar removed, outer cannula left in place
• Thoracoscope inserted for inspection of entire chest cavity
• Performance of diagnostic and therapeutic procedure(s)
• Insertion of chest drain
• Chest wall closure (muscle, fascia and skin layers)

31. Safety triangle for the recommended site of chest entry

34. Thoracoscope
advanced into the
pleural cavity under
direct vision
through the trocar.

37. Pleuroscopic view
1. mesothelioma
2. adenocarcinoma
3. tuberculosis

38. BLEB
An apical bleb (black
arrow) close to
subclavian artery
(white arrow) in a
case of primary
spontaneous
pneumothorax

39. Diagnostic utility of medical thoracoscopy in undiagnosed
exudative pleural effusions.
Marwah V, Bhattacharyya D, Ali MF, Rajput AK, Sengupta P, Bhati G. Med J DY Patil Vidyapeeth
2020;13:525-8.

40. Ranganatha R, Tousheed SZ, MuraliMohan BV, Zuhaib M, Manivannan D, Harish BR, et al.
Role of medical thoracoscopy in the treatment of complicated parapneumonic effusions. Lung
India 2021;38:149-53.

41. Radiological evaluation
Ultrasonography showing
loculated effusions
CT showing loculated
effusions

42. Thoracoscopic view
showing thick adhesions
pleural biopsy being taken
after adhesiolysis

43. Chest X-ray showing pleural fluid drainage;
(a) before drainage (b) after drainage

44. Conclusion :Early adhesiolysis and drainage of fluid
using medical thoracoscopy should be considered in
patients with multiloculated complicated PPE after
careful radiological (ultrasonography and CT)
stratification, as a more cost-effective and safe method
of management. 10.4103/lungindia.lungindia_543_20

45. • Eight studies included
• The pooled treatment success rate of thoracoscopy was 85% when
used as first-line intervention or after failure of chest tube
• The pooled complication rate was 9.0%
Conclusions: Medical thoracoscopy is effective and safe when
prescribed for complicated parapneumonic effusions and
empyema. Bacteriological negativity of pleural effusion
specimens and administration of adjuvant intra-pleural
fibrinolysis after the procedure are associated with a higher
success rate.

46. Limitation of the semi-rigid
thoracoscopy
• smaller sample size and the more superficial
sampling of the pleura.
• Though the smaller size of samples obtained with
semi-rigid thoracoscope does not affect diagnostic
yield, a larger biopsy tissue sample will always be
beneficial for further subclassi- fication using IHC
and doing molecular testing if we are dealing with a
malignancy.
• Difficult to obtain a sample with a flexible forceps
biopsy when the pleura is thickened or fibrosed

48. Modifications in semi-rigid thoracoscopy
• Cryobiopsy through semi-rigid pleuroscope
• Electrocautery guided pleural biopsy using the IT knife
• Autofluorescence video thoracoscopy
• Narrow band imaging (NBI)
• Protective sheath guided pleurodesis
• Pleural infiltration of Lidocaine using TBNA needle

49. Cryobiopsy through semi-rigid pleuroscope
Pleuroscopic view showing the
cryo probe passed through the
working channel of pleuroscope
and freezing an area of parietal
pleura
Comparison of the size of sample
taken via conventional flexible biopsy
forceps (smaller piece on top) and
cryoprobe (larger piece)

50. White light pleuroscopy and narrow-band imaging (NBI) showing
abnormal vascular pattern due to malignant mesothelioma
White light pleuroscopy with
irregular vascular pattern
NBI pleuroscopy with enhanced
vascular tortuosity due to
malignant mesothelioma

51. Protected sheath guided
pleurodesis using oxytetracycline
Pleural infiltration with lidocaine
using TBNA needle.

52. Ongoing studies in MT
• A RCT in India is exploring the use of a “mini-rigid” thoracoscope with a
5.5 mm diameter working channel, comparing diagnostic yield and
patient-centered outcomes against the semi-rigid thoracoscope
(NCT02851927).
• Another group hopes to improve the diagnostic yield of the semi-rigid
approach by performing cryobiopsy of parietal pleura with the
standard flexible cryoprobe, comparing yield to the standard forceps
biopsy (NCT02500277).
• REPEAT trial hopes to establish the comparability of MT and VATS
pleural biopsy, with respect to diagnostic yield and the need for
additional interventions in patients with suspected malignancy
(NCT02834455).
• Majid et al. are exploring the role of MT in the management of complex
parapneumonic effusions in a trial comparing the procedure against
current standard-of-care medical therapy with combined intrapleural
tPA and DNase (NCT02973139).

53. Conclusion
• Medical thoracoscopy is an overall safe procedure
with very low complication and mortality rate when
performed by trained pulmonologists.
• The application of MT in pleural diseases is
supported by studies showing high diagnostic yield
and effective therapeutic intervention.
• Medical thoracoscopy appears to be valuable in
patients who are not surgical candidates or are at an
increased risk of complications from more invasive
procedures such as VATS.

54. REFERENCES
• Expert consensus for diagnosis and treatment using medical
thoracoscopy in China J Thorac Dis 2020;12(5):1799-1810 |
http://dx.doi.org/10.21037/jtd-19-2276
• Evolution of semi-rigid thoracoscopy Indian journal of tuberculosis (
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• Deschuyteneer EP, De Keukeleire T. BMJ Open Resp Res 2022;9:e001161.
doi:10.1136/bmjresp-2021-001161
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• Kay Choong See and Pyng Lee Advances in the diagnosis of pleural
disease in lung cancer Ther Adv Respir Dis (2011) 5(6) 409–418 DOI:
10.1177/1753465811408637

55. REFERENCES cont.
• Mondoni et al. BMC Pulm Med (2021) 21:127 Medical
thoracoscopy treatment for pleural infections: a systematic
review and meta-analysis
• Ranganatha R, Tousheed SZ, MuraliMohan BV, Zuhaib M,
Manivannan D, Harish BR, et al. Role of medical thoracoscopy
in the treatment of complicated parapneumonic effusions.
Lung India 2021;38:149-53.
• Madan K, Tiwari P, Thankgakunam B, Mittal S, Hadda V,
Mohan A, et al. A survey of medical thoracoscopy practices in
India. Lung India 2021;38:23-30.
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• DOI: 10.3892/etm.2018.6742 Diagnostic value of medical
thoracoscopy for undiagnosed pleural effusions

56. REFERENCES cont.
• Murthy and Bessich. MT: its evolving role J Thorac Dis 2017;9(Suppl
10):S1011-S1021
• ERS monograph: Interventional Pulmonology
• https://doi.org/10.1007/978-3-319-58036-4 Interventions in Pulmonary
Medicine
• Essentials of Clinical Pulmonology: https://doi.org/10.1007/978-3-319-
58036-4
• Thoracoscopy for Pulmonologists: A Didactic Approach © Springer-Verlag
Berlin Heidelberg 2014
• Marwah V, Bhattacharyya D, Ali MF, Rajput AK, Sengupta P, Bhati G.
Diagnostic utility of medical thoracoscopy in undiagnosed exudative pleural
effusions. Med J DY Patil Vidyapeeth 2020;13:525-8

57. THANK YOU