A local anaesthetic video-assisted thoracoscopy service: Prospective performance analysis in a UK tertiary respiratory centre

doi:10.1016/j.lungcan.2009.02.023

Lung Cancer

Volume 66, Issue 3, December 2009, Pages 355-358

https://doi.org/10.1016/j.lungcan.2009.02.023 Get rights and content

Abstract

Introduction

Local anaesthetic video-assisted thoracoscopy (LAVAT) is a safe, reliable and therapeutic procedure used by respiratory physicians in the management of pleural disease, especially pleural malignancy. We describe a prospective analysis of a UK LAVAT service set up in a tertiary respiratory centre to complement an existing large surgical video-assisted thoracic surgery (VATS) service.

Methods

A prospective analysis of 125 LAVAT procedures over a 34-month period was performed looking at a variety of quality control endpoints comparing them to national thoracic surgical VATS standards.

Results

Talc pleurodesis was effective in over 86% of cases and this did not significantly lengthen bed stay (median 4.5 days). Bed stay was also unchanged between the ages of 60–89 years. Over 77% of the 48 patients with proven metastatic pleural lung malignancy or mesothelioma received either surgical decortication or oncological treatment (palliative chemotherapy in 57%). In only 6% were biopsies not possible because of technical factors. LAVAT biopsies had a diagnostic accuracy of 97.4%, sensitivity 95.4%, specificity 100%, positive predictive value 100%, and negative predictive value 94.7%. Our complication rate was 4% and mortality rate 0.8%.

Discussion

Our LAVAT service meets surgical VATS standards for diagnosis and safety with a good pleurodesis efficacy rate. It complements our surgical VATS service, offering a pleural diagnostic service for patients with non-complex pleural exudates or too frail for VATS. Our data demonstrate there is a demand and potential for respiratory physicians dealing with pleural malignancy to develop LAVAT and enhance their local lung cancer and pleural diagnostic pathway.

Introduction

Local anaesthetic video-assisted (“medical”) thoracoscopy performed using a single port under conscious sedation (LAVAT) allows drainage of a pleural effusion, multiple biopsies of the parietal pleura under direct vision achieving a high diagnostic yield and effective talc pleurodesis during one procedure [1]. It avoids the risks of general anaesthesia in patients, many of whom have comorbidities and reduced performance status. Thus it offers several advantages in the investigation of simple unilateral pleural effusion of unknown cause but particularly in suspected malignant pleural disease. However, it is not a substitute for video-assisted thoracoscopic surgery (VATS) in the investigation and treatment of complex pleural effusions.

UHL NHS Trust has a thoracic surgical unit with considerable expertise in VATS. With thoracic surgical support, we started a LAVAT service in 2005 in response to the need to develop a complementary pleural diagnostic service for patients with simple unexplained pleural exudates (and most commonly pleural malignancy). We prospectively audited our LAVAT service from 2005 to 2008 and conducted a cost analysis.

Section snippets

Methods

Prospective audit of all LAVAT procedures registered onto a database on the date the procedure was performed. Data were analysed using Graph Pad Prism version 4 software. Normality testing was assessed by the Ryan-Joiner test. Means and standard error (S.E.) in parentheses are quoted for normal data. Medians and inter-quartile range (IQR) in parentheses are quoted for nonparametric data. Box and whisker plots show median, IQR and extreme ranges. Two column data were analysed with either

Results

125 procedures were performed over a 34-month period, equating to 3.7 thoracoscopies per month or 44 annually. There was a male preponderance (75.2%) with mean (S.E.) age 69.9 (1.12) ranging from 27 to 88. The 10th–90th age percentiles were 54.8, 61, 66.2, 69, 71, 75, 77.8, 81 and 84, respectively.

Talc pleurodesis was performed in 66 (52.8%) of cases. Pleurodesis was effective (confirmed by failure of recurrence of the effusion on subsequent imaging or requiring further pleural drainage for at

Discussion

Our data confirm that our LAVAT service is safe and effective. LAVAT has a high diagnostic yield (91%) which fulfils the national thoracic surgical guidelines for VATS (90–95% yield for previously uninvestigated effusions) [3] and a high pleurodesis success rate (86.4%) which is better than for talc slurry in a recent prospective study [4] although a recent larger North American randomised trial of 501 patients failed to show any overall superiority for talc poudrage over slurry [5]. Our

Conflict of interest statement

The authors have no financial or personal conflicts of interest to declare.

Funding

None to declare.

References (8)

S.S. Amr et al.
Struma ovarii with pseudo-Meigs’ syndrome: report of a case and review of the literature
Eur J Obstet Gynecol Reprod Biol
(1994)
C.M. Dresler et al.
Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion
Chest
(2005)
N.A. Maskell et al.
BTS guidelines for the investigation of a unilateral pleural effusion in adults
Thorax
(2003)
Society for Cardiothoracic Surgery in Great Britain and Ireland. Video assisted thoracic surgery—guidelines for...

There are more references available in the full text version of this article.

Cited by (29)

DIAGNOSTIC AND THERAPEUTIC ASPECTS IN MALIGNANT PLEURAL MESOTHELIOMA
2015, Revista Medica Clinica Las Condes
Para el diagnóstico de mesotelioma se requiere distinguir entre afectación mesotelial benigna y maligna, y entre mesotelioma maligno y carcinoma metastásico. Para ello son necesarias técnicas inmuno-histoquímicas realizadas sobre biopsias amplias. La toracoscopia es la técnica de elección, aunque la biopsia con aguja usando técnicas de imagen en tiempo real puede ser muy útil si hay marcado engrosamiento nodular. Es improbable que la cirugía radical (pleuroneumonectomía) sea realmente curativa, por lo que está ganando adeptos la reducción de masa tumoral mediante pleurectomía/decorticación, con asociación de quimioterapia y radioterapia a la cirugía (terapia multimodal). Cuando la resección no es factible se plantea quimioterapia, con pleurodesis o colocación de un catéter pleural tunelizado si se requiere el control del derrame pleural y se reserva la radioterapia para tratar la infiltración de la pared torácica. También es esencial un completo control del dolor (que adquiere particular protagonismo en esta neoplasia) en unidades especializadas.
Diagnosis of malignant pleural mesothelioma requires making the distinction between benign mesothelial hiperplasia and true mesothelioma, and between malignant mesothelioma and metastatic pleural adenocarcinoma. This involves immunohisto-chemical techniques applied on large biopsy specimens, and thoracoscopy is the best choice for obtaining them. Real-time image-guided needle biopsy can also be very helpful in presence of marked nodular pleural thickening. Radical surgery (ie, extrapleural pneumonectomy) is unlikely to cure completely the patient, and cyto-reduction surgery with preservation of the underlying lung (pleurectomy/decortication), with addition of chemo and radiation therapy (muiltimodal treatment) is gaining adepts in the last few years. When surgery is not feasible at all, early chemotherapy -with pleurodesis or placement of a indwelling pleural catheter (to control the effusion if necessary)- is advisable. Radiation therapy should be reserved to treat chest wall infiltration in those cases, and complete control of pain in specialized units is also essential in those patients.
Thoracoscopy
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
Diagnosis and Treatment of Malignant Pleural Mesothelioma
2015, Archivos de Bronconeumologia
El diagnóstico del mesotelioma pleural maligno presenta 3 importantes retos: es necesario distinguir entre hiperplasia mesotelial benigna y mesotelioma, entre mesotelioma maligno (con subtipos) y carcinoma metastásico, y también se requiere demostrar la invasión de estructuras vecinas a la pleura. Para aclarar los 2 primeros aspectos hay que basarse en un panel de anticuerpos monoclonales con adecuado estudio inmunohistoquímico —realizado por manos muy expertas— y para el tercero hay que apoyarse en biopsias suficientemente amplias y profundas, y la toracoscopia es la técnica de elección. La biopsia con aguja guiada con técnicas de imagen en tiempo real puede ser de gran ayuda cuando existe marcado engrosamiento nodular difuso y derrame pequeño o ausente. Dadas las dificultades de un diagnóstico precoz, es infrecuente que se consiga un tratamiento curativo mediante cirugía radical (pleuroneumonectomía), por lo que en los últimos años está ganando adeptos la liberación de masa tumoral mediante pleurectomía/decorticación, con asociación de quimio y radioterapia a las técnicas quirúrgicas (terapia multimodal). En los casos en que la cirugía no es factible se plantea la quimioterapia (combinando pemetrexed y compuestos de platino en la mayoría de los casos), con pleurodesis o colocación de un catéter pleural tunelizado si se requiere el control del derrame pleural, y se reserva la radioterapia para el tratamiento del dolor asociado a infiltración de la pared torácica o cualquier otra estructura vecina. En todo caso, es esencial un completo tratamiento de soporte para el control del dolor (que adquiere particular protagonismo en esta neoplasia) en unidades especializadas.
There are three major challenges in the diagnosis of malignant pleural mesothelioma: mesothelioma must be distinguished from benign mesothelial hyperplasia; malignant mesothelioma (and its subtypes) must be distinguished from metastatic carcinoma; and invasion of structures adjacent to the pleura must be demonstrated. The basis for clarifying the first two aspects is determination of a panel of monoclonal antibodies with appropriate immunohistochemical evaluation performed by highly qualified experts. Clarification of the third aspect requires sufficiently abundant, deep biopsy material, for which thoracoscopy is the technique of choice. Video-assisted needle biopsy with real-time imaging can be of great assistance when there is diffuse nodal thickening and scant or absent effusion. Given the difficulties of reaching an early diagnosis, cure is not generally achieved with radical surgery (pleuropneumonectomy), so liberation of the tumor mass with pleurectomy/decortication combined with chemo- or radiation therapy (multimodal treatment) has been gaining followers in recent years. In cases in which surgery is not feasible, chemotherapy (a combination of pemetrexed and platinum-derived compounds, in most cases) with pleurodesis or a tunneled pleural drainage catheter, if control of pleural effusion is required, can be considered. Radiation therapy is reserved for treatment of pain associated with infiltration of the chest wall or any other neighboring structure. In any case, comprehensive support treatment for pain control in specialist units is essential: this acquires particular significance in this type of malignancy.
Medical Pleuroscopy
2013, Clinics in Chest Medicine
Citation Excerpt :
These complications include hemorrhage, port site tumor invasion, persistent air leak, pneumonia, and empyema, although all are rare. Pooled data from 51 studies, including 4956 patients (47 of which were analyzed by Rahman and colleagues9 as part of a wide-ranging review),8,14–16 showed a major complication rate of 2.1%. Mortality associated with pleuroscopy is extremely uncommon, with most deaths seemingly caused by pre-existing medical factors or as a result of reactions unrelated to the procedure itself.17
Theoretical cost benefits of medical thoracoscopy (MT)
2010, Respiratory Medicine
Current Status of Medical Pleuroscopy
2010, Clinics in Chest Medicine
Citation Excerpt :
To deliver a robust training program, there needs to be an appropriate service demand in terms of procedures performed per year, which suggests this would not be a procedure for all pulmonologists. Significant demand can occur in tertiary centers despite having thoracic surgery on site.14 MP offers pulmonologists an opportunity to take multiple pleural biopsies to diagnose malignant and nonmalignant pleural diseases.

View all citing articles on Scopus

View full text

A local anaesthetic video-assisted thoracoscopy service: Prospective performance analysis in a UK tertiary respiratory centre

Abstract

Introduction

Methods

Results

Discussion

Introduction

Section snippets

Methods

Results

Discussion

Conflict of interest statement

Funding

Eur J Obstet Gynecol Reprod Biol

Chest

BTS guidelines for the investigation of a unilateral pleural effusion in adults

Thorax