Medical Thoracoscopy/Pleuroscopy: A Porthole to the Pleural Cavity When Looking at the Pleura from the Outside Is Not Enough

Abstract

Medical thoracoscopy (MT) /pleuroscopy (P) is a minimally-invasive endoscopic procedure that has become an unavoidable tool for the management of pleural diseases. Offering direct access to the pleural cavity allows pulmonologists to perform diagnostic and therapeutic maneuvers at the same time with efficiency usually shortening the hospitalization duration. A distinction must be made between MT/P done by pulmonologists, which may be video-assisted, and surgical thoracoscopy or video-assisted thoracoscopy surgery (VATS). MT is usually performed by pulmonologists using a non-disposable rigid or semi-rigid telescope in the endoscopy suite under local anesthesia and with intravenous conscious sedation/analgesia or mild anesthesia with a patient in spontaneous breathing. Conversely, VATS usually requires general anesthesia and double-lumen tracheal intubation. MT/P is mainly indicated for diagnostic purposes (pleural effusions) and/or talc pleurodesis ( "poudrage" ) to prevent the recurrence of persistent pleural effusions or pneumothorax. In these cases, one can say that "when a chest tube is required it should take for an interventional pulmonologist a few additional minutes to introduce an endoscope via the same incision, to inspect the pleural cavity, to locate potential adhesions, to obtain pleural samples, to insufflate agent for pleural symphysis and to put the chest tube in adequate position." For these most common indications, MT/P performed by pulmonologists is safe. Prospective studies are nevertheless mandatory to define the place of MT/P, although usually feasible, for the management of pleural infections and pneumothorax. This comprehensive review describes the role of MT/P in assessing pleural diseases providing insights into procedural details, diagnostic performance, safety considerations, and clinical applications. In weighing the advantages and disadvantages of this procedure in comparison to alternative diagnostic and therapeutic modalities, this review aims to show the benefits of MT/P in different scenarios. Finally, a few thoughts about the future directions of this endoscopy procedure are proposed.