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What is Medical Thoracoscopy?
Medical Thoracoscopy or pleuroscopy is an invasive procedure where a person’s pleural space is accessed by an instrument introduced through a small cut in the chest wall. Pleural space is a potential space between the parietal and visceral lining of the lung (pleura). Medical thoracoscopy can be used to visualize pleural surface and obtain pleural and peripheral lung biopsies.

What are the indications of Medical thoracoscopy?

1. Evaluation of pleural effusion of unknown cause
2. Tissue diagnosis in case of suspected pleural malignancy – Parietal pleural biopsy
3. Staging of lung cancer in case of suspected metastasis
4. Tuberculous pleural effusion
5. Pleurodesis
6. Breaking thin adhesions in pleural cavity
7. Peripheral lung biopsy
8. Visceral pleural biopsy
9. Coagulating blebs in case of pneumothorax
10. Sympathectomy
11. Pleuroscopic lavage for pleural infections

Who does medical thoracoscopy?
Interventional pulmonologists are trained to perform medical thoracoscopy. Thoracic surgeons do a similar but advanced procedure known as VATS (video assisted thoracoscopic surgery). While medical thoracoscopy is primarily a diagnostic technique, VATS can be used for variety of procedures including lobectomy (to resect part of the lung), bullectomy, pleurectomy etc. While a single port is enough for medical thoracoscopy, three ports are need for VATS.

What are the complications of medical thoracoscopy?
Medical thoracoscopy is generally considered as a safe procedure in experienced hands. Some of the complications that may occur include

1. Pneumothorax (air leaking into pleural cavity)
2. Hemothorax (bleeding into the pleural cavity)
3. Tumor seeding other areas
4. Post procedure fever
5. Re-expansion pulmonary edema if large volume of pleural fluid is removed.
6. Empyema – pus in the pleural cavity
7. Cardiac complications
8. Anesthesia related complications

How does the diagnostic yield of medical thoracoscopy differ from other pleural biopsy procedures?
The following is the list of diagnostic yields of different procedures in cases of suspected malignancy

• Medical thoracoscopy – 90 to 95%
• CT guided pleural biopsy -87 to 88%
• Closed pleural biopsy – 64 -89%
• Pleural fluid cytology -62%

In a cost analysis done in UK, medical thoracoscopy saves an amount of around $2000 per patient, mainly by avoiding the need for repeat procedure if the results of the first procedure is inconclusive.

What anaesthesia is given?
Medical thoracoscopy can be done under iv sedation and local infiltration of anaesthetic agent in the chest wall. It can also be done under short general anaesthesia either with single lumen endotracheal tube or double lumen endotracheal tube. In the later the lung with the pleural effusion is collapsed by blocking the main bronchus. Collapse of the lung unilaterally results in larger space for thoracoscopist to maneuver without causing injury to the lung.

Is there any pre-procedure instructions to follow?
Your physician may review all your medications and may stop certain medications like clopidogrel that may increase the risk of bleeding. Your anaesthesiologist may instruct on the number of hours you should not take orally (food and drink) before the procedure.