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Thoracoscopy with the fiberoptic bronchoscope
Thoracoscopy with the fiberoptic bronchoscope A simple method in diagnosing pleuropulmonary diseases II! this report, we shall describe our use of the flexible jiberoptic bronchoscope in thoracoscopy. This device is superior to the earlier type of thoracoscope because it is not rigid. The high yield of accurate diagnoses, ease of application, and minimal discomfort to the patient make this technique preferable to other non thoracotomy forms of diagnosis. With further refinement, the flexible jiberoptic bronchoscope may limit the need for formal thoracotomy in the diagnosis of pulmonary disease.
Aref Senno, M.D., Sha Moallem, M.D., Eligio R. Quijano, M.D., Adebayo Adeyemo, M.D., and Roy H. Clauss, M.D., New York, N. Y.
The
flexible fiberoptic bronchoscope has extended diagnostic capabilities in pulmonary diseases. Direct visualization of lesions, sampling secretions, biopsy, and photography are now possible in areas inaccessible to the conventional rigid bronchoscope. The flexibility of this scope, the remote control of its tip, and the possibility to biopsy lesions by aspiration, brush, punch, or bite techniques encourages its use in thoracoscopy as well as in tracheobronchial examination. This preliminary study into a method virtually abandoned describes the new method of thoracoscopy with the fiberoptic bronchoscope and discusses the high diagnostic yield from this simple procedure. Indications
Careful study of posteroanterior, lateral, and oblique chest x-ray films usually differentiates intrapulmonary from pleural From the Department of Surgery of New York Medical College, Metropolitan Hospital Center, and Flower Fifth Avenue Hospital, 1249 Fifth Ave., New York, N. Y. 10029. Received for publication Sept. 7, 1973.
606
densities. Indications for thoracocentesis or needle biopsy of pleura or lung now may warrant consideration of incidental fiberoptic thoracoscopy. Pleuropulmonary densities or effusions in patients with known primary tumors appear to present the greatest opportunity for earliest diagnosis by systematic visualization and selective biopsy of the processes. The appearances of evolving infarcts and post-traumatic events may be determined. Newer interpretations and earlier therapeutic implications are found for problems with postsurgical space through the possibility of visualizing trouble spots. Methods
Thoracoscopy usually is accomplished without fluoroscopy. The patient is given slight sedation (Valium or Demerol). Local and intercostal anesthesia (0.5 to 2 per cent lidocaine) is administered, and a small stab incision is made in the midline or posterior axillary line at the level of the fifth or sixth intercostal space. A chest tube (Nos. 32 to 36 Fr.) with trochar is usually used, but in case the intercostal space is narrowed,
Volume 67 Number 4
Thoracoscopy with fiberoptic bronchoscope
607
April, 1974
Fig. 1. A, Flexible fiberoptic bronchoscope beside a full-length Argyle chest tube, which is attached to a j-shaped Pharmaseal connector. The tube is cut as indicated. B, Airtight fit of the flexible fiberoptic scope (used as a thoracoscope) and the Pharmaseal connector is achieved by preselecting the length of chest tube (right) and impaling the scope (left) or affixing the latex drain or diaphragm with the aperture to the scope.
a cylindrical metal cannula with side-arm may be introduced; the outer diameter of a metal cannula is smaller while the inner diameter is adequate for the diameter of the scope. If pleural fluid is present, it is removed and specimens are sent for the indicated infectious and cytologic examinations. After the chest tube has been directed to the location and distance desired, the unused length is cut off near the chest wall, and this end of the tube is fitted to a T-shaped connector (Pharmaseal) (Fig. 1). One limb of this connector is attached to underwater seal, occasionally to an Emerson pump, to control the amount of pneumothorax desired or needed. A rubber dia-
phragm with a 5 mm. orifice or a segment of half inch rubber drain is fixed over the end of the other straight limb of the T connector. The fiberoptic bronchoscope is inserted into this aperture in the connector, through the chest tube, into the pleural space. Visceral and parietal pleural surfaces then are inspected systematically. Biopsies are taken from lesions or abnormal-appearing sites, often from different areas of the pleura or lung surface. Case reports Pleural metastases. A 50-year-old woman was admitted to Metropolitan Hospital Center with the diagnosis hemothorax on the right side. Thirteen years earlier a right radical mastectomy
The Journol of
608
Senno et at.
Tho ra cic on d Cardiovascular Surgery
Fig. 2. Posteroanterior (A) and lateral (B ) chest x-ray films showing hydropneumothorax immediately prior to thoracoscopy and biopsy of visceral and parietal pleural metastases with the fiberoptic scope.
Fig. 3. Chest x-ray film of a patient with primary lung tumor visible at fiberoptic thoracoscopy. Thoracoscopic biopsy showed epidermoid carcinoma. had been performed for adenocarcinoma of the breast, and 4 years before the present admiss ion an ovari an papillary scirrhous carcinoma had been controlled by total abdominal hysterectom y with salpingo-oophorectomy. The patient was well until shortly before this adm ission. A chest tube was inserted via the right sixth intercostal space, 2,000 c.c, of serosanguineous fluid was removed,
and the fiberoptic bronchoscope was introduced through the chest tube . Three biopsies, two from suspicious lesions of the surface of the lung and one from the parietal pleura, revealed met astatic adenocarcinoma (Fig . 2). Primary tumor of lung. A 57-year-old woman was admitted three times in two years to the Metropolitan Ho spit al Center with hemoptysis and a mass lesion in the right upper lung field (Fig . 3). Temporal lobe epileps y, peptic ulcer, hydronephrosis, atherosclerosis, and cardiomyopathy had been considered contraindications to exploratory thoracotomy. Sputum cytology, broncho scopy , bronchotracheal washings, and aspiration biopsy failed to give a diagnosis of tumor. Since we reasoned that brief and limited pneumothorax would be tolerated, a chest tube was inserted via the sixth intercostal space at the midaxillary line , its tip directed to the tumor area , and the fiberoptic "thoracoscope" was introduced. Neoplasm was seen or iginating in the lung with local exten sion. Biopsies from the tumor and areas adj acent to it disclo sed ep idermoid carcinoma. Primary pleural tumor. A 54-year-old man was admitted to the hospital complaining only of shortness of breath. Physic al and x-ray examinations were consistent with pleural effusion on the righ t. The remainder of the physical examination and the laboratory findings, including sputum stud ies, intravenous pyelography, barium enema , upper gastrointestinal series, and bronchoscopy, were within normal limits. Thoracocentesis permitted removal of 2,300
Volume 67
Thoracoscopy with fiberopt ic bronchoscope
Number 4
609
April ,1974
CD Fig. 4. Posteroanterior (A) and lateral (B) chest x-ray films of patient with mesothelioma of the pleura after thoracocentesis, thoracoscopy, and biopsy. ml. of cloudy, yellow fluid, again nondiagnostic by culture, cytologic smear, and block examinations. Repeat chest film (Fig. 4) showed expansion of the right lung with no evidence of parenchymal disease. Suction needle biopsy produced no pathological finding . Pleural fluid reaccumulated rapidl y necessitating insertion of a chest tube in the six intercostal space, right midaxillary line, through which thoracoscopy was performed . Discrete, flattened , fine nodul ar tumefaction over the surface of the lung was biopsied and showed mesothelioma. Trauma. A 34-year-old m an was admitted with a stab wound at the left of the xiphoid and a right hemopneumothorax. After initial removal and replacement of blood, bleeding continued at a rate of about 200 c.c. per hour. The fiberoptic scope, inserted through a seco nd che st tube , was directed to the anterior pericardiophren ic area. The site of knife entry, the amount and character of bleeding , the normal appe aring pericardium, and the absence of bleeding from the lung were evident.
Discussion This report describes the modified technique of thoracoscopy with the flexible fiberoptic bronchoscope. I The 5 mm. diameter of the fiberoptic scope perm its its insertion via a chest tube or metal cannula. The 130 degree flexion and 30 degree extension of its tip through 360 degrees rotation facilitates inspection of the pleurae and
the surface of the lung under bright illumination (Fig. 5). Thoracoscopy with the fiberoptic scope has major advantages over the usual nonthoracotomy techniques in the investigation of idiopathic and neoplastic pleural effusions and hence in the diagnosis of pulmonary diseas e. Thoracocentesis has yielded malignant cells in pleural fluid in 34 " and 54 per cent " of cases. Fleishman I examined pleural exudate for tubercle bacilli through culture and biologic methods in 76 cases of idiopathic pleural effusions and obtained positive results in only 3. Alth ough the nonthoracotomy techniques (pleural biopsy with various needles , trephin e lung biopsy, cutting needle , and bronchial brush biopsies ) have yielded accurate diagnoses in 72 to 94 per cent of instances, they have their own limitations and compli cati ons. Needle asp iration is most frequently used for diffuse pulmonary disease; it is surprising that pneumothorax is reported in only 28 per cent of the cases ." Cutting needle biopsy is restricted to periph eral lung masses extending to the pleura, but this techn ique may induce serious lung hemorrhages. " Trephine lung biopsy achie ves diagnosis in 85 per cent of cases but induces
The Journal of
6 10
Senno et al.
Thoroc ic and Cordiova scular Surgery
Fig. 6. Flexible fiberoptic scope inside a No . 32 Fr. che st tube , superimposed upon an x-ray film. The scope is at the sixth intercostal space in the midaxillary line, with its tip directed at a foreign body.
Fig. 5. Two views of tip of the fiberoptic scope protruding from the intrathoracic portion of the chest tube.
such compli cations as pneumothoraces requiring chest tubes (39 per cent) and minimal-to-severe hemoptysis (7 per cent) . 7 Fiberoptic bronchoscopy with brush biopsy is an excellent procedure for the diagnosi s of central and midJung lesions (80 per
cent), but in "peripheral lesions diagnostic accuracy is decreased due to difficulty in getting the brush on target. '" The ease in visualizing the pleurae and the surface of the lung and hence its lesions, the mobilit y and capability of the biopsy curette to scrape deep into selected tissue masses, and the possibility of taking more than one biopsy increased the diagnostic accuracy to approach 100 per cent. This technique makes it possible to locate and to biopsy even small metastatic lesions in cases in which all other currently used techniques have provided false-negative results. Lymph nodes, cysts, and discrete tumefactions around the pericardium, diaphragm, and mediastium may be visualized, thus preventing any need for diagnostic surgical intervention. In this way, the flexibility of the scope is a decided advantage over the old rigid thoracoscope" (Fig. 6). This promising concept is associated with minimal risk and discomfort to the pat ient. Anticipated further refinement of the instrument (e.g., addition of a flexible coagulation tip) might further limit formal thora-
Volume 67 Number 4
Thoracoscopy with fiberoptic bronchoscope
6I I
April, 1974
cotomy as a diagnostic method in many kinds of pulmonary, mediastinal, and pericardial conditions. REFERENCES Ikeda, S.: Flexible Bronchofiberscope, Ann. Otol. Rhinol. Laryngol. 79: 916, 1970. 2 Oswald, N. D., Hiscn, K. F. W., Canti, G., and Miller, A. B.: The Diagnosis of Primary Lung Cancer With Special Reference to Sputum Cytology, Thorax 26: 623, 1971. 3 Boddington, M. M., and Springs, A. I.: Cytological Diagnosis of Cancer: Its Uses and Limitations, Br. Med. J. 1: 1523, 1965. 4 Fleishman, S. J., Lichter, A. I., Buchanan, G., and Sichel, R. J. S.: Investigation of Idiopathic Pleural Effusions by Thoracoscopy, Thorax 11: 324, 1956.
5 Zavala, D. C.: The Diagnosis of Pulmonary Disease by Nonthoracotomy Techniques, Chest 64: 100, 1973. 6 Newhouse, M. T.: Suction Excision Biopsy for Diffuse Pulmonary Disease, Chest 63: 707, 1973. 7 Boylen, C. T., Johnson, M. R., Richters, V., and Balchum, O. J.: High Speed Trephine Lung Biopsy: Methods and Results, Chest 63: 59, 1973. 8 Zavala, D. C., Richardson, R. H., Mukerjee, P. K., Rossi, N. P., and Bedell, G. N.: Use of the Bronchofiberscope for Bronchial Brush Biopsy: Diagnostic Results and Comparison With Other Brushing Techniques, Chest 63: 889, 1973. 9 DeCamp, P. T., Moseley, P. W., Scott, M. 1.., and Hatch, H. B., Jr.: Diagnostic Thoracoscopy, Ann. Thorac. Surg. 16: 79, 1973.
Aref Senno, M.D., Sha Moallem, M.D., Eligio R. Quijano, M.D., Adebayo Adeyemo, M.D., and Roy H. Clauss, M.D., New York, N. Y.
The
flexible fiberoptic bronchoscope has extended diagnostic capabilities in pulmonary diseases. Direct visualization of lesions, sampling secretions, biopsy, and photography are now possible in areas inaccessible to the conventional rigid bronchoscope. The flexibility of this scope, the remote control of its tip, and the possibility to biopsy lesions by aspiration, brush, punch, or bite techniques encourages its use in thoracoscopy as well as in tracheobronchial examination. This preliminary study into a method virtually abandoned describes the new method of thoracoscopy with the fiberoptic bronchoscope and discusses the high diagnostic yield from this simple procedure. Indications
Careful study of posteroanterior, lateral, and oblique chest x-ray films usually differentiates intrapulmonary from pleural From the Department of Surgery of New York Medical College, Metropolitan Hospital Center, and Flower Fifth Avenue Hospital, 1249 Fifth Ave., New York, N. Y. 10029. Received for publication Sept. 7, 1973.
606
densities. Indications for thoracocentesis or needle biopsy of pleura or lung now may warrant consideration of incidental fiberoptic thoracoscopy. Pleuropulmonary densities or effusions in patients with known primary tumors appear to present the greatest opportunity for earliest diagnosis by systematic visualization and selective biopsy of the processes. The appearances of evolving infarcts and post-traumatic events may be determined. Newer interpretations and earlier therapeutic implications are found for problems with postsurgical space through the possibility of visualizing trouble spots. Methods
Thoracoscopy usually is accomplished without fluoroscopy. The patient is given slight sedation (Valium or Demerol). Local and intercostal anesthesia (0.5 to 2 per cent lidocaine) is administered, and a small stab incision is made in the midline or posterior axillary line at the level of the fifth or sixth intercostal space. A chest tube (Nos. 32 to 36 Fr.) with trochar is usually used, but in case the intercostal space is narrowed,
Volume 67 Number 4
Thoracoscopy with fiberoptic bronchoscope
607
April, 1974
Fig. 1. A, Flexible fiberoptic bronchoscope beside a full-length Argyle chest tube, which is attached to a j-shaped Pharmaseal connector. The tube is cut as indicated. B, Airtight fit of the flexible fiberoptic scope (used as a thoracoscope) and the Pharmaseal connector is achieved by preselecting the length of chest tube (right) and impaling the scope (left) or affixing the latex drain or diaphragm with the aperture to the scope.
a cylindrical metal cannula with side-arm may be introduced; the outer diameter of a metal cannula is smaller while the inner diameter is adequate for the diameter of the scope. If pleural fluid is present, it is removed and specimens are sent for the indicated infectious and cytologic examinations. After the chest tube has been directed to the location and distance desired, the unused length is cut off near the chest wall, and this end of the tube is fitted to a T-shaped connector (Pharmaseal) (Fig. 1). One limb of this connector is attached to underwater seal, occasionally to an Emerson pump, to control the amount of pneumothorax desired or needed. A rubber dia-
phragm with a 5 mm. orifice or a segment of half inch rubber drain is fixed over the end of the other straight limb of the T connector. The fiberoptic bronchoscope is inserted into this aperture in the connector, through the chest tube, into the pleural space. Visceral and parietal pleural surfaces then are inspected systematically. Biopsies are taken from lesions or abnormal-appearing sites, often from different areas of the pleura or lung surface. Case reports Pleural metastases. A 50-year-old woman was admitted to Metropolitan Hospital Center with the diagnosis hemothorax on the right side. Thirteen years earlier a right radical mastectomy
The Journol of
608
Senno et at.
Tho ra cic on d Cardiovascular Surgery
Fig. 2. Posteroanterior (A) and lateral (B ) chest x-ray films showing hydropneumothorax immediately prior to thoracoscopy and biopsy of visceral and parietal pleural metastases with the fiberoptic scope.
Fig. 3. Chest x-ray film of a patient with primary lung tumor visible at fiberoptic thoracoscopy. Thoracoscopic biopsy showed epidermoid carcinoma. had been performed for adenocarcinoma of the breast, and 4 years before the present admiss ion an ovari an papillary scirrhous carcinoma had been controlled by total abdominal hysterectom y with salpingo-oophorectomy. The patient was well until shortly before this adm ission. A chest tube was inserted via the right sixth intercostal space, 2,000 c.c, of serosanguineous fluid was removed,
and the fiberoptic bronchoscope was introduced through the chest tube . Three biopsies, two from suspicious lesions of the surface of the lung and one from the parietal pleura, revealed met astatic adenocarcinoma (Fig . 2). Primary tumor of lung. A 57-year-old woman was admitted three times in two years to the Metropolitan Ho spit al Center with hemoptysis and a mass lesion in the right upper lung field (Fig . 3). Temporal lobe epileps y, peptic ulcer, hydronephrosis, atherosclerosis, and cardiomyopathy had been considered contraindications to exploratory thoracotomy. Sputum cytology, broncho scopy , bronchotracheal washings, and aspiration biopsy failed to give a diagnosis of tumor. Since we reasoned that brief and limited pneumothorax would be tolerated, a chest tube was inserted via the sixth intercostal space at the midaxillary line , its tip directed to the tumor area , and the fiberoptic "thoracoscope" was introduced. Neoplasm was seen or iginating in the lung with local exten sion. Biopsies from the tumor and areas adj acent to it disclo sed ep idermoid carcinoma. Primary pleural tumor. A 54-year-old man was admitted to the hospital complaining only of shortness of breath. Physic al and x-ray examinations were consistent with pleural effusion on the righ t. The remainder of the physical examination and the laboratory findings, including sputum stud ies, intravenous pyelography, barium enema , upper gastrointestinal series, and bronchoscopy, were within normal limits. Thoracocentesis permitted removal of 2,300
Volume 67
Thoracoscopy with fiberopt ic bronchoscope
Number 4
609
April ,1974
CD Fig. 4. Posteroanterior (A) and lateral (B) chest x-ray films of patient with mesothelioma of the pleura after thoracocentesis, thoracoscopy, and biopsy. ml. of cloudy, yellow fluid, again nondiagnostic by culture, cytologic smear, and block examinations. Repeat chest film (Fig. 4) showed expansion of the right lung with no evidence of parenchymal disease. Suction needle biopsy produced no pathological finding . Pleural fluid reaccumulated rapidl y necessitating insertion of a chest tube in the six intercostal space, right midaxillary line, through which thoracoscopy was performed . Discrete, flattened , fine nodul ar tumefaction over the surface of the lung was biopsied and showed mesothelioma. Trauma. A 34-year-old m an was admitted with a stab wound at the left of the xiphoid and a right hemopneumothorax. After initial removal and replacement of blood, bleeding continued at a rate of about 200 c.c. per hour. The fiberoptic scope, inserted through a seco nd che st tube , was directed to the anterior pericardiophren ic area. The site of knife entry, the amount and character of bleeding , the normal appe aring pericardium, and the absence of bleeding from the lung were evident.
Discussion This report describes the modified technique of thoracoscopy with the flexible fiberoptic bronchoscope. I The 5 mm. diameter of the fiberoptic scope perm its its insertion via a chest tube or metal cannula. The 130 degree flexion and 30 degree extension of its tip through 360 degrees rotation facilitates inspection of the pleurae and
the surface of the lung under bright illumination (Fig. 5). Thoracoscopy with the fiberoptic scope has major advantages over the usual nonthoracotomy techniques in the investigation of idiopathic and neoplastic pleural effusions and hence in the diagnosis of pulmonary diseas e. Thoracocentesis has yielded malignant cells in pleural fluid in 34 " and 54 per cent " of cases. Fleishman I examined pleural exudate for tubercle bacilli through culture and biologic methods in 76 cases of idiopathic pleural effusions and obtained positive results in only 3. Alth ough the nonthoracotomy techniques (pleural biopsy with various needles , trephin e lung biopsy, cutting needle , and bronchial brush biopsies ) have yielded accurate diagnoses in 72 to 94 per cent of instances, they have their own limitations and compli cati ons. Needle asp iration is most frequently used for diffuse pulmonary disease; it is surprising that pneumothorax is reported in only 28 per cent of the cases ." Cutting needle biopsy is restricted to periph eral lung masses extending to the pleura, but this techn ique may induce serious lung hemorrhages. " Trephine lung biopsy achie ves diagnosis in 85 per cent of cases but induces
The Journal of
6 10
Senno et al.
Thoroc ic and Cordiova scular Surgery
Fig. 6. Flexible fiberoptic scope inside a No . 32 Fr. che st tube , superimposed upon an x-ray film. The scope is at the sixth intercostal space in the midaxillary line, with its tip directed at a foreign body.
Fig. 5. Two views of tip of the fiberoptic scope protruding from the intrathoracic portion of the chest tube.
such compli cations as pneumothoraces requiring chest tubes (39 per cent) and minimal-to-severe hemoptysis (7 per cent) . 7 Fiberoptic bronchoscopy with brush biopsy is an excellent procedure for the diagnosi s of central and midJung lesions (80 per
cent), but in "peripheral lesions diagnostic accuracy is decreased due to difficulty in getting the brush on target. '" The ease in visualizing the pleurae and the surface of the lung and hence its lesions, the mobilit y and capability of the biopsy curette to scrape deep into selected tissue masses, and the possibility of taking more than one biopsy increased the diagnostic accuracy to approach 100 per cent. This technique makes it possible to locate and to biopsy even small metastatic lesions in cases in which all other currently used techniques have provided false-negative results. Lymph nodes, cysts, and discrete tumefactions around the pericardium, diaphragm, and mediastium may be visualized, thus preventing any need for diagnostic surgical intervention. In this way, the flexibility of the scope is a decided advantage over the old rigid thoracoscope" (Fig. 6). This promising concept is associated with minimal risk and discomfort to the pat ient. Anticipated further refinement of the instrument (e.g., addition of a flexible coagulation tip) might further limit formal thora-
Volume 67 Number 4
Thoracoscopy with fiberoptic bronchoscope
6I I
April, 1974
cotomy as a diagnostic method in many kinds of pulmonary, mediastinal, and pericardial conditions. REFERENCES Ikeda, S.: Flexible Bronchofiberscope, Ann. Otol. Rhinol. Laryngol. 79: 916, 1970. 2 Oswald, N. D., Hiscn, K. F. W., Canti, G., and Miller, A. B.: The Diagnosis of Primary Lung Cancer With Special Reference to Sputum Cytology, Thorax 26: 623, 1971. 3 Boddington, M. M., and Springs, A. I.: Cytological Diagnosis of Cancer: Its Uses and Limitations, Br. Med. J. 1: 1523, 1965. 4 Fleishman, S. J., Lichter, A. I., Buchanan, G., and Sichel, R. J. S.: Investigation of Idiopathic Pleural Effusions by Thoracoscopy, Thorax 11: 324, 1956.
5 Zavala, D. C.: The Diagnosis of Pulmonary Disease by Nonthoracotomy Techniques, Chest 64: 100, 1973. 6 Newhouse, M. T.: Suction Excision Biopsy for Diffuse Pulmonary Disease, Chest 63: 707, 1973. 7 Boylen, C. T., Johnson, M. R., Richters, V., and Balchum, O. J.: High Speed Trephine Lung Biopsy: Methods and Results, Chest 63: 59, 1973. 8 Zavala, D. C., Richardson, R. H., Mukerjee, P. K., Rossi, N. P., and Bedell, G. N.: Use of the Bronchofiberscope for Bronchial Brush Biopsy: Diagnostic Results and Comparison With Other Brushing Techniques, Chest 63: 889, 1973. 9 DeCamp, P. T., Moseley, P. W., Scott, M. 1.., and Hatch, H. B., Jr.: Diagnostic Thoracoscopy, Ann. Thorac. Surg. 16: 79, 1973.