Transcription
So I'm very actually excited to tell you some things about uh new developments. So what we are going through there is a lot of slides. We'll go through what actually medical thoracoscopy is, because I expected that some people will be around who won't have a clear idea what we are talking about, how we do it, why we do it, what we're afraid of. We talk about complications a little bit, a little bit of results, and what is new actually in the field of um equipment at the moment.
So what is medical thoracoscopy? I know that you who are sitting here already know that it's a scopic procedure in the lung cavity where we take samples and perhaps make a pleurodesis. But I asked ChatGPT what artificial intelligence thinks about that, because medical thoracoscopy has been around for more time than we have, and it developed when there were no mobile phones, no computers, whatever—more than 100 years ago. The idea was to make a decent pneumothorax in patients with tuberculosis; that's how thoracoscopy began. But now it's evolved into many other indications. So now we distinguish uh medical and surgical thoracoscopy. Surgical thoracoscopy is usually used for lobectomies or bigger procedures, but medical thoracoscopy should be very simple. We use it for diagnosis of pleural diseases where we are not able to get a diagnosis from cytology. So we use thoracoscopy as a quick and simple procedure, mostly for biopsy and pleurodesis. We don't remove lobes out of the chest cavity. We use local anesthesia and a bit of sedation. So even the patient with low performance status can tolerate it very well. And uh people who are submitted to this procedure, they breathe spontaneously. They don't need intubation and ventilation and general anesthesia and whatever. Uh we do it in a partial pneumothorax, not a complete collapse of the lung. And we use only one point of entry. We don't use two, three, or more, like surgeons do. So surgical thoracoscopy is more complex, requires general anesthesia, intubation, and anesthesia, and usually more points of entry. It's usually a more invasive procedure. So ours is simple, and uh that's uh why it's used quite a lot and improves our workflow with the patients who need diagnosis and we are unable to do that.
So why do we do it? We have patients with pleural effusion. This is the main indication. We take a thoracentesis, but we don't get the firm diagnosis. There are no malignant cells. There are some lymphocytes, but we don't know what kind of malignancy there is. If it is an infection, for example tuberculosis—in tuberculosis-prevalent countries, it fastens the diagnosis very much—and if there are some kind of inflammation, for example chronic rheumatoid arthritis. But in cases where diagnosis cannot be established a different way, we have several therapeutic options like pleurodesis, which is most often used for patients who have malignant pleural effusion. We do some adhesions sometimes in patients with infection and empyema, and that's mostly what we do. And there are some rare indications which I won't mention here. So pleural effusion has a very lot of causes, but mostly we diagnose mesothelioma, cancer, tuberculosis, and some idiopathic effusions which cannot be diagnosed other ways. So this is our main group of indications. So why, in malignant pleural effusion, different carcinomas—lung cancer, breast cancer, whatever—differently shed cells in the pleural cavity. So some are very simple to diagnose, and normal thoracentesis has a high diagnostic yield. But for example, in mesothelioma or squamous cell lung cancer, the diagnostic yield of repeated thoracentesis is pretty low—20-30%—and since we don't have a diagnosis, we have to get into the chest cavity and take a piece of tissue to be sure what we have. What's the point in tuberculosis? In tuberculosis, when we use just pleural fluid and that's not a clear empyema, which is very rare I suppose—I practically see it once or twice in my lifetime—but there's a lot of non-empyema tuberculosis effusion. We rarely find bacilli in the pleural fluid, and if you wait for a culture, we can wait several weeks before we have a diagnosis. But if we go and take a histologic sample, and we can see bacilli under the microscope, we have the diagnosis in the same day, and we also have bacilli for culture and for antibiotic tests. For example, if it's rifampicin-resistant, we can do this pretty much faster—several weeks faster—than classically. Indeed, nucleic acid amplification has high sensitivity, but we don't isolate bacilli, and we cannot make an antibiogram. The next thing is talc pleurodesis. In the COIN database, talc pleurodesis is still the most effective way to make a pleurodesis in patients with malignant pleural effusion, and the semiflexible thoracoscope is just made for it.
How do we do it? We do it simply. We don't need a surgical room for that. We can do this in normal endoscopy rooms, almost bedside. So the only requirement is to prepare the patient as for an operation. We use a lot of washing, a lot of disinfection. We cover the patient, and we do this procedure very briefly. Usually, from entering of the endoscope to the end of the procedure, it's like 15-20 minutes, but preparation is much longer—usually taking half an hour before we start because of all this disinfection. The procedure goes like that. First, we check the patient with ultrasound and select the right point of entry where there are no adhesions, where there is effusion, that we don't injure the lungs when we enter with the endoscope. The next step is some local anesthesia and sedation for the patient so that it's calm, and then we introduce the pneumothorax. Pneumothorax is essential because the lung should be removed from the chest wall so that the endoscope safely enters into the pleural cavity. So we do this quite often under the control of fluoroscopy. But if there's a big effusion, you don't need fluoroscopy. You can check with ultrasound and make a deflator with ultrasound. Then we completely disinfect the patient. We cover it and also put the drape over the skin so that we minimize the risk of infection. Uh so there's a lot of this preparation—never enough of this infection prevention. And now then we have a very nice semiflexible, semi-rigid instrument. It looks like a bronchoscope. It has a rigid shaft, but the tip is flexible. So we can look at every possible direction in the chest cavity. And the field of vision is much bigger than this rigid scope, because a rigid scope cannot look upwards and in the direction where the bronchoscope/thoracoscope is introduced, but only in several directions. But with the semi-rigid scope, we can look everywhere. So the next step, very important, is access to the pleural cavity. We have flexible blunt trocar catheters which can adapt a little bit when we move the thoracoscope. It's not so rigid and doesn't make so much strain to the chest wall and doesn't introduce so much pain to the patient. The next step is maneuverability and inspection. Here I have a short movie. So I hope, yeah, it works. So you can see we can go everywhere. We can turn the scope back, and we see our point of entry, and we can inspect all the chest cavity around, and there are no secret places for us; we see everything. So this with a rigid thoracoscope is not possible. And then there is what is important—biopsy. We have two major modes of biopsy: one is forceps biopsy, the other is cryobiopsy. I'll go into this further, and we are able to get big samples of tissues. This is a surgical size of tissue sample—more than enough for pathological diagnosis and also for all molecular markers which you need and also for tissue banking if you want to store some tissue for later and for some research—this is plenty of it. So it's more than enough. So the fear that with a semiflexible thoracoscope it's not possible to take a proper sample is not on the place, because for several years, for many years since the instrument was introduced to the market, it was told that it's flexible, you cannot get proper decent samples, but it's not true; the samples can be taken, and they are big. And there was many times talking about what about mesothelioma. Mesothelioma is difficult to biopsy. As you see here, we can get large chunks of tissue, even in mesothelioma. Of course, we don't pull the forceps through the working channel like in a bronchoscope, but remove it en bloc—the thoracoscope all together—and as you will see—I'm sorry that the movie doesn't go fast enough—pieces like 2-3 cm. And since this is malignant tissue, this doesn't hurt the patient; the patient doesn't feel the pain because we biopsy the cancer, not the healthy tissue. So when you see this on the glass slide, it's a really big one. So you need one such biopsy, and you have more than enough tissue for all the procedures which you need.
So the next step is cryobiopsy. If you're not satisfied with the forceps, we can use a cryoprobe. So a cryoprobe is useful when we have nodular changes on the pleura. When you just have flat and hard pleura, it's maybe cryobiopsy is a little bit more problematic. But in cases when they have a nodular lesion, you just attach a cryoprobe to the lesion, freeze it, and gently harvest it, and you get the whole piece of it. So it's and you remove it all together with the thoracoscope in order that you preserve the whole sample. So that's a trick.
So results—I won't go through all the numbers—but the diagnostic yield for rigid and semiflexible is actually just the same, and the cryoprobe as well. The cryoprobe has an advantage when they have nodular lesions, not just flat pleura. This is flat pleura where the forceps are a little bit better for taking biopsies. This is a nodular lesion where cryobiopsy has an advantage because we are able to get significantly bigger samples with this method.
So the next step, I'll just show you a little bit, is pleurodesis. Uh we don't insert the talc directly through the working channel of a thoracoscope because it may be dirty and blocked, but through a catheter. We introduce a catheter through the working channel of the thoracoscope, and we gently blow the talc into the space—not to the lungs, not to the chest cavity, but to the space—that we have like a snowstorm, and this talc evenly settles on all surfaces of the pleura—visceral and parietal—in a very thin layer and makes the best possible effect. If you just blow the talc to the lungs, onto the chest cavity, we have accumulations of talc. It is not so nice and good if you have a thin layer of a snowstorm in the whole chest cavity.
So these are rare indications. For example, this patient had fluid pneumothorax due to carcinoma. Here you see the fistula, and these lungs were not expandable because there is a fistula. And what we did was we used—we identified the fistula during thoracoscopy and made a small electrocautery touch to close the fistula, and then it was possible to reexpand the lung and to put the talc in the same session, and the patient had effective pleurodesis, and also spontaneous pneumothorax due to malignancy didn't recur thereafter. These are actually these are rare indications. You don't see them every day, but it's possible just with a small touch of electrocautery that you close the fistula, and then you can then treat the patient and remove a lot of symptoms and hospital stays which patients have. So you don't need a lot—just a little bit of touching and cauterization—and the fistula can be closed if you find such a case.
So we go further—what are we afraid of? So what are the possible complications? Complications—when you read the literature and even in live practice—I have hundreds of thoracoscopies behind me—the complications are very rare. If you do—if you know your anatomy of the chest cavity, you know where the vessels are, where the heart is, where the lung is, and you don't touch the areas which you—which you don't, for example, the aorta or heart or such things, you don't have complications. You can take a biopsy safely. You just peel the layer of the pleura; you don't go deep into the thoracic wall, because what you're interested in is on the surface, not deep in the thoracic wall or in the lungs. So the worst complications are associated with poor patient selection—patients who had cardiac dysfunction usually, or they have respiratory failure, or they are hypercarbic, and so on, or they are very bad performance status, like WHO 3 or 4. Um, sometimes when we perform a pleurodesis in a very old patient, the inflammation which talc induces can also make a complication in such a patient. And if there is massive pleural effusion, if we expand the whole lung in one moment, it can complicate. So we expand lungs slowly after the procedure. So when you are doing thoracoscopy, better don't—you go to find a publication or this book I very much recommend from the colleague Philip Ast—when you have such things, be very cautious about that. If you have one patient with a healthy lung and the other with massive effusion, even if the patient has slow functional capacity, you can do thoracoscopy on the side where there is massive effusion because there won't be any problems, but don't do it on the opposite side.
So results—let's go first with tuberculosis effusion. A low diagnostic yield; closed needle biopsy makes sense in countries with high prevalence of tuberculosis as the first procedure, but in low-prevalence countries, this number is seen lower, and maybe thoracoscopy is the next procedure in this area. Why is this important? Because diagnosis is much—is getting in much shorter time. In the same day we can see bacilli in the histological sample and we can make an antibiogram for possible resistance. If we wait for a culture for pleural effusion, it takes weeks, and it's not so reliable. These are 30-year-old data on malignant pleural effusion: cytology, biopsy, needle combined, and thoracoscopy lined up. And these are the new data from one or two years ahead—meta-analysis—still the same data as 30 years ago. So thoracoscopy is very useful in that one-third of the patients where we cannot get a diagnosis with fluid cytology, and even mesothelioma is much worse. Mesothelioma is more difficult to diagnose if it's not advanced, if it's in the early stages. So the same 30-year-old data and just recent data are practically the same as they were 30 years ago. So histology makes a difference here. So why is this important? I already mentioned that certain cancers shed malignant cells very early and a lot of it, like ovarian cancer or adenocarcinoma of the lung, but certain ones like mesothelioma or squamous cell lung cancer, whatever—cytological yield from pleural effusion is very low—so these are candidates for thoracoscopy. When we have negative pleural effusion, this is again meta-analysis data. I won't go through all these studies, but you can see cytology around 60%, thoracoscopy diagnostic yield around 90% when they're going through it.
So bringing the future, and the future is already now because I have to advertise a little bit the new thoracoscopic instrument. There is better optics, high-definition imaging, a larger working channel, more robust forceps, and a little bit more flexibility, even that you can see the entry point, but also with the older instrument it was already possible. So what this makes in clinical practice—this is a several-years-old thoracoscopy when we have chronic pleuritis and we make a peeling biopsy with the old instrument. You see that the picture is a little blurred, that it's not so resolute, but again, histology is important; we get a decent sample, but the visibility is not so good. So now with the new instrument, as you will see in a moment. So this is not the same patient. This is a recent procedure in a different patient but with the same disease. So you can see a lot more details on the pleura, a lot more small vessels, early changes maybe in some different disease. Again, we see in very much detail what is below the pleura. And we have a special modality when we can assess bleeding much more accurately. We see bigger vessels, submucosal vessels, and we can change this imaging modality. It's called LDI modality. I'll show in the next slides what this means.
So if we connect this new instrument with the new X1 processor, which is also available for a while, around it. So this is the normal white image. Do you see something there? Okay. But now you see in the TXI image that there are small nodules. This is the beginning of the mesothelioma, the early mesothelioma. Maybe we could miss it with normal white light. But this is becoming a new standard—more resolute image like texture and color enhancement. So all these modalities in the image—like texture, color, and brightness—are processed separately, and that's why we get a more resolute and more contrast image. Uh so I'll go once again to the same patient again. Here are some small nodules, not so clearly visible, but when I change the image modality to TXI, you see that there are small nodules which are basically the early mesothelioma, which was proven then with histology as well.
So the next thing is narrow-band imaging. The narrow-band imaging shows superficial vessels in the chest cavity. What we are doing here is intercostal nerve block. We go with the needle in the vicinity of the intercostal nerve. We inject a little bit of lidocaine and make an effective anesthesia for the whole half of the chest cavity. This is for patients when we will perform a pleurodesis. Pleurodesis is a very painful procedure, and we can do this intercostal nerve block for the whole half of the chest cavity in a matter of one minute. And the chest cavity is then anesthetized for almost six or seven hours, the time when pleurodesis is very painful. So you see when when we when we started with that we saw, okay, narrow-band imaging is showing us the vessels, and we can avoid the vessels, intercostal vessels, and that we are at no risk of bleeding. So I'll go to the next slide. This one slide is important. So here you see a lot of superficial structures, but you don't see in the depths. So this is one of the complications—a small—we have bleeding because we hit a deeper vessel. It's actually a small, self-limiting bleeding, but it's not nice. Uh when we turn the image modality to the yellow one—to add the ICG—the achromatic image—it's just the opposite. We go deep through the pleura and we see even deeper vessels, and we can avoid them. So it's another major improvement. So with narrow-band, we don't see them; with that yellow ICG—we go once again—we see them. This is the same patient; so you can see deeply through the pleura and avoid the bigger intercostal vessels and avoid the bleeding.
So I will end now here. Thoracoscopy—what should every physician know? It's safe and effective; it spares you a lot of time; you get earlier diagnosis, more reliable diagnosis in patients where you cannot establish a diagnosis from just pleural effusion. It's not so difficult to learn. From my experience, bronchoscopy is more difficult to learn than thoracoscopy. But it's a rare procedure. You don't need so much skill. You learn your anatomy. You try several times in an experienced setting, and you can do it. So Andrew can testify to that because he started to do thoracoscopies recently, and he's doing a lot of them. And as we talked, you don't have complications because they are even rarer than in bronchoscopy. So the method is still underused in Europe, and it's a shame because we have nice equipment now, which most interventional pulmonologists are familiar with. It resembles a bronchoscope, and it's effective, and it's not dangerous for the patient, and it doesn't need general anesthesia and major surgery. So I would like to encourage you to use the method in order to benefit your patients. Thank you. Thank you very much. If there are some comments or questions, I'm available for you later. You think? Yeah. This—you can just go back to—Yeah, I'll try to. All right. So this device is commercially available. It's pre-packed, sterile, talc graduated, and you already have now these catheters packed with it. But in the older thoracoscope, it was a little bit too thick. It didn't pass through the working channel in mild pleural effusion sometimes—mild pleural effusion. So I'm not comfortable to induce pneumothorax, honestly speaking. I don't know. Um, do you find it like really safe also to go just, you know, and the fluoroscopy—I don't know how you—So I'll show you—you use this atraumatic needle which is meant—which has a blunt tip, okay, blunt tip, and is meant…
To evacuate a plusion, you just put it into the plusion and open it, because negative pressure will suck the air inside, and the pleator Forex will be made passively.
Is this a specific needle? Comes to orus needle? No, this is a it's called a various needle. Various needle. P E R E S blind tip blind tip needle. Blind tip needle. It's available everywhere.
Is it the same that you use for plural uh plural plural tab? I have specific for plural tab. It's the same one. Green and red. Then you know where you are. It's the same. You just introduce the needle to the plural fusion. You uh aspirate a little bit, that you're sure that you are there, and then disconnect will be made passively.
Okay. How do you make sure other than the the ultrasound? Can you can you see it in the fluoroscopy? Not really. Right. In the can I see the the it's the new is difficult to see in the fluoroscopy right there. Yeah. It's seen on fluoroscopy. But you can palpate it. You go with the needle as deep as plusion and aspirate all the time. In one moment you will suck the the water, and then you remove, and as far as you suck the air, such big as the pleator.
And what's the worst that has ever happened to you? What what is the worst complication that you have ever faced in real life? The worst complication, mean after in PMA after thoricoscopy, can be a severe complication, but nothing nothing so dramatically as severe bleeding or or whatever. But uh I think that in PMI if happens alpha tooscopy is is is a big complication. So we uh so we are very careful about preparing uh cleaning disinfection. Sterility sterility. Yeah. Sterility is the most important here. Yes.
How much is is uh better do the code during thoracoscopy or with the tube? How how better is thoracoscopy? Better works. Thoracoscopy then chest tube versus more is the same. Yeah. Tal versus that one. It's a dark slurry. Okay. Dark rush. It's almost small difference. It is difference, but it's not the big one. Okay. Yeah. Thank you. I've got one more question.
How do you go about uh patients when they come to you with already chest tube in and no diagnosis? Do you go through the same port? Do you cut the tube and you go? So how you you go separately from different side? We disconnect the chest tube. So on the theater now on the on the table. So you disconnect disconnect to introduce the pneumorax. First for the chest tube we leave some air inside, then disconnect the chest tube and we enter different side because the first one is already contaminated. Yeah. So we have to go to for the different clean side. Okay. I'm sure. And then when we insert another chest tube, the another chest tube goes through clean side, not from Yeah. Definitely. So you just keep it open to get air in, then take it out, then go space above or anterior or posterior a little bit. Right. And we close the first opening from the chest tube, but then we go to the second point. Sure. New side. And we leave the new chest tube in the new side. Sure. Sure. Thank you very much. These are questions always running in our mind.