A review of the outcomes of rigid medical thoracoscopy in a large UK district general hospital

Our plain-English summary of A review of the outcomes of rigid medical thoracoscopy in a large UK district general hospital, by A. Aujayeb, K. Jackson (Pleura and Peritoneum, 2020).

The study

• Authors: A. Aujayeb, K. Jackson
• Journal: Pleura and Peritoneum
• Published: 2020;5(4):20200131
• Cited by: 10 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Objectives: Local anesthetic medical thoracoscopy (LAT) is a well-established diagnostic, therapeutic, and preventative intervention in undiagnosed pleural effusions with a high diagnostic sensitivity and low complication rates. There is a large variability in practice. We describe a nine-year experience in a large district general hospital in England.

Methods: Two hundred seventy-five patients had LAT between January 2010 and December 2018. Data on outcomes and complications were obtained from the patients' notes, electronic records, laboratory, and radiographic findings.

Results: The main diagnoses were malignant pleural mesothelioma (MPM) (n=110, 40%), chronic inflammation/fibrinous pleuritis (77, 28%), lung cancer (26, 9.5%), and breast cancer (16, 6%). LAT failed to diagnose cancer in 7/275 patients (false-negative rate 2.5%, diagnostic sensitivity 97.5%). Out of the 105 patients with chronic inflammation/fibrinous pleuritis or atypical proliferative processes, 21 (20%) were subsequently diagnosed with malignancy. Talcum pleurodesis was performed in 146 patients, and was successful in 86%. Seventy eight (28%) patients had trapped lung; 27 of those had a repeat procedure. The median length of stay was 3.96 days. There was one hospital death (0.3% mortality). Complications of LAT included pleural (3, 1%) and wound infections (4, 1.4%), persistent air leaks (9, 3.2%), subcutaneous emphysema (10, 3.6%), and tumor extension to the access port (1, 0.3%).

Conclusions: In this cohort, LAT was safe, effective, and enabled high diagnostic sensitivity. Further areas of study include optimal sedation and anesthetic pathways and combining LAT with indwelling pleural catheters (IPC).

© 2020 Avinash Aujayeb and Karl Jackson, published by De Gruyter, Berlin/Boston.

In plain English

This retrospective study at one NHS trust in north-east England covered all 275 patients who had local anesthetic medical thoracoscopy, a rigid-scope pleural biopsy procedure, between 2010 and December 2018. The most common diagnosis was malignant pleural mesothelioma (110 patients, 40%). The procedure missed cancer in 7 of 275 patients; the authors reported a diagnostic sensitivity of 97%. Of 105 patients whose biopsies showed chronic fibrinous pleuritis or atypical changes, 21 (20%) were later diagnosed with malignancy, 10 with biopsy-proven pleural mesothelioma. Without trapped lung, talc pleurodesis (done in 146 patients) succeeded in 86%, meaning no further procedure for pleural fluid within 30 days. One patient died (0.3%), of probable pneumonia 36 days later, after kidney injury from a preventive gentamicin dose; the authors found no causal link between the procedure itself and the death. Major complications occurred in 5.4% and minor ones in 2.5%. The article did not report measurements of patients' asbestos exposure. The authors concluded the procedure, done by experienced physicians, was safe and highly effective, though their single-centre, retrospective findings cannot be widely generalized.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective study of consecutive patients at a single centre (review of hospital records)
• Who was studied: 275 patients who had local anesthetic medical thoracoscopy at Northumbria Healthcare NHS Foundation Trust, north-east England, January 2010 to December 2018
• Exposure: The article did not report measurements of patients' asbestos exposure, and exposure is not among the data the authors list as collected. The study assessed a procedure: rigid thoracoscopy with biopsy and graded talc pleurodesis. In the discussion, the authors linked the high local mesothelioma rate to historical asbestos use in local shipbuilding and construction.
• Main results:
  • Malignant pleural mesothelioma was the main diagnosis: 110 of 275 patients (40%)
  • The procedure failed to diagnose cancer in 7 of 275 patients. The main text reports this as a diagnostic sensitivity of 97%.
  • Of the 105 patients with chronic fibrinous pleuritis or atypical proliferative processes, 21 (20%) were later diagnosed with malignancy
  • In 10 of those 21 patients, the malignancy was biopsy-proven pleural mesothelioma
  • Within the follow-up group of 105, asbestos-related benign pleural effusion was diagnosed in 67 patients (63.8%)
  • Pleurodesis was performed in 146 patients (53.1%). In the absence of trapped lung it was successful in 86%. Success was defined as not needing another procedure for pleural fluid within 30 days.
  • 78 patients (28%) had a nonexpandable lung. 27 of 275 patients (9.8%) needed an additional intervention after the procedure.
  • There was one death after the procedure (0.3%). A prophylactic gentamicin dose was followed by acute on chronic kidney injury, and the patient died of probable pneumonia 36 days after the procedure. The case investigation found no causal relationship between any intraprocedural aspect of the procedure and the death.
  • Major complications occurred in 5.4% of patients and minor complications in 2.5%
  • Among the major complications were surgical emphysema in 10 patients (3.6%) and tumor extension in 1 patient (reported as 1% in the main text)
• The authors' conclusion: The authors concluded that their results add to the literature showing that the procedure, in the hands of experienced physicians, is safe and highly effective at achieving a histological diagnosis
• Limitations the authors state:
  • The study has limitations due to its retrospective nature
  • It was a single-centre series with a high rate of mesothelioma, so the findings cannot be widely generalized
  • Recording of intraoperative observations on anesthetic charts varied considerably
  • Data on atrial fibrillation and intraoperative hypotension, which count as minor complications, were not collected

Topics

Medical terms in this study, explained in our Lexicon: Medical Thoracoscopy, Pleural Effusion, Pleural Mesothelioma, Chronic Inflammation, Lung Cancer, Pleurodesis, Trapped Lung, Emphysema.

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• Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative — Z.S. DePew, D. Wigle, et al. (2014)
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• Outcome of patients diagnosed with fibrinous pleuritis after medical thoracoscopy — M. Metintas, G. Ak, et al. (2012)
• Outcomes and complications following medical thoracoscopy — F.J. Brims, M. Arif, et al. (2012)

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