seminar_thoracoscopy

seminar_thoracoscopy - DM SEMINAR FEBRUARY 04, 2005 T H O R...

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DM SEMINAR FEBRUARY 04, 2005 THORACOSCOPY (MEDICAL AND VIDEO ASSISTED SURGICAL) NAVNEET SINGH DEPARTMENT OF PULMONARY MEDICINE
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HEADINGS •INTRODUCTION • MEDICAL THORACOSCOPY VS VATS • INDICATIONS • CONTRA-INDICATIONS •COMPLICATIONS •PROCEDURE OVERVIEW •FUTURE DIRECTIONS
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INTRODUCTION •First introduced by Jacobaeus (internist, 1910, Stockholm) as diagnostic procedure in two cases of exudative (tuberculous) pleuritis •Accu m ulated experience ofthoracoscopy with: –Malignant P E (differentiate between 1 ° & 2 ° tu m o urs of chest wall, pleura, lung & m e diastinu m) –Tubercular PE –Rheumatic and nonspecific parapneumonic effusions –E mpyemas (esp nontubercular) –Pneumothorax (visualizing defect in idiopathic spont
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INTRODUCTION • Subsequent 4 decades Æ Thoracoscopy used worldwide almost exclusively for lysi sof pl adhesions by thoracocautery ("Jacobaeus‘ Operation") –facilitate pneu m o thorax as Rx of TB •I n itiation of use for evalu ation of pl-pul diseases Europe Æ MT came under scope of respiratory physicians •C o n c u r r e n t use of ST (VATS) by thoracic surgeons
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MT vs VATS OT Suite/R oom Procedure Site Multiple ( 3) Single-Double Ports of entry Disposable Non-disposable Instrum ents ++ + Cost + S afety + Invasiveness Yes (Double lum e n) No Intubation GA LA/ Sedation Anaesthesia Rx D x of Pl disease Main Indications VATS MT
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TREATMENT DIAGNOSIS Medical Thoracoscopy VATS
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WHEN TO DO?
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INDICATIONS Pleural Effusion of Unknown Etiology • >20–25% of PE remain undiagnosed even after extensive diagnostic work-up of PF •Dxbycytologi cexamination Æ M etastatic pleural involve m e nt (60 to 80%) •Dxby closed needle Bx 45% (neoplastic inv) •I f facilities exist, MT should be perform ed (high sensitivity for malignancy and TB) Æ 4 % re m ain undiagnosed or truly idiopathic
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INDICATIONS Pleural Effusion of Unknown Etiology •Initial Evaluation of PE nondiagnostic (esp if suspicion of neoplastic disease) Æ MT: –Exploration + parietal pleural Bx Æ Dx in 90–100% – Staging – Complete fluid removal Æ Re-expansion potential • VATS M T (m ore invasive & expensive, results similar) –reserved for cases where MT difficult or impossible e.g. severe pleuropulmonary adhesions (repeated therapeutic thoracenteses)
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INDICATIONS Tubercular Pleural Effusion •Dxby closed needle Bx 70% (30–90 %) •Use of MT: –Visualization of grayish- w hite granulo m a (parietal & diaphrag matic pl esp costovertebral gutter) –Multiple biopsies from selected sites ( Æ HP Dx in 94-98%) –TB cultures more frequently positive (esp when fibrin production is significant) • D x by M T + C ulture + H P E Æ 100% (> Closed needle Bx + Culture of PE)
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INDICATIONS Tubercular Pleural Effusion •Areas with low prevalence of TB, MT should be done when needle Bx are –ve •Areas with high prevalence, MT not usually reqd forDx since m ost cases Dx by needle Bx(HPE + AFB stain & C/S from each of 3 specimens). If Cytology & closed needle Bx both –ve, probability ofDx by MT 5-6%
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INDICATIONS Tubercular Pleural Effusion •Ind ica
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seminar_thoracoscopy - DM SEMINAR FEBRUARY 04, 2005 T H O R...

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