Diagnostic and therapeutic thoracoscopy: techniques and indications in pulmonary medicine

Recently thoracoscopy has been used with increasing frequency for the diagnosis and treatment of pleuropulmonary diseases.

The main requirements for thoracoscopy are rigid telescopes, forceps, scissors, stapler and a video recorder. The procedure can be performed either under general anaesthesia with or without double lumen intubation or under neuroleptanalgesia after inducing an artificial pneumothorax. At the end of the procedure a chest tube should always be inserted even if it is only for a few minutes until the lung re-expands after diagnostic thoracoscopy. Complications are exceptional and mortality is less than 0.017%.

Thoracoscopy is useful for diagnosis of a number of lung diseases. For pleural effusion, the sensitivity of thoracoscopy is 92-97% and its specificity is 99%. This is much better than needle pleural biopsy and/or fluid cytology. In malignant mesothelioma, thoracoscopy allows accurate staging. Similarly in spontaneous pneumothorax, classification based on the endoscopic aspects of the lung according to the classification of Vanderschueren allows a better selection of therapeutic alternatives. For diffuse pulmonary diseases, thoracoscopic lung biopsy has a sensitivity ranging from 60-98% depending on whether the underlying disease is sarcoidosis, idiopathic fibrosis, collagenous diseases or other rare diseases. Interventional thoracoscopy is a rapidly expanding domain. In this review the most widespread techniques are summarized. Thoracoscopic pleurodesis is performed for pleural effusion. It can be achieved by talc poudrage but other methods are available. For spontaneous pneumothorax, pleurodesis must be associated with treatment of the causal lesions. The other therapeutic procedures described here are sympathectomy for palmar hyperhidrosis, pulmonary biopsy using an endo-GIA stapler and pericardial biopsy.