Thorax: first published as 10.1136/thx.43.4.327 on 1 April 1988. Downloaded from Thorax 1988;43:327-332 Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope wi-th a rigid thoracoscope A C DAVIDSON, R J GEORGE, C D SHELDON, G SINHA, B CORRIN, D M GEDDES From the London Chest Hospital ABSTRACT The practicality of physicians performing thoracoscopy for diagnostic purposes was assessed in 30 patients with pleural effusions of unknown cause. A rigid thoracoscope was compared with a fibreoptic bronchoscope used as a flexible thoracoscope and the diagnostic adequacy ofbiopsy specimens obtained with the two instruments assessed. The two instruments were inserted by a physician in the bronchoscopy suite using local anaesthesia. The procedure proved safe, acceptable, and diagnostically effective. The rigid thoracoscope proved a more satisfactory instrument but the fibreoptic bronchoscope, with minor adaptations, may be used for thoracoscopy. Introduction Methods Introduced originally for diagnostic purposes,' From May 1985 to July 1986 thoracoscopy was thoracoscopy gained widespread use for lysis of performed by a physician on 30 consecutive patients tuberculous pleural adhesions, falling into disuse with presenting to the London Chest Hospital with pleural http://thorax.bmj.com/ the introduction of effective chemotherapy. More effusion of unknown cause. The first 10 examinations recently, however, its diagnostic usefulness, par- were carried out with a rigid thoracoscope (a forward ticularly in cases ofpleural effusion ofunknown cause, looking Storz thoracoscope of 9 mm external has led to its reintroduction.2`5 Various instruments diamater) alone. Subsequently both the rigid and anaesthetic techniques have been used.2 Most thoracoscope and a fibreoptic bronchoscope (Pentax often a specially designed rigid thoracoscope is FB 19H, external diameter 5 9 mm) were used. employed, thoracic surgeons usually favouring gen- The indications for thoracoscopy were conven- eral anaesthesia and physicians local anaesthesia."8 tional. Patients underwent the procedure when the The fibreoptic bronchoscope has also been used as a cause of the pleural effusion remained unclear after on October 2, 2021 by guest. Protected copyright. thoracoscope, some claiming it to be technically aspiration (the fluid being sent for cytological, superior to rigid instruments'° " but others finding it microbiological, and immunological examination) unsatisfactory.'2"3 Only one group has compared the and a successful Abrams punch pleural biopsy. Other two instruments7: few patients were studied and appropriate investigations-for example, bron- difficulty was experienced in histological interpreta- choscopy or lymph node biopsy-had also to have tion of the smaller specimens obtained with the yielded negative results before thoracoscopy was fibreoptic bronchoscope. undertaken. A further requirement was that the The aims of the present study were, firstly, to assess patient had to be considered fit for thoracoscopy. To the practicality of thoracoscopy performed by assess this, spirometry was performed and, if hypox- physicians in the bronchoscopy suite using local aemia was suspected, arterial blood gases were sam- anaesthesia and, secondly, to compare the diagnostic pled. The patient had to be able to lie comfortably effectiveness of the fibreoptic bronchoscope used without respiratory distress. No patient was con- as a flexible thoracoscope with that of the rigid sidered unfit for the procedure during the course ofthe thoracoscope. study. Patients were admitted for 24 hours unless already Address for correspondence: Dr A C Davidson, Medical Unit, St under inpatient investigation. The procedure was Thomas's Hospital, London SE 1. (Reprints will- not be available.) explained and consent obtained. Before thoracoscopy Accepted 15 December 1987 100-200 ml pleural fluid was aspirated and replaced 327 Thorax: first published as 10.1136/thx.43.4.327 on 1 April 1988. Downloaded from 328 Davidson, George, Sheldon, Sinha, Corrin, Geddes with a similar volume of air. A decubitus radiograph drain as soon as air was no longer being expelled by with the affected side uppermost was taken to deter- coughing--that is, within a few minutes. When inspec- mine the presence of adhesions or loculations and to tion had suggested malignancy or when the effusion assess the degree of pleural thickening. Premedication had previously reaccumulated rapidly, drainage was consisted of intramuscular atropine (600 pg) and continued to allow a tetracycline pleuradesis to be papaveretum (10-20 mg). Thoracoscopy was per- performed (with 500 mg tetracycline dissolved in 50 ml formed in the bronchoscopy suite, usually at the end of saline with a dwell time of two hours and routine a routine bronchoscopy list, with the patient lying in suction for 24 hours). Drainage was also maintained if the lateral decubitus position. An electrocardiograph adhesions or visceral pleural thickening were likely to was attached for monitoring purposes and intraven- limit full expansion, 10-20 cm H20 negative pleural ous diazepam (5-20 mg) was given as necessary. pressure being applied. In all cases a radiograph was Oxygen was supplied by mask or nasal prongs if taken within 24 hours. The patients were reviewed at arterial oxygen tension had been found to be less than monthly intervals or, in cases ofsecondary referral, the 9 3 kPa or if respiratory distress occurred during the referring physician was contacted for information on procedure. On some occasions an ear oximeter (Biox follow up. A final diagnosis was made in the light of III) was also used for monitoring purposes. the biopsy findings and the subsequent clinical course. The rigid thoracoscope and the fibreoptic in- The specimens obtained with the two instruments strument were sterilised by cold immersion in 2% were processed separately. They were fixed in 10% glutaraldehyde for at least 30 minutes.'4 The operator neutral buffered formalin, embedded first in agar to and assistant scrubbed and wore surgical mask, gown, prevent tissue loss and then processed automatically to and gloves. After skin preparation 20 ml 1% lig- paraffin. Sections 3-5 gm thick were cut at three levels, nocaine were infiltrated between the 6th and the 7th or care being taken to ensure that all the embedded tissue the 7th and the 8th ribs in the posterior axillary line was sampled. Haematoxylin and eosin staining was down to and including the parietal pleura, aspiration performed routinely and immunocytochemical stain- ofair confirming pleural puncture. A stab incision was ing, with the use of monoclonal antisera to carcino- then made and a track created by blunt dissection with embryonic antigen, cytokeratin, and human milk fat forceps. The Storz trocar was inserted and the pleural globulins I and 2, was performed ifindicated. Reports cavity opened to atmospheric pressure, any remaining on the fibreoptic specimens were made independently pleural fluid being aspirated. A full examination ofthe of those on the rigid specimens but a combined report http://thorax.bmj.com/ pleural cavity was then made and biopsy specimens of was issued for clinical use. Subsequently all sections parietal and visceral pleura were taken as appropriate were examined in random order by a second patho- under direct vision. After the first 10 examinations the logist without knowledge of biopsy method or clinical pleural space was examined with both the rigid data. thoracoscope and the flexible bronchoscope in ran- dom order. The bronchoscope was introduced Results through the Storz trocar (after removal of the flap valve assembly) in the first 10 cases and through a size Adequate pleural tissue was obtained in all but tne 24 Argyle chest drain acting as a sheath for the case, in which access was limited by multiple adhesions on October 2, 2021 by guest. Protected copyright. bronchoscope89 in three cases. In the remaining and only normal lung tissue was obtained. The patients the bronchoscope was passed through a histological diagnosis in the remaining 29 patients was Maligar trocar. adenocarcinoma in five, mesothelioma or probable All 30 patients were examined by one operator mesothelioma in 13, suspicion of malignancy in two, (ACD), who had assisted at several "surgical" tuberculosis in one, and chronic non-specific pleurisy thoracoscopies before undertaking "medical" in eight. The final diagnosis subsequently proved to be thoracoscopy. In the case of the 20 patients examined malignancy in all of the cases considered to be with both instruments, care was taken to select equally malignant after thoracoscopy, although a necropsy abnormal areas for biopsy. Multiple (5-7) biopsy was not performed in all cases. Of the eight cases of samples were taken with each instrument to avoid any non-specific pleurisy, the final diagnosis proved to be bias toward one or other technique in the assessment malignancy in three (adenocarcinoma 2, meso- of the diagnostic usefulness of the two instruments. thelioma I) and probable mesothelioma in a fourth. In At the end of the procedure our initial practice was only four cases was the outcome benign, Mycobac- to introduce an Argyle drain through the thoraco- terium tuberculosis subsequently being cultured from scopy incision and confirm lung expansion radio- the biopsy material in one patient. Thoracoscopy graphically before removal of the tube. Since routine therefore provided diagnostic material or specimens drainage may increase