T h o r a c o s c o p y : A Real-Life Perspective

Frank C. Detterbeck, MD
KEYWORDS
 Video-assisted thoracic surgery  Thoracoscopy  Pleuroscopy

KEY POINTS
 It is clear that some pleural conditions are more straightforward and lend themselves more easily to being managed by practitioners with a variety of backgrounds, if they have the interest and acquire the necessary skills.  Management of more complex pleural infections requires more experience and judgment.  How care is delivered depends on many different factors in a particular institution, and there is no simple answer that fits all situations. The value of a dedicated interest in organizing the care process and proactively working to make it better is crucial.  Exceptional care requires a team that works together seamlessly.

INTRODUCTION
Thoracoscopy, commonly known as videoassisted thoracic surgery (VATS), refers to the use of a camera and optics to visualize the inside of the chest and carry out diagnostic and therapeutic thoracic procedures. There is some variation in what this means beside the use of a video camera. Some have referred to procedures performed only with video camera and visualization on a monitor as a complete VATS. Some have used the term VATS-assisted for procedures in which the camera is used as an adjunct, with at least part of the surgical procedure being performed with direct visualization of intrathoracic structures through a small (limited thoracotomy) incision.1 However, there is consensus that the term thoracoscopy should be applied to procedures performed through a small incision, without any rib spreading, with essentially all of the procedure being performed with visualization via a monitor.2,3 For all practical purposes, thoracoscopy began to be implemented in the late 1980s, although its roots can be traced back many decades earlier. In the early 1990s, thoracoscopy had evolved to be used for major procedures such as lobectomy.4 However, although it had become standard to

Disclosures: None. Department of Thoracic Surgery, Yale University School of Medicine, 330 Cedar Street, BB205, New Haven, CT 06520-8062, USA E-mail address: [email protected] Clin Chest Med 34 (2013) 9398 http://dx.doi.org/10.1016/j.ccm.2012.12.002 0272-5231/13/$ see front matter 2013 Elsevier Inc. All rights reserved.

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perform minor procedures via thoracoscopy, for a variety of reasons, major thoracoscopic resections were performed infrequently until about a decade later. This situation was partly because of resistance to change and the learning curve, especially among older practitioners, and partly because there was a lack of significant outcomes data for resection of lung cancer via VATS until around 2000. However, since then, there have been many studies, enough to summarize in systematic reviews and meta-analyses.59 These studies have all shown that compared with open thoracotomy, VATS has a lower rate of morbidity and mortality and shorter hospital lengths of stay. Furthermore, for lung cancer, long-term outcomes have been equivalent.58,10 This benefit comes at a minor cost of about 20 minutes longer operative times for anatomic lung resection (eg, lobectomy) by VATS. Most of these data come from nonrandomized comparative studies, but are corroborated by randomized studies, case-matched analyses, and large database outcomes studies.1115 VATS lobectomy is becoming the standard of care for early-stage lung cancer, according to the third edition of the American College of Chest Physicians Lung Cancer Guidelines. Although only

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about 25% of lobectomies in the United States are performed via VATS, in the centers that perform VATS, most major lung resections are performed this way.10,16 The VATS approach has been extended to procedures such as segmentectomy, pneumonectomy, sleeve resections, lobectomy with en-bloc chest wall resection, and even extrapleural pneumonectomy for mesothelioma.6,1720 The focus of this issue of Clinics in Chest Medicine is pleural disease, and therefore the rest of this article is restricted to thoracoscopy for pleural procedures, both diagnostic and therapeutic. For a well-referenced article on medical thoracoscopy (pleuroscopy) in the management of pleural disease, please see that by Pyng and Colt elsewhere in this issue. The present article examines whether there is a real difference between pleuroscopy and thoracoscopy or VATS and how thinking should be structured regarding management of pleural disease in the modern context of available approaches and interventions. involved with. This discussion should go beyond medical versus surgical training roots and include many other aspects, such as whether the individual has a focus on thoracic versus general or cardiac surgery, has a focus on pleural procedures, and has experience with the increasing number of technologies available for pleural interventions. Sometimes thoracoscopy and pleuroscopy are differentiated by whether the procedure is performed under general anesthesia or local anesthesia and conscious sedation, or whether it is performed in an operating room or a procedure suite. This distinction may be useful in separating complex procedures from simple procedures, but even this is probably mostly a reflection on traditional mind-set. For example, even thoracoscopic lobectomy is being performed under local anesthesia regularly at some centers,2123 and most interventional pulmonologists who are focused on this specialty are comfortable in the operating room environment and in performing procedures under anesthesia. Therefore, the distinction of the anesthetic technique and facility setting is not likely reflective of an inherent difference as much as it is of habit and tradition, and thus is not a good basis for making a distinction. Pleuroscopy is sometimes defined as being limited to the pleura itself, whereas procedures that involve the lung are considered to be thoracoscopic. However, this distinction is also gray, considering that malignant pleural effusions and empyema often extensively involve the visceral pleura. Another distinction has been that pleuroscopy should refer to procedures in patients who do not have pleural adhesions. However, it is often difficult to reliably predict this finding before the procedure. Furthermore, what degree of adhesions is sufficient to push a procedure over the line from pleuroscopy to thoracoscopy? These considerations make it clear that both procedures examine the inside of the chest, but that existing definitions do not define clear distinctions between pleuroscopy and thoracoscopy.

IS THERE A DIFFERENCE BETWEEN PLEUROSCOPY AND THORACOSCOPY?

From a semantic perspective, pleuroscopy refers to visualization of the pleural space and pleural surfaces, whereas thoracoscopy is more generic, referring to visualization of essentially anything in the chest. However, because this article is restricted to thoracoscopy for pleural procedures, it is unclear whether in this context, there is a difference semantically. Probably the most common distinction between the 2 refers to the background of the person performing the procedure. Thoracoscopy is used primarily when the intervention is performed by someone who has had formal surgical training, whereas (medical) pleuroscopy is used when performed by someone with primary internal medicine training. However, given the need for additional training among those with a major focus on interventional thoracic procedures, and the evolution of a more disease-based and organ-based multispecialty team approach to care, the future appropriateness of traditional divisions in medicine and training is highly questionable. If the distinction is a matter of who performs the procedure, a more transparent and straightforward description is provided by terms such as thoracoscopy performed by a thoracic surgeon or thoracoscopy performed by an interventional pulmonologist. However, the background of the person performing the procedure is probably important in determining the extent and complexity of pleural interventions with which they are comfortable or that they should be apprehensive about getting

FRAMING THE DISCUSSION

Those who are able to successfully complete medical school are also able to learn to function in any area of medicine. It is not a question of whether people have the ability to master a skill, but rather a question of what constitutes their training and scope of practice. Given differences in how training is structured in different parts of the world, it is also clear that there are many ways to become adequately skilled in a particular field. As medical care shifts to more of a multidisciplinary

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team approach within focused areas, boundaries between skills needed by different team members become less distinct. For example, cardiac anesthesiologists become adept at performing transesophageal echocardiograms and use it to assess valve function, contractility, and regional wall motion changes. In many parts of the world, pulmonologists focused on lung cancer administer chemotherapy. Boundaries are generally artificial and of our own making; it is less a matter of what could be done as it is a matter of what should be done in a particular environment. It is crucial to recognize the importance of the setting when discussing thoracic interventional procedures. The fact that a physician working in Africa might become particularly experienced in pleural interventions to deal with tuberculous empyemas does not necessarily imply that every physician of the same specialty in another part of the world should be the person to perform this procedure. Although it is feasible to learn this procedure, as described earlier, does it make sense for the practitioner to assume the role in a different practice environment? The setting has a large impact on which is the best way to structure particular aspects of a patients care, and includes such aspects as the size of the institution, the depth and breadth of the multidisciplinary team, and specific local needs and challenges. An approach to the topic of invasive pleural procedures is to consider the nature of the procedure, potential risks, and ways of managing complications caused by the procedure. This approach can be used to build a framework to assess which skills and structural components should be available to those who undertake these procedures. This is a more practical approach, which allows processes for disease management to evolve without being constrained by history, preconceived attitudes, or artificial boundaries. We must free ourselves from emotional reactions, and from assessments based on personal financial, egotistical, or professional incentives or disincentives, because these are less likely to result in approaches that stand the test of time. We should not be driven by what has been done in the past, by what can be done sometimes, or by what one can often get away with. We must learn to identify relevant inherent characteristics of the patients, diseases, and interventions, and recognize the available skills, resources, and limitations that exist in that particular institutional setting. We must use end points related to patient outcomes as the basis for constructing optimal systems of care. Although this approach is subject to challenges from people with particular viewpoints, it is more likely to persevere because the basis of the disease management is more fundamentally correct. The route taken, including type of subspecialty training, location of procedure, and type of anesthesia, matters less when the measurement is patient-centered procedural outcomes. Of course, ongoing evaluation of results achieved is necessary.

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CATEGORIES OF PLEURAL PROCEDURES

Issues to consider with respect to pleural procedures include the technical difficulty of the procedure itself. Perhaps more important is the risk of either serious short-term complications (eg, major bleeding) or complications with significant longterm implications (eg, loss of function of part of the lung or diaphragm or development of a chronically infected space). The nature of potential complications is important: a complication that requires immediate attention (eg, bleeding) or expertise to avoid long-term problems necessitates a different level of backup and planning than a complication that evolves more slowly, allowing time to organize further input or even transfer of the patient to another level of care if needed. Perhaps the most difficult issue is the ability to identify cases that are potentially more challenging or risky from those that are straightforward before beginning the procedure. Associated conditions or previous history can play a major role, but some things remain more difficult to predict. A list of pleural procedures and a qualitative assessment of important considerations are provided in Table 1. These procedures include some that do not typically fall under the realm of thoracoscopy, but are germane to the discussion of potential problems. A place to start the discussion is with diagnostic pleural procedures. There is little potential for acute or long-term complications when obtaining pleural biopsies in a patient with relatively normal pleura and an enigmatic effusion. Pleural nodules are still straightforward, but if there is the possibility of mesothelioma, the biopsy site should be located in a way to facilitate excision of the biopsy site (ie, along a thoracotomy incision) if curative intent resection might be considered. Such considerations are easy to learn, but familiarity with definitive management of mesothelioma may not be standard knowledge, even for thoracic surgeons. Management of a noninfected effusion is also associated with little risk of potential acute or long-term complications, although the presence of adhesions and underlying lung disease may significantly complicate the management by adding an ongoing air leak to the initial problem of an effusion. Most often, pneumothorax is managed

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Table 1 Categorization of pleural procedures Risk of Unanticipated More Complex Situation Very low Low Moderate High Very low Very low Very low Very low Moderate Low Moderate Moderate Moderate High High Low Low Low Moderate Moderate High Potential for Major Complications Potential Complicating Factors Previous procedures Adhesions Adhesions Comorbidities Previous Previous Previous Previous Previous procedures procedures procedures procedures procedures Acute Very low Low Low High Very low Very low Very low Very low Low Very low Very low Low Moderate Moderate Moderate Very low Very low Very low Very low Low Low Chronic Very low Low Moderate High Very low Very low Low Very low Low Very low Very low Low Low High High Very low Very low Very low Low High High Overall Categorya CS SF CBC WWIT CS CS CS CS SF CS SF CBC CBC WWIT WWIT CS CS SF SF WWIT WWIT

Procedure Diagnostic Biopsy of normal pleura (undiagnosed effusion, no nodules) Biopsy of pleural nodules/masses on chest CT Biopsy/pleurodesis of mesothelioma Decortication/pleurectomy of mesothelioma Therapeutic for Effusion (not Infected) Drainage of fluid Insertion of tunneled pleural catheter Talc poudrage (pleurodesis) Insertion of tunneled pleural catheter under direct vision Lysis of adhesions/destruction of loculations, pleurodesis Therapeutic for Effusion (Infected) Drainage of simple empyema (thoracentesis, tube, TPA) Drainage of complex empyema (lysis of adhesions/loculations) Decortication,b loosely adherent Decortication,b densely adherent, via thoracotomy Drainage of lung abscess and decortication Management of chronic empyema cavity Therapeutic for Pneumothorax Evacuation of pneumothorax Evacuation of pneumothorax and pleurodesis Resection of blebs and pleurodesis Lysis of adhesions/destruction of loculations, pleurodesis Plication of major bullae Treatment of chronic pleural fistula

Usual Technical Difficulty Very low Very low Moderate High Very low Very low Very low Low Low Very low Low Moderate Moderate High High Very low Very low Low Low Moderate High

Adhesions TB, lung disease Comorbidities Lung disease TB, lung disease TB, lung disease COPD, previous events COPD, previous events COPD, previous events COPD, previous events COPD, previous events COPD, ILD, and so forth

Abbreviations: COPD, chronic obstructive pulmonary disease; CT, computed tomography; ILD, interstitial lung disease; TB, tuberculosis; TPA, tissue plasminogen activator. a Overall categories: CS, chip shot; SF, straightforward; CBC, could be challenging; WWIT, what was I thinking?. b Stripping visceral pleural fibrin layer.

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by surgeons, perhaps because the lung parenchyma is clearly involved. However, unless there is severe underlying lung disease, the management is straightforward. Management of an infected pleural space is more difficult. There are certainly many patients for whom a simple thoracentesis or drainage resolves the problem. For other patients, decortication may be needed. This procedure carries more potential risks of serious bleeding from the pulmonary artery in the fissure, or incomplete reexpansion of the lung, with the risk of a chronically infected pleural cavity (and open window or muscle flap transposition). The problem with management once simple drainage has not worked is that it has proved difficult to reliably predict preoperatively how involved a decortication procedure is going to be. Thus, it is easy to argue that decortication should be reserved for the hands of surgeons with extensive thoracic experience. involvement of an interventional pulmonologist versus a thoracic surgeon. Most pleural procedures carried out by surgeons are performed by VATS in essentially every institution with any degree of thoracic surgical specialization. Decades ago, there may have been a significant difference between a thoracotomy and nonsurgical approaches; however, to argue that there is a difference in invasiveness between a surgical thoracoscopy and a medical pleuroscopy for the same patients clinical problem borders on being ridiculous. An important aspect of what a patient experiences is the system of care that exists to deliver it. This situation affects the efficiency, the extent to which outcomes and processes are critically assessed, and whether opportunities for improvement are identified. It may be better to enhance a system that is already in place and working well than to try to develop a new system when considering how to integrate pleuroscopy into the approach to pleural disease. The value of an existing system and how much effort it takes to create a new, wellfunctioning one should not be underestimated. A critical aspect of care delivery is having a champion who is interested and takes ownership of making sure that the system of care works well. Pleural diseases are not the most glamorous, and often patients are managed because it is necessary but with little interest in the diseases or the overall process of care delivery. This situation is probably more true of most thoracic surgeons than interventional pulmonologists. Whatever the local situation, the value of a champion cannot be overemphasized.

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ASSESSING THE PROCESS OF PROVIDING CARE FOR PLEURAL CONDITIONS

By which measures should the level of service provided with respect to pleural procedures be judged? Obvious measures are the rate of achieving resolution of the problem at hand, and the ability to achieve this with a low rate of complications. It is easier to measure this rate with respect to pleural diagnostic procedures or pneumothorax. Because of the varying degrees of complexity of the disease process, this process is more difficult in the case of pleural effusions, particularly when associated with infection. Was the process worse to begin with and therefore required further interventions, or did poor quality of the initial procedure (or judgment) lead to additional procedures that could have been avoided? Less obvious measures of how well pleural issues are managed are how burdensome the management is for the patient, and also for the institution and practitioners. The burden of care is a combination of how long it takes until resolution, the number of days in the hospital, the amount of pain and anxiety of the patient, and other factors. A comprehensive way to assess this situation is needed; looking at 1 aspect does not give the whole picture. It may be less burdensome to undergo an early thoracoscopic drainage and partial decortication with rapid resolution than to spend days undergoing less invasive attempts (eg, chest tube, instillation of intrapleural lytics), which may have a diminished chance of success. On the other hand, this strategy is not always necessary. The level of invasiveness is important, but of limited value in discussing the relative merits of

DRAWING CONCLUSIONS
How do we deliver the best care for patients with pleural conditions? How does this discussion help us integrate thoracoscopy, pleuroscopy, and other pleural procedures into an efficient, high-quality, programmatic approach? It is clear that some pleural conditions are more straightforward and lend themselves more easily to being managed by practitioners with a variety of backgrounds, if they have the interest and acquire the necessary skills. Others, such as management of more complex pleural infections, require more experience and judgment. It is also clear that how care is delivered depends on many different factors in a particular institution, and there is no simple answer that fits all situations. It depends on local availability of expertise from various individuals, constraints on peoples time, and the ability to deliver care in various settings (ie, the operating room vs procedure suite; the use of general anesthesia vs

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conscious sedation). The value of a dedicated interest in organizing the care process and proactively working to make it better is crucial. It is also clear that exceptional care requires a team that works together seamlessly. No matter how focused, experienced or knowledgeable any individual is, there are always limits. As medical knowledge progresses, and there is an ever greater amount of literature and skills to be mastered, we must transform from individual practitioners delivering care to care delivered by individuals who function collaboratively within a team. This approach allows collective knowledge, judgment, and skills to be applied to the problem at hand. It does not benefit us to argue about semantics, backgrounds of a practitioner, or how access to the pleural space is attained. Time is better spent reviewing results of the pleural procedure to ensure that the process of care delivery optimizes the results for the patient and the care system. As we provide thoracoscopic care in 2013 and beyond, it behooves us to define that care more in terms of appropriate access to the pleural space, with the anticipated results and minimal complications, than to maintain useless definitions based on who performed the procedure and where.
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