Page 54 - World Association of Laparoscopic Surgeons - Journal

WJOLS

The Role of Thoracoscopy in Diagnosis and Treatment of Pleural Disease

thoracic surgery). Techniques of thoracoscopic pleural margins, equivalent recurrence rates, and comparable long-
biopsy, fluid drainage, and pleurodesis are now recognized term outcome compared with the time-honored open
components of the interventional pulmonologist’s practice. thoracotomy with lymph node dissection. Further
Unquestionably, most therapeutic and operative procedures prospective trials are currently underway to directly compare
are the domain of the thoracic surgeon. It is imperative, VATS with open lobectomy for stage I non-small cell lung
therefore, that the pulmonologist and thoracic surgeon have carcinoma. We do not routinely perform VATS lobectomy.
a close working relationship to ensure proper patient care. The issue of the expense of thoracoscopic surgery is
At this time, it is unclear which anesthesia technique is best becoming increasingly important. Although some studies
for ‘diagnostic’ thoracoscopy. Several large series confirm suggest that VATS reduces postoperative pain and hospital
its efficacy and safety under local anesthesia. 2,24,74 stay, 7,8,36 a benefit in terms of health-care savings has not
Nevertheless, performing thoracoscopy in an operating room been clearly documented. 8,80,82,83 The disposable
with assistance from the anesthesiologist, using single-lung instrumentation and the video equipment are expensive.
ventilation, and the ability to move quickly to open It is clear that attempts should be made to use more reusable
thoracotomy has distinct advantages. However, the equipment. Also, complications or inadequate results that
operating room approach is more time-consuming and require longer stays, subsequent interventions, or result in
expensive. shorter survival must be accounted for in the final
Disagreement exists regarding the appropriateness and summation of cost. Finally, measuring direct costs alone
timing of thoracoscopy for routine investigation of effusions may not reflect total benefits. Indirect benefits such as an
of unknown origin. Management of patients with suspected earlier return to work are difficult to assess.
malignant effusion varies-recommendations range from
CONCLUSION
observation to progressively invasive procedures
culminating in a thoracotomy. Currently, thoracoscopy is Modern thoracoscopy provides a potentially less invasive
employed after several attempts by conventional pleural means to diagnose and to treat a variety of intrathoracic
sampling are nondiagnostic. Thoracoscopy does increase diseases. Simple rigid thoracoscopy is safe and effective
the diagnostic yield for both benign and malignant disease. for the diagnosis of benign and malignant pleural disease.
Preoperative patient characteristics (such as history of It is useful for therapeutic procedures, such as pleurodesis
malignancy at any time) and clinical data that are predictive and uncomplicated empyema drainage. Current endoscopic
of finding malignancy at thoracoscopy have been and VATS techniques have the potential to limit morbidity
identified. 15 Knowledge of such features will aid patient and reduce hospital stays for major operations. This ability,
selection. The impact of thoracoscopy on the long-term however, provides the potential for its overuse. Thoracos-
outcome of patients having malignant pleural disease is copy’s ultimate acceptance should be based on the results
uncertain. Given the poor prognosis of patients with of controlled, randomized trials. Further questions still
malignant pleural disease, one can argue that the utility and remain regarding its patient selection, operators, timing,
necessity of diagnosing pleural malignancy by thoracoscopy effects on long-term outcome and cost-effectiveness.
is questionable until further therapeutic options are
developed. VATS wedge resection is being used to treat REFERENCES
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