Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative

Our plain-English summary of Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative, by Z.S. DePew, D. Wigle, J.J. Mullon, et al (Chest, 2014).

The study

• Authors: Z.S. DePew, D. Wigle, J.J. Mullon, F.C. Nichols, C. Deschamps, F. Maldonado
• Journal: Chest
• Published: 2014;146(2):398-405
• Cited by: 45 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Medical thoracoscopy (MT) is performed by relatively few pulmonologists in the United States. Recognizing that an outpatient minimally invasive procedure such as MT could provide a suitable alternative to hospitalization and surgery in patients with undiagnosed exudative pleural effusions, we initiated the Mayo Clinic outpatient MT program and herein report preliminary data on safety, feasibility, and outcomes.

Methods: All consecutive patients referred for outpatient MT from October 2011 to August 2013 were included in this study. Demographic, radiographic, procedural, and histologic data were recorded prospectively and subsequently analyzed.

Results: Outpatient MT was performed on 51 patients, with the most common indication being an undiagnosed lymphocytic exudative effusion in 86.3% of the cohort. Endoscopic findings included diffuse parietal pleural inflammation in 26 patients (51%), parietal pleural studding in 19 patients (37.3%), a normal examination in three patients (5.9%), diffuse parietal pleural thickening in two patients (3.9%), and a diaphragmatic defect in one patient (2%). Pleural malignancy was the most common histologic diagnosis in 24 patients (47.1%) and composed predominantly of mesothelioma in 14 (27.5%). Nonspecific pleuritis was the second most frequent diagnosis in 23 patients (45.1%). There were very few complications, with no significant cases of hemodynamic or respiratory compromise and no deaths.

Conclusions: Outpatient MT can be integrated successfully into a busy tertiary referral medical center through the combined efforts of interventional pulmonologists and thoracic surgeons. Outpatient MT may provide patients with a more convenient alternative to an inpatient surgical approach in the diagnosis of undiagnosed exudative pleural effusions while maintaining a high diagnostic yield and excellent safety.

In plain English

This retrospective review of prospectively collected data described an outpatient medical thoracoscopy program at Mayo Clinic in Rochester, Minnesota. In this procedure a pulmonologist examined and biopsied the lining of the chest under moderate sedation. Thoracoscopy was attempted in 55 patients referred between October 2011 and August 2013, most of whom had fluid around the lung whose cause had not been found. Of these, 51 procedures were completed. The article did not study asbestos exposure. Pleural malignancy was found in 24 patients (47.1%), most often mesothelioma, which was found in 14 patients (27.5%). Nonspecific pleuritis was the second most frequent diagnosis, in 23 patients (45.1%). There were few complications: one minor adverse event, three hospital admissions after the procedure, and no deaths. The authors concluded that outpatient thoracoscopy was safe and feasible in appropriately selected patients. They noted that about 9 months of follow-up was too short to confirm that patients with nonspecific pleuritis did not have cancer, and that no conclusions about cost could be drawn.

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 review of prospectively collected data from a single-center outpatient medical thoracoscopy program; procedures used moderate sedation with fentanyl and midazolam
• Who was studied: 55 consecutive patients referred for outpatient medical thoracoscopy at Mayo Clinic, Rochester, Minnesota, October 2011 to August 2013, mostly with undiagnosed exudative pleural effusions; 51 completed procedures (38 of 51, 74.5%, men; mean age 68.1 years)
• Main results:
  • Of 55 attempted procedures, 4 were aborted (3 because the pleural space could not be adequately accessed, 1 because of equipment failure) and 51 were completed
  • Pleural malignancy was confirmed on biopsy in 24 of 51 patients (47.1%)
  • Mesothelioma was the most common malignancy, found in 14 of 51 patients (27.5%)
  • Non-small cell lung cancer was found in 7 of 51 patients (13.7%)
  • Nonspecific pleuritis was the second most frequent diagnosis, in 23 of 51 patients (45.1%); with a mean follow-up of about 9 months, none of these patients had been found to have pleural malignancy
  • The cohort had few complications: one minor adverse event (a clinically insignificant pneumothorax ex vacuo caused by trapped lung)
  • Three patients whose procedure was completed were admitted to the hospital afterward (two for pain needing IV analgesia, one for postanesthesia confusion); the authors counted these as complications
  • There were no deaths among the patients
  • The average procedure time was about 40 minutes
  • 14 of 51 patients (27.5%) underwent a subsequent procedure for management of the pleural space; 6 patients (11.8%) had a later operation that the authors said might have been avoided with an initial surgical diagnostic procedure
• The authors' conclusion: The authors concluded that outpatient medical thoracoscopy is safe and feasible in appropriately selected patients and may offer an alternative to surgery in selected patients with undiagnosed exudative pleural effusions
• Limitations the authors state:
  • Follow-up of about 9 months was insufficient to confirm the absence of malignancy in patients with nonspecific pleuritis
  • No conclusions about cost-effectiveness could be drawn from the study
  • Physician-directed sedation with drugs such as fentanyl is not allowed in some countries, which may limit generalizability
  • There was no formal multidisciplinary panel discussion of cases
  • Around 12% of patients had a later operation that might have been avoided with an initial surgical diagnostic procedure
  • Patients referred for outpatient evaluation are likely different from those referred directly to thoracic surgeons

Topics

The National Library of Medicine indexes this study under subjects our site covers: Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Medical Thoracoscopy, Pleural Effusion, Inflammation, Pleural Thickening, Mesothelioma.

Related studies

• The safety of medical thoracoscopy in a group at high risk for complications — M. Metintas, G. Ak, et al. (2013)
• Medical thoracoscopy vs CT scan-guided Abrams pleural needle biopsy for diagnosis of patients with pleural effusions: a randomized, controlled trial — M. Metintas, G. Ak, et al. (2010)
• Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions in Denmark — F. Willendrup, U. Bodtger, et al. (2014)
• Medical thoracoscopy in the diagnosis of unexplained pleural effusion — M.L. Wilsher, A.G. Veale (1998)
• Medical thoracoscopy, results and complications in 146 patients: a retrospective study — M. Hansen, P. Faurschou, et al. (1998)
• Outcomes and complications following medical thoracoscopy — F.J. Brims, M. Arif, et al. (2012)

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