WHAT WE NEED FOR THORACOSCOPY - ERS-education · 2014. 11. 23. · Business plan A place to do. Dedicated Course on Thoracoscopy & Pleural Techniques. Marseille October 2013 ... •

Dedicated Course on Thoracoscopy & Pleural Techniques. Marseille

WHAT WE NEED FOR THORACOSCOPY

Marios Froudarakis, MD

Department of Pneumonology

University Hospital of Alexandroupolis

[email protected]

Medical SchoolDemocritus University

of Thrace

Dedicated Course on Thoracoscopy & Pleural Techniques. Marseille October 2013

What we need: easy!

� Lot of enthousiasm

� Some skills-training� Few money

� Business plan

� A place to do


Few money

� Few or more

� Support by friends

� Support by industry

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Equipment• Trocar 5, 7, 9, 11mm

• Optics

– Direct or oblique vision

– Diameter 2, 5, 7, 9mm

• Biopsy forceps connected to the optic

• Set pleurodesis

• Set drainage


Thoracoscopy: which tool?

� Rigid: “classic”

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� Semi-flexible: “modern”


Rigid the “classic” tool

� Advantages

– Large biopsies

– Adhesionlysis

– Parenchyma biopsies



� Limitations

– Need some experience

– Pain at the port of entry

– Troubles with the surgeons


Flex-Rigid: advantages-limitations

� Advantages

– Looks like bronchoscope

– Compatible with electrocauthery, laser Rx, NBI

– Interfaces well with existing processor (CV-160)

and light source (EVIS EXERA 160, EVIS 100,

140)

– Flexbility and therefore ability to investigate

“difficult” areas

� Limitations

– Small size of biopsies

– Adhesionlysis difficult




Flex-rigid

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Diagnostic accuracy of flex and flex-rigid in malignant PE

Series Patients (n)

Thoracoscopy (n) Accuracy (%) Benign (n) Non specific (n)

Gwin et al, 1975 (flexible) 9 9 4/4(100%) 4 1

Kerby et al 1975 (flexible) 16 16 8/11 (72.2%) 2 6

Davidson et al 1988 (flexible) 30 30 20/24 (83.3%) 6 4

Edmondstone 1990 (flexible) 28 28 13/20 (65%) 8 7

Robinson et al 1995 (flexible) 12 12 4/4 (100%) 1 7

Emad &Rezaian 1998 (flexible) 49 49 17/20 (85%) 15 17

Total flex 144 144 66/83 (79.5%) 36/144 (25%) 42/144 (29%)

McLean et al 1998 (flex-rigid) 24 24 13/16 (81%) 8 -

Ernst et al 2004 (flex-rigid) 36 14 4/14 (28.5%) - -

Lee et al 2007 (flex-rigid) 51 51 34/36 (94%) 13 2

Munavvar et al 2007 (flex-rigid) 54 54 32/37 (86.5%) 17 5

Wang et al, 2008 (flex-rigid) 27 27 19/21 (90.5%) 6 2

Total flex-rigid 192 192 102/124 (82.2%) 44/178 (24.7%) 9/132 (6.8%)

Froudarakis M, review


Diagnostic accuracy of rigid in malignant PE

Series Patients (n)

Thoracoscopy (n)

Accuracy (%) Benign

(n)

Non specific

(n)

De Camp et al 1973 126 121 47/50 (94%) 32 44

Canto et al 1977 208 172 129/137 (94%) 49 30

Weissberg et al 1980 127 127 69/70 (98.5%) 49 8

Boutin et al 1980 233 195 113/128 (88%) 32 38

Boutin et al 1981 215 215 131/150 (87%) 25 40

Enk & Viskum 1981 556 216 95/137 (69%) 78 1

Page et al 1989 121 107 90/91 (99%) 15 15

Wu et al 1989 152 152 71/74 (96%) 72 9

Hucker et al 1991 102 102 61/76 (80%) 5 21

Menzies et al 1991 102 104 42/44 (96%) 53 9

Ohri et al 1992 56 56 37/38 (97%) 11 7

Harris et al, 1995 182 182 93/98 (94.9%) 58 (31.8) 26 (14.2)

Colt 1995 50 28 12/12 (100%) 14 2

Hansen et al 1998 147 147 91/103 (88%) 11 33

Janssen et al 2004 709 709 318/349 (91%) 360 31

Ferrer et al 2005 93 93 50/56 (89%) 26 11

Simpson 2007 89 89 69/73/ (94.5%) 12 4

Fletcher et al 2007 50 50 40/42 (95%) 4 4

Medford et al 2009 125 117 60/63 (95.2%) 30 24

Total 3583 3120 1655/1811 (91.4%)

1811/3120 (58%)

976/3120 (31.3%) 415/3120 (8.3%)

Froudarakis M, review


Cost of instruments

� Rigid: 15-20,000 euros

– Total equipment

� Optics

� Trocarts

� Forceps

� Camera and processor

� Multi adaptor light source

� Flex-rigid: 20-50,000– Device 20,000

– Excera system +


“If you have more… buy both !”

(Like Paco says)

� Yet, “RIGID”– Larger biopsies

� Mesothelioma

� Molecular techniques

– Adhesionlysis

– Empyema treatment

– Lower costPorsche

Mahindra Reva


Thoracoscopy: How to get skillsERS Course on Medical Thoracoscopy, Marseille and Alexandroupolis


Get skills by studying with the experts





Philippe AstoulMarc Noppen

Yo Aeloni

Henri Colt



F. Rodriguez-Panadero (Paco)

JM TschoppGF Tassi

Yo Aeloni

� Fellowships

� Dedicated booksQuickTime™ and a

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Enthousiasm

� Good relation with

thoracic surgeons

� To convince the boss

� To convince

collegues of work

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Time from initial symptoms to thoracoscopic

diagnosis of pleural effusion

Year duration in months (mean ± SD)

� 2002 6.3 ± 2.6

� 2003 6.1 ± 4.2

� 2004 2.8 ± 2.5

� 2005 1.4 ± 0.9

0

1

2

3

4

5

6

7

8

9

2002 2003 2004 2005

Overall p=.0002

Data on file


After meet the basic conditions

� Nice assistantsQuickTime™ and a

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� Happy personnel

� Place to do


Endoscopy suite

� Cardiovascular monitoring

� Respiratory monitoring

� Rescusitation devices

� A procedure table

� Oxygen supplementation

� Aspiration equipment to drain and collect fluid

� Overhead lighting

� Chest tube with seal, “light surgical” instrumentation


Instrumentation

� Needles and syringes

� Scalpels

� Boutin needle

� Scissors, forceps and clamps

� Trocars

� Chest drain and sutures

� Soap and warm saline

� Betadin

� Gauge

� Formol

� On-site evaluation ?


Trained and dedicated personnel

� Time saving

� Important for the outcome

� Know how to react when

trouble (automatisms)

� Always happy


Find the patients� Congratulations: you made it








The day before the procedure:

� Review the patient– Full history and physical examination

– Be sure of no contraindications

– History/examination

– Blood results

– Anaesthetic review/ ECG/ ECHO

� Review radiology

� Explain the procedure– Consent (in some countries mandatory)


Patients’ selection

� When starting carefully selection

of patients

– Make the right choice: young, rich, healthy, handsome and … smart

– Good PS

– Long Survival

� Undiagnosed pleural effusions

� Talc poudrage

– After diagnosis


Preparation� Lateral decubitus position

– Arm fully extended overhead

� Port of entry: mid axillary line


Standardize the method

� Technique

� Indications

– Undiagnosed pleural effusions

– Talc poudrage

�After diagnosis






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Diagnostic thoracoscopy and staging

� Thoracoscopy

– When lung cancer is associated to pleural effusion we must prove malignancy

� 47-year old, male, non-smoker

– Lung adenocarcinoma


Pleurodesis: aim

� Improvement of quality of life

– Symptoms improvement

� Maintain the Performance Status

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� 68-year old, female, non-smoker

– breast adenocarcinoma


Collect your data

� Data base of your patients

� Think of research

– Simple questions

– Simple answers

� Participate to protocols


Thoracoscopy and clinical research� Simple question: Fever of Talcage vs Diagnostic Thoracoscopy

Froudarakis M, Klimathianaki M, Pougounias M. Chest 2006;129:356-61


Thoracoscopy and clinical research� Evolution of inflammatory cells

� WBC

� PN � LP

� CRP

Froudarakis M, Klimathianaki M, Pougounias M. Chest 2006;129:356-61


Thoracoscopy in COPD with PNO

� 41 Patients with PSP due to COPD were

recruited for pleuroscopy and talc poudrage

under local anaesthesia

� Pain scores, safety and outcome

Lee P, et al. Chest 2004; 125: 1315-20




Thoracoscopy in COPD with PNO

� Deaths due to

– Respiratory status

– Comorbidities








Why increased mortality in such patients

� Froudarakis M et al, Respiration 2010










Why increased mortality in such patients



� Froudarakis M et al, Respiration 2010


European Association of Bronchology

and Interventional Pulmonology (EABIP)

� Article of the month




Safety Of Talc poudrage In Malignant pleural effusion (SOTIM study)Safety Of Talc poudrage In Pneumothorax (SOTIP study)

� Participating Centers

– Astoul Philippe, Marseille France

– Bolliger Chris, Cape Town South Africa

– Driesen Peter, Turnhout Belgium

– Froudarakis Marios, Heraklion Greece

– Janssen Julius, Nijmegen the Netherlands

– Loddenkemper Robert, Berlin Germany

– Marquette Charles Hugo, Lille France

– Noppen Marc, Brussels Belgium

– Rodriguez-Panadero Francisco, Sevilla Spain

– Tassi Gianfranco, Brescia Italy

– Tschopp Jean-Marie, Montana Switzerland

� Study Coordinators

– Jean Marie Tschopp

– Julius Janssen

� Data Collection Center

– Julius Janssen

ERS Berlin 2001

Group on Medical Thoracoscopy

Participate to protocols

Janssen J et al, Lancet 2007;369:1535-9


WHAT WE

NEED

� Enthousiasm




Ευχαριστώ

Αλεξανδρούπολη

ERS course, 2008

[email protected]

Documents

WHAT WE NEED FOR THORACOSCOPY - ERS-education · 2014. 11. 23. · Business plan A place to do. Dedicated Course on Thoracoscopy & Pleural Techniques. Marseille October 2013 ... •