Thoracoscopy. A prospective study of safety and outcome

To assess a standard classification of adverse events and evaluate the safety and long-term outcome of thoracoscopy in patients with pleural disease.

Prospective nonrandomized cohort study.

The Pulmonary Special Procedures and Nd:YAG Laser Unit of the University of California San Diego Medical Center, San Diego.

Fifty consecutive patients undergoing thoracoscopy for diagnosis of pleural effusion or thickening, pleurodesis, or empyema drainage.

A list of major and minor adverse events that could be temporally related to thoracoscopy performed for diagnosis or treatment of pleural processes was established before beginning this prospective study. Procedures were performed using multiple point-of-entry techniques and either local or general anesthesia. Most procedures were performed in the operating room using double-lumen intubation. Patients were seen daily during hospitalization and at least 7, 30, and 90 days after thoracoscopy. Long-term follow-up data were obtained by telephone calls, clinical visits, or medical chart reviews or all of these, until 12 months after procedures.

Occurrence of major and minor adverse events possibly related to thoracoscopy was recorded prospectively. Demographic and clinical data, as well as efficacy and outcome after thoracoscopy, were also noted.

Fifty-two procedures were performed in 50 patients. Median age was 60 years (range, 18 to 88 years). Thoracoscopy provided a diagnosis in 93% of patients with pleural disease of unclear origin. Pleurodesis by thoracoscopic talc insufflation was successful in 95% of cases and in 91% of patients with malignant pleural effusions still available for evaluation and follow-up examination 3 months after pleurodesis. Thoracoscopic drainage of empyema was successful in six of seven patients and led to referral for open decortication in one. There were no procedure-related deaths or intraoperative accidents. Open-chest surgery intervention was never required. Only 1 major adverse event occurred: a patient with scleroderma and trapped lung had recurrent pleural effusion requiring chest tube drainage 1 week after hospital discharge. Minor adverse events, however, were noted in ten instances (19%). These included fever after talc pleurodesis, asymptomatic pneumothorax after chest tube removal, and minor would infection in a patient with empyema.

Using the proposed classification of major and minor adverse events, prospective evaluation demonstrated the safety, diagnostic utility, and long-term efficacy of thoracoscopy performed for diagnosis and management of pleural processes. Potential dangers, however, of thoracoscopy are acknowledged, and limitations of the procedure are addressed.