Ultrasound-guided medical thoracoscopy in the absence of pleural effusion

Medical thoracoscopy (MT) is a diagnostic and therapeutic procedure that permits the study of the pleural space. The presence of pleural adhesions is the most important contraindication to performing MT. Lesions of the pleura in absence of pleural effusion are usually studied in video-assisted thoracoscopic surgery (VATS) with preoperative ultrasound evaluation. No data are available about ultrasound-guided MT in the absence of pleural effusion.

From January 2007 to June 2013, 622 consecutive MTs were performed under ultrasound guidance without inducing a pneumothorax. A retrospective cohort of 29 patients affected by pleural diseases without fluid was reviewed. The fifth or sixth intercostal spaces along the midaxillary line with a good echographic "sliding sign" and normal appearance of the pleural line were chosen as the entry site. The pleural cavity was explored, and biopsies were performed.

The mean age of the patient cohort was 62.8 years; there were 20 male patients and nine female patients. Pleural adherences were avoided, and adequate number of pleural biopsies were performed. No parenchymal lung injuries, bleeding, or hematoma occurred. Seventeen patients had a completely free pleural cavity, four patients had a single pleural adhesion, and eight had multiple pleural adhesions; in all cases, however, endoscopic exploration was possible and biopsy specimens were adequate. The most frequent histopathologic diagnosis was malignant pleural mesothelioma.

We have shown that thoracic ultrasound accurately identifies intrathoracic adhesions and, in experienced hands, can guide MT access, replacing the VATS approach, even in the complete absence of pleural effusion.