Outcomes and complications following medical thoracoscopy

Our plain-English summary of Outcomes and complications following medical thoracoscopy, by F.J. Brims, M. Arif, A.J. Chauhan (The Clinical Respiratory Journal, 2012).

The study

• Authors: F.J. Brims, M. Arif, A.J. Chauhan
• Journal: The Clinical Respiratory Journal
• Published: 2012;6(3):144-9
• Cited by: 23 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Thoracoscopy is an invasive procedure that may be performed by physicians for the investigation of exudative pleural effusion using local anaesthesia, conscious sedation and a rigid thoracoscope.

Objectives: We sought to evaluate the safety and outcome of thoracoscopy in Portsmouth Hospitals, UK, a dockyard city with high previous asbestos usage.

Methods: Retrospective casenote, radiology and laboratory result analysis of patients undergoing thoracoscopy in our institution over a 12-month period.

Results: Fifty-seven of 58 casenotes were available for analysis. Median (interquartile range) age was 73.0 (66.5-79.0) years and 44 (77.2%) were male. Median time with chest drain post-procedure was 3.0 (2.0-5.0) days, and length of stay (LOS) was 4.0 (2.0-8.0) days. Malignant histology was reported in 40 (70.2%), with 25 (62.5%) cases of mesothelioma. There were no deaths related to the procedure. Hospital-acquired infection (HAI) occurred in six (10.5%: pneumonia four, empyema two), all had malignancy. The presence of HAI significantly prolonged the LOS 9.0 (7.5-23.5) vs no HAI 4.0 (2.0-7.0) days; P = 0.006). Four patients died within 1 month of the procedure, three had a malignant diagnosis, all had suffered HAI. Trapped lung (persistent hydropneumothorax 5 days post-procedure) occurred in 11 (19.2%), six of whom had benign histology. Performance status (European Cooperative Oncology Group) prior did not differ with reported histological type: benign 2.0 (2.0-2.0), malignant 2.0 (2.0-3.0), P = 0.170.

Conclusions: Serious complications following thoracoscopy are rare. HAI is associated with malignancy and prolonged hospital stay. Benign histology may still confer significant morbidity.

© 2011 Blackwell Publishing Ltd.

In plain English

This retrospective review examined medical thoracoscopy at Portsmouth hospitals, UK. In this procedure a doctor views the inside of the chest through a small opening. Patients had unexplained exudative fluid around the lung, filling at least half of one side of the chest, with no cancer cells found on fluid tests. The authors describe Portsmouth as a dockyard city where significant amounts of asbestos were used; patients' own exposure was not studied. Of 58 consecutive procedures over 12 months, 57 had complete data. Biopsies showed cancer in 40 patients, 25 of them mesothelioma. No deaths resulted from the procedure. Six patients, all with cancer, developed hospital-acquired infection; their median stay was 9.0 days versus 4.0 without infection (P = 0.006). Four patients died within one month; three had cancer. The text reports trapped lung in 11 patients, six with benign biopsy findings, though one table lists 10. The authors concluded that serious complications were rare, infection was linked to cancer and longer stays, and benign biopsy findings may still bring significant illness. They cautioned that numbers were small and from one centre.

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 audit (consecutive case series) of patient records, X-rays and laboratory results at a single centre
• Who was studied: 58 consecutive thoracoscopies over a 12-month period (dates not given) at Portsmouth Hospitals NHS Trust, UK, with complete data for 57. Patients had unexplained exudative, cytology-negative pleural effusion occupying at least half of the hemithorax. Median age was 73.0 years and 44 (77.2%) were male.
• Exposure: The study examined the thoracoscopy procedure, with talc poudrage in 45 (78.9%) patients. Patients' asbestos exposure was not measured or reported. The authors describe the city as having a historically large shipbuilding industry that used significant amounts of asbestos.
• Main results:
  • No deaths resulted from the procedure, and there were no episodes of respiratory failure or ARDS among the 57 patients.
  • At least one complication occurred in 23 of the 57 patients (40.4%).
  • Malignant histology was found in 40 patients (70.2%). Mesothelioma accounted for 25 of these (62.5% of malignancies; 43.9% of all 57 cases).
  • One patient whose biopsy was reported as benign (chronic lymphoid inflammation) was diagnosed with non-Hodgkins lymphoma 3 months later. This patient remained in the benign group for analysis.
  • Hospital-acquired infection occurred in six patients (pneumonia four, empyema two), all with a malignant diagnosis. Median hospital stay was 9.0 days with infection versus 4.0 days without (P = 0.006).
  • Four patients died within one month of the procedure, three of whom had a malignant diagnosis. The authors state that none of these deaths was a direct result of the thoracoscopy.
  • The authors reported a non-significant trend towards higher one-month mortality with hospital-acquired infection: 2 deaths among patients with infection and 2 among those without (P = 0.051).
  • The article's text reports trapped lung (persistent air and fluid in the chest beyond 5 days) in 11 patients, six of whom had benign histology. Table 3, however, lists trapped lung in 10 (17.5%).
  • Patients with trapped lung had a longer median hospital stay: 8.0 days versus 4.0 days without trapped lung (P = 0.009).
  • Trapped lung occurred in 6 of 17 patients with benign histology versus 5 of 40 with malignant histology (P = 0.041).
  • Performance status before the procedure did not differ between benign and malignant groups (median 2.0 in both; P = 0.170).
  • The authors calculated the sensitivity of thoracoscopy for a true malignant diagnosis in this series as 97.5%.
• The authors' conclusion: The authors concluded that thoracoscopy by experienced physicians is generally safe and effective for diagnosis. They found that hospital-acquired infection is associated with malignancy and prolonged hospital stay, and that benign histology may still confer significant illness.
• Limitations the authors state:
  • This was a retrospective audit that was not designed or statistically powered to show differences in outcomes.
  • Numbers in some subgroups were small, so results should be interpreted with caution.
  • This was a single-centre experience, so findings should not be over-generalised.
  • The high mesothelioma rate reflects pre-test selection and high local incidence, which may have influenced the results.
  • The 5-day definition of trapped lung was arbitrary, which may explain the higher rate seen in the benign group.

Topics

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

Medical terms in this study, explained in our Lexicon: Medical Thoracoscopy, Thoracoscopy, Pleural Effusion, Histology, Mesothelioma, Empyema, Trapped Lung, Performance Status.

Related studies

• Medical thoracoscopy, results and complications in 146 patients: a retrospective study — M. Hansen, P. Faurschou, et al. (1998)
• 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)
• 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)
• Outcome of patients diagnosed with fibrinous pleuritis after medical thoracoscopy — M. Metintas, G. Ak, et al. (2012)
• Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions in Denmark — F. Willendrup, U. Bodtger, et al. (2014)

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