Name: local anesthetic thoracoscopy for undiagnosed pleural effusion
Uploaded: 2023-11-10T13:40:00
Description: Watch this Scientific Journal Video about Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion at JoVE.com

No funding was received. JP and MM captured the photographs shown in Figure 1A. RB and MM captured the ones shown in Figure 3.

The following protocol will describe how to perform LAT in a clinical setting. The protocol is in accordance with the clinical practice and guidelines of the authors&#39; hospitals (Odense, N&#230;stved, Lleida, Bristol, and Preston). Written informed consent is obtained from the patient prior to the procedure. The main inclusion criteria for the procedure is recurrent pleural effusion of unknown cause, despite guideline-based work-up. Exclusion criteria include complete obliteration of the pleural space due to adhesions...

Anesthetic Thoracoscopy for Diagnosis of Pleural Effusions

<ol>
	<li>Bodtger, U., Hallifax, R. J., Maskell NA, L. C., Lee, Y. C. G., Rahman, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Pleural disease. Ers monograph 2020;87:1-12. 87, (2020).</li><li>Froudarakis, M. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+work-up+of+pleural+effusions.">Diagnostic work-up of pleural effusions.</a> Respiration. 75 (1), 4-13 (2008).</li><li>Holling, N., Patole, S., Medford, A. R. L., Maskell, N. A., Bibby, A. 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This article provides a practical approach for performing LAT.
A single randomized trial compared rigid with semirigid LAT and found no differences concerning diagnostic yield or safety15. Evidence on how to optimize the critical steps is sparse. A group of one of the authors suggested eight critical steps for semirigid LAT and presented a competence checklist for learning LAT in a phantom based on their own experiences, narrative reviews8,<...

An erratum was issued for:&#160;<a href="https://www.jove.com/t/65734">Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion</a>. The Authors section was updated from:
Uffe Bodtger1,2 
Jos&#233; M. Porcel3 
Rahul Bhatnagar4,5 
Mohammed Munavvar6,7 
Casper Jensen1 
Paul Frost Clementsen1,8 
Daniel Bech Rasmussen1,2 
1Respiratory Research Unit PLUZ, Department of Respiratory Medicine, Zealand University Hospital 
2Institute of Regional Health Research, University of Southern Denmark 
3Pleural Medicine Unit, Department of Internal Medicine, Hospital Universitari Arnau de Vilanova, IRBLleida 
4Respiratory Department, Southmead Hospital, North Bristol NHS Trust 
5Academic Respiratory Unit, University of Bristol 
6Lancashire Teaching Hospitals 
7University of Central Lancashire 
8Centre for HR and Education, Copenhagen Academy for Medical Education and Simulation
to:
Uffe Bodtger1,2 
Jos&#233; M. Porcel3 
Rahul Bhatnagar4,5 
Nick Maskell4,5 
Mohammed Munavvar6,7 
Casper Jensen1 
Paul Frost Clementsen1,8 
Daniel Bech Rasmussen1,2 
1Respiratory Research Unit PLUZ, Department of Respiratory Medicine, Zealand University Hospital 
2Institute of Regional Health Research, University of Southern Denmark 
3Pleural Medicine Unit, Department of Internal Medicine, Hospital Universitari Arnau de Vilanova, IRBLleida 
4Respiratory Department, Southmead Hospital, North Bristol NHS Trust 
5Academic Respiratory Unit, University of Bristol 
6Lancashire Teaching Hospitals 
7University of Central Lancashire 
8Centre for HR and Education, Copenhagen Academy for Medical Education and Simulation

An erratum was issued for:&#160;<a href="https://www.jove.com/t/65734">Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion</a>. The Authors section was updated.

Erratum: Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

The incidence and prevalence of pleural diseases are increasing worldwide, especially pleural effusions, which have more than 50 recognized causes1,2. Pleural malignancy is the leading cause of recurrent pleural effusion, mostly due to metastases from extrapleural lung, breast, or lymphoma malignancies3. Existing guidelines recommend pleural biopsies if the medical history, physical examination, radiology, and pleural tap for cytology, culture, and biochemistry fail to provide a diagnosis4. Pleural biopsies can be obtained either image-guided or under direct vision. Ultrasound (US)- or CT-guided percutaneous core biopsies allow sampling from most lesions in the costal part of the parietal pleura, with a diagnostic yield of 84% and 93%, respectively, in a recent systematic review5. US-guided pleural biopsy is superior in terms of a lower complication rate (4% vs. 7%), no irradiation, and availability as a bedside procedure5. Case reports show that lesions in the mediastinal pleura can be sampled using echoendoscopes6.
Thoracoscopy allows direct visual inspection and sampling of lesions in both the mediastinal, diaphragmatic, or costal pleura, making it the gold standard in the diagnosis of recurrent pleural effusion of an unknown cause4,7. Thoracoscopy is performed as either a local anesthetic thoracoscopy (LAT) or video-assisted thoracoscopic surgery (VATS)8. LAT (also known as medical thoracoscopy or pleuroscopy) is a single-port procedure, routinely performed by pulmonologists in the bronchoscopy suite, and it carries a diagnostic yield for malignancy of 93%9,10. LAT can be performed with either a semirigid or rigid endoscope, usually connected to a video-imaging source. A few publications discuss the benefits and disadvantages of these approaches8,11,12,13. Briefly, the semirigid thoracoscope resembles a bronchoscope, and biopsies are obtained using similar forceps. The rigid endoscope has a larger diameter, is cheaper, and allows for larger biopsies, although this does not readily translate into marked differences in diagnostic yield10,14,15. The safety of LAT is high, with a mortality rate of less than 0.5%, with this strongly related to pre-existing medical conditions3,4. Contraindications of LAT are fewer than for VATS and include complete obliteration of the pleural space due to adhesions, skin infection at the site of entry, respiratory failure, cardiac instability, and uncorrectable coagulopathy7,8,12. VATS is an in-hospital, 2 or 3-port procedure performed by thoracic surgeons, which must take place in a surgical theatre, requiring general anesthesia, intubation, single-lung ventilation, and post-operative admission. VATS has a diagnostic yield and complication rate similar to that of LAT but allows for more complex procedures to be undertaken10,16.
Guidelines recommend LAT as the first-choice thoracoscopy due to its high diagnostic yield, low risk, lower costs, and the possibility for daycase management, reserving VATS for selected cases4. The choice of a rigid or semirigid thoracoscope is usually determined by local preference. LAT is not a new procedure, as it was described as early as the mid-19th century, popularized by Jacobaeus in 1910, increasingly used to treat pleural tuberculosis until the 1950s, and &#34;rediscovered&#34; in the 1980s as an important tool to diagnose recurrent pleural effusions8,17.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Chest tube</td>
			<td></td>
			<td></td>
			<td>16-24F</td>
		</tr>
		<tr>
			<td>Forceps</td>
			<td></td>
			<td></td>
			<td>narrow tip, straight or curved&#160;</td>
		</tr>
		<tr>
			<td>Indwelling pleural catheter</td>
			<td>Rocket Medical plc.</td>
			<td>R55400-16-MT</td>
			<td>or PleurX (from Becton Dickinson) or similar</td>
		</tr>
		<tr>
			<td>Local anaesthetics</td>
			<td></td>
			<td></td>
			<td>20 mL of lidocaine 1% (or mepivacaine 2%) &#177; adrenaline</td>
		</tr>
		<tr>
			<td>Non-absorbable suture</td>
			<td></td>
			<td></td>
			<td>Eg. Dafilon 2/0</td>
		</tr>
		<tr>
			<td>Rigid thoracoscope</td>
			<td>Karl Storz GmbH&#160;</td>
			<td>Hopkins-II</td>
			<td>with forceps 26072A and cannula+trocar 30120 NOL (or similar from eg. Richard Wolf GmbH)</td>
		</tr>
		<tr>
			<td>Scalpel</td>
			<td></td>
			<td></td>
			<td>triangular</td>
		</tr>
		<tr>
			<td>Semirigid thoracoscope</td>
			<td>Olympus</td>
			<td>LTF-160</td>
			<td>with forceps FB-420K and cannula+trocar N1002130</td>
		</tr>
	</tbody>
</table>

local anesthetic thoracoscopy for undiagnosed pleural effusion

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed pleural effusions. This single-port procedure is conducted with the patient under mild sedation and involves a contralateral decubitus position. It is performed in a sterile setting, typically a bronchoscopy suite or surgical theater, by a single operator with support from a procedure-focused nurse and a patient-focused nurse.
The procedure begins with a thoracic ultrasound to determine the optimal entry point, usually in the IV-V intercostal space along the midaxillary line. Lidocaine/mepivacaine, with or without adrenaline, is used to anesthetize the skin, thoracic wall layers, and parietal pleura. A designated trocar and cannula are inserted through a 10 mm incision, reaching the pleural cavity with gentle rotation. The thoracoscope is introduced through the cannula for systematic inspection of the pleural cavity from the apex to the diaphragm. Biopsies (typically six to ten) of suspicious parietal pleura lesions are obtained for histopathological evaluation and, when necessary, microbiological analysis. Biopsies of the visceral pleura are generally avoided due to the risk of bleeding or air leaks. Talc poudrage may be performed before inserting a chest tube or indwelling pleural catheter through the cannula. The skin incision is sutured, and intrapleural air is removed using a three-compartment or digital chest drainage system. The chest tube is removed once there is no airflow, and the lung has satisfactorily re-expanded. Patients are usually discharged after 2-4 h of observation and followed up on an outpatient basis. Successful LAT relies on careful patient selection, preparation, and management, as well as operator education, to ensure safety and a high diagnostic yield.

The described LAT technique using either the rigid or semirigid thoracoscopes (Figure 1 and Figure 2) enables the operator to perform conclusive biopsy sampling from the visceral pleural (Figure 3) with a diagnostic yield of 93% in a large systematic review on more than 5000 procedures (Table 1 and Supplementary File 1) (rigid: 93% [95% confidence interval 91%-95%]; semirigid: 93% [89%-97%])<sup cla...

Watch this Scientific Journal Video about Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion at JoVE.com

Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

Local anesthetic thoracoscopy (LAT) is essential for diagnosing recurrent, undiagnosed pleural effusion when a guideline-based workup fails to provide a specific cause. LAT can be performed as a day-case procedure by chest physicians. Here, we present a step-by-step approach for a successful and safe procedure.

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed ...

To begin, perform a patient health check, reaffirming his consent and health conditions. Prepare and check any medications such as sedatives. Place the patient in a lateral decubitus position on a pillow, effusion side up, and ensure patient vital signs monitoring is in place.With ultrasound guidance, mark the expected entry side on the thorax with a blunt indentation marker. Reconfirm with ultrasound after marking. Once the practitioner has scrubbed and donned the appropriate sterile gear, prepare and check the equipment and local anesthetic which will be used in the procedure.In parallel, the prepared sedative medications can be administered by an assistant. Thoroughly disinfect the insertion site and create a sterile field. Then inject the anesthetic solution into the insertion site.While the anesthetic is taking effect, prepare and check the camera and other equipment. Next, make a 10-millimeter-long incision on the skin. Widen the incision with a pair of surgical scissors.After dissecting down a few millimeters, insert a closing suture. With a pair of narrow-tip forceps, carefully dissect the layers between the skin and the pleura until the pleural cavity is entered. For some patients, wider forceps may also need to be used.If needed, reconfirm the position of the tract using the local anesthetic needle. Now, insert the trocar and the cannula using gentle pressure. Then remove the trocar.Now insert a suction tube via the cannula to remove the remaining fluid using a suction system. Insert the thoracoscope via the cannula and inspect the pleural cavity, turning the scope gently to obtain a clear view of as wide an area as possible. Note the position, appearances, and movement of the diaphragm, lung, and pleural surfaces.If biopsies are to be performed using the rigid scope, switch to a zero-degree lens with biopsy forceps attached. Obtain pleural biopsies from suspicious areas by gripping the pleura with the forceps and gently peeling the layers away incrementally. Areas of nodularity may be biopsied using a more traditional pinch approach.After each biopsy, remove the scope and inspect the sample to ensure adequacy. Once biopsies are complete, inspect the pleural cavity for signs of significant bleeding. To finish, remove the trocar and insert the post-lat chest tube into the pleural space using the port tract.Secure the chest tube using a skin suture, ensuring that the suture is kept separate from the closing suture. Wrap the closing suture with a cotton gauze pad. Then cover the procedure site with adequate padding and dressing.

Research

JoVE Journal

Medicine

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