Page 50 - World Association of Laparoscopic Surgeons - Journal

WJOLS

The Role of Thoracoscopy in Diagnosis and Treatment of Pleural Disease

complete debridement, pleurectomy, and decortication for connective tissue diseases, and other inflammatory
empyema management has yet to be adequately proved. The disorders. Thoracoscopy may be warranted when recurrent
precise role for thoracoscopy instead of chest tube drainage, effusions cause symptoms and are not controlled by repeated
instillation of fibrinolytic agents, rib resection, or large-volume thoracentesis. Usually, pleural biopsy
thoracotomy-decortication is still controversial. specimens are obtained to exclude infectious or neoplastic
etiologies, and pleurodesis is performed. Results are usually
Malignant Pleural Effusions
excellent when talc is used, with success rates varying from
In addition to diagnosis, an important indication for 65 to (is greater than) 90%.
thoracoscopy in patients with malignant pleural effusions
is pleurodesis. 10 Complete evacuation of pleural fluid, Chylothorax
maximization of lung expandability by removing adhesions, Thoracoscopy has changed diagnostic and therapeutic
and pleurodesis by talc insufflation (also known as talc approaches to patients with chylothorax. Chylothorax is
poudrage) results in short and long-term success rates of usually caused by trauma or malignancy (primarily
(is greater than) 90%. 11 Distribution of sterile, asbestos- lymphoma). Thoracoscopic exploration may precede or
free, US Pharmacopeia-approved talk powder on all pleural replace an open thoracotomy. If the torn thoracic duct is
surfaces is confirmed by thoracoscopic visualization. visualized (having the patient drink heavy cream about
Following pleurodesis, low-grade fevers should be expected 1 hour prior to the procedure may facilitate its detection), it
in up to 30% of patients, and hospitalization duration can be clipped or ligated endoscopically. Although survival
averages 4.8 days. Pleurodesis can also be achieved by is often limited in case of chylothorax from lymphoma, talc
pleurectomy using standard dissection techniques or pleurodesis may provide satisfactory resolution of effusions
hydrodissection. 12 Because survival of patients with and prevent deterioration of respiratory, nutritional and
advanced pleural carcinomatosis is often short, the risks immunologic status. 18
and benefits of thoracoscopic pleurodesis must be carefully
Parenchymal Applications
weighed against those of repeated thoracentesis, tube
thoracostomy, or bedside pleurodesis through an indwelling Spontaneous pneumotherax may occur in any individual,
chest tube. The talc stimulates an adhesive obliterative including those without existing lung disease. It is almost
pleuritis. Austin and Flye 54 reported an overall 90% always caused by the rupture of a subpleural bleb or bullae. 55
effectiveness for talc compared with 87% for tetracycline The choice of treatment depends on the size, symptoms,
and 55% for tube thoracotomy alone in malignant pleural presence of continued air leak and the recurrence rate. Small,
effusions. Thus, thoracoscopic tale poudrage is an effective asymptomatic pneumothoraces in patients with adequate
option for managing symptomatic effusions; however, it cardiopulmonary reserve may be managed by simple
usually requires general anesthesia in a high-risk population. aspiration or observation. If the pneumothorax is large or
Talc itself is inexpensive, but the charges for sterilization, symptomatic, closed tube thoracostomy is the main
general anesthesia, and the operating room can substantially therapeutic approach. But with a recurrence rate of 30%
increase the total cost. Talc can be simply administered by after the first episode and even higher for each subsequent
slurry through tube thoracostomy, but only a limited number recurrence, this may not be effective. 56 Thoracoscopy
of patients have been studied. Appropriate dosages, provides an excellent alternative to repeated chest tube
measures to ensure complete pleural distribution, and drainage in patients with recurrent or prolonged [usually
adverse effect profiles for slurry have not been determine. 55 (is greater than) 5 days] pneumothorax. 24 Thoracoscopy
Moreover, talc’s overall effect on patient outcome in allows definitive treatment or inspection prior to
25
malignant pleural disease is questionable as evidenced by performance of a lateral or axillary thoracotomy. Various
10
the poor survival in the patients of Ohri et al. Currently, thoracoscopic techniques are available to manage
thoracoscopic talc poudrage is reserved for the selected spontaneous pneumothorax; namely talc poudrage, laser
symptomatic group that does not respond to other agents therapy and stapling. Thoracoscopic findings in patients with
applied through closed tube thoracostomy. 54,55 It is also spontaneous pneumothorax include normal appearance,
performed in those patients with good performance status pleural adhesions, small blebs [(is less than) 2 cm] on the
and a reasonable expected survival. visceral pleural surface, and large bullae [(is greater
than) 2 cm]. Lesions can be removed using electrocautery,
Recurrent Pleural Effusions of Benign Etiology
argon plasma coagulation, or stapled lung resection, with
Recurrent pleural effusions of benign etiology are frequently results that are similar to those obtained after open
caused by heart failure, cardiac surgery, nephrotic syndrome, thoracotomy (although the resulting pleurodesis may be

World Journal of Laparoscopic Surgery, January-April 2012;5(1):4-15 9