Resph'ato o, Medicine (1992) 86, 365-366
Editorials
Thoracoscopy: the dawn of a new age! That thoracoscopy should be considered within the domain of the physician is not a new suggestion. Indeed, thoracoscopy was introduced by a Swedish internist, H. C. Jacobaeus in 1919 (I). His first procedures were carried out using a cystoscope and a specially developed trocar. He was able to take advantage of the good field of view given by the contemporary use of artificial pneumothoraces for therapeutic purposes in patients with tuberculosis. Even though Jacobaeus primarily developed thoracoscopy as a diagnostic procedure (2), during the ensuing 40 years it was applied on a worldwide scale, almost exclusively for the lysis of pleural adhesions by means of electrocautery. With the advent of active anti-tuberculous chemotherapy in the 1950s, the era of pneumothorax therapy came to an end. This led to a shift in emphasis for thoracoscopy, from a therapeutic role to more of a diagnostic one. It was used on a much broader basis for evaluating many kinds of pleural and pulmonary disease. Thoracoscopy and biopsy was the order of the day. As more sophisticated investigative techniques became available, its use became variable and often ill-defined. All too frequently it was used as a final attempt to make a difficult diagnosis where other methods of investigation had failed. The development of highresolution CT scanning with guided needle biopsy, had reduced its useage to a very low level in many institutions. Our article in this edition reflects such a use ofthoracoscopy as a final arbiter for difficult problems. Used in this way, its diagnostic yield will often be lower than one might expect, because all of the 'easier diagnoses' will have been made by extensive use of CT scan, pleural aspiration and cytology and needle biopsy. In our series (where only a small proportion of patients seen by our chest physician colleagues with pleural disease had been referred for the procedure), a sensitivity of 83% was achieved but with a specificity of 100%. In other words, diagnostic accuracy was high, but in a few patients diagnosis awaited a formal thoracotomy or new developments in their disease. These results are similar to those of other published series (3). The recently advocated liberalization of thoracoscopy as a diagnostic tool, by the use of fibre-optic systems carried out by our physician colleagues (4) wiI1 no doubt have a high positive diagnostic yield in line 0954-611 I/92/050365 + 02 $08.00/0
with the surgical results outlined above. This will be enhanced further by the inclusion of patients whose diagnoses had previously been made by CT scan, needle cytology and/or biopsy histology alone. This approach needs to be evaluated with a cost-benefit analysis and ought to be the basis of a randomized prospective trial with the cost of earlier and more frequent thoracoscopic intervention by physicians as an important parameter. What, therefore, is the future of surgical thoracoscopy? Surgical colleagues need not fear for the threatened loss of a part of their practice as we stand on the threshhold of exciting new horizons. New developments in optics, electronics and instrumentation have laid the foundations for increasingly extensive surgical procedures to be carried out using a thoracoscopic approach visualized on a television monitor. This concept of minimally invasive surgery follows close on the heels of video-assisted laparoscopy and procedures such as laparoscopic cholecystectomy. Similar dividends are to be expected for thoracic patients with a reduced length of hospital stay and hence reduced costs, less discomfort for the patient and a concomitant earlier return to a normal lifestyle, including work. Several affordable visualization systems are already available, with others on their way. Developments in stapling and suturing devices are advancing hand-inhand with laser and electrocautery. Initial experiences are already being published with respect to the management of spontaneous pneumothoraces (5) and wedge resection of pulmonary nodules and coin lesions (6). Other more adventurous procedures are being carried out, such as excision of posterior mediastinal neural tumours, bronchogenic and foregut cysts, thymic lesions and pericardial resections. Others are working experimentally on still more extensive procedures such as lobar pulmonary resections, oesophageal procedures and the treatment of giant bullous emphysema. The stapling of sub-pleural blebs and bullae with friction pleurodesis, or pleurectomy is becoming commonplace (7). Patients are left with three relatively painless 1.5 cm incisions and often a hospital stay of less t~aan 3 days duration. This paves the way for © 1992 Baillitre Tindall
366
Editorial
much earlier definitive treatment of spontaneous pneumothorax supporting some of the arguments regarding the timing of surgical intervention rehearsed recently in an editorial of this journal (8). These procedures must stay within the domain of the surgeon, as anyone practicing them must be able to deal with the potential complications which may often involve a thoracotomy. It is likely that with such minimally invasive surgery our physician colleagues will lower their resistance to referral for surgical help in lung and pleural biopsies and a host of other situations. In conclusion, it appears therefore, that of the two areas of use for thoracoscopy, diagnostic and therapeutic, the extensive growth area is once again in therapy. Once physicians are aware of the exposure and visualization available with the new techniques I suspect flexible fibre-optic thoracoscopy, carried out in the clinic or on the ward, will once again be placed in context and disavowed for the more effective videoassisted systems. The capability for diagnosis and treatment at one sitting, especially if hospital stay may be only 1-3 days, will firmly place the new videoassisted surgical thoracoscope approach as the gold standard once again. Time will tell. F. C. WELLS* S. W. H. KENDALL Surgical Unit Papworth Hospital
Papworth Everard Cambridgeshire CB3 8RE U.K. *To whom correspondence should be addressed.
References
I. JacobaeusHC. ~berdieM6ghichkeit, dieZystoskopiebei Untersuchung Ser6ser H6hlungen anzuwenden. Miinch Med Wschr 1910;57: 2090-2092. 2. Jacobaeus HC. The practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922; 34: 289-296. 3. Page RD, Jeffrey RR, Donnelly RJ. Thoracoscopy: a review of 121 consecutive surgical procedures. Ann Thorac Surg 1989;481: 66--68. 4. Davidson AC, George RJ, Sinha G. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988;43: 327-332. 5. Wakabayaski A, Brenner M, Wilson AF, Tadir Y, Berus M. Thorascopic treatment of spontaneous pneumothorax using carbon dioxide laser. Ann Thorac Surg 1990; 50: 786-790. 6. Landreneau RJ, Herlan DB, Johnson JA, Boley TM, Nawarawong W, Ferson PF. Thorascopic neodymium: yttrium-aluminium garnet laser-assisted pulmonary resection. Ann Thorac Surg 1991;52:1176-1178. 7. Natharson LK, Shimi SM, Wood RAB, Cuschieri A. Videothorascopic ligation of bulla and pleurectomy for spontaneous pneumothorax. Ann Thorac Surg 1991; 52: 316-319. 8. Parry GW, Juniper ME, Dussek JE. Surgical intervention • .t in spontaneous pneumothorax. Respir Med 1992;86: 1-2.
Editorials
Thoracoscopy: the dawn of a new age! That thoracoscopy should be considered within the domain of the physician is not a new suggestion. Indeed, thoracoscopy was introduced by a Swedish internist, H. C. Jacobaeus in 1919 (I). His first procedures were carried out using a cystoscope and a specially developed trocar. He was able to take advantage of the good field of view given by the contemporary use of artificial pneumothoraces for therapeutic purposes in patients with tuberculosis. Even though Jacobaeus primarily developed thoracoscopy as a diagnostic procedure (2), during the ensuing 40 years it was applied on a worldwide scale, almost exclusively for the lysis of pleural adhesions by means of electrocautery. With the advent of active anti-tuberculous chemotherapy in the 1950s, the era of pneumothorax therapy came to an end. This led to a shift in emphasis for thoracoscopy, from a therapeutic role to more of a diagnostic one. It was used on a much broader basis for evaluating many kinds of pleural and pulmonary disease. Thoracoscopy and biopsy was the order of the day. As more sophisticated investigative techniques became available, its use became variable and often ill-defined. All too frequently it was used as a final attempt to make a difficult diagnosis where other methods of investigation had failed. The development of highresolution CT scanning with guided needle biopsy, had reduced its useage to a very low level in many institutions. Our article in this edition reflects such a use ofthoracoscopy as a final arbiter for difficult problems. Used in this way, its diagnostic yield will often be lower than one might expect, because all of the 'easier diagnoses' will have been made by extensive use of CT scan, pleural aspiration and cytology and needle biopsy. In our series (where only a small proportion of patients seen by our chest physician colleagues with pleural disease had been referred for the procedure), a sensitivity of 83% was achieved but with a specificity of 100%. In other words, diagnostic accuracy was high, but in a few patients diagnosis awaited a formal thoracotomy or new developments in their disease. These results are similar to those of other published series (3). The recently advocated liberalization of thoracoscopy as a diagnostic tool, by the use of fibre-optic systems carried out by our physician colleagues (4) wiI1 no doubt have a high positive diagnostic yield in line 0954-611 I/92/050365 + 02 $08.00/0
with the surgical results outlined above. This will be enhanced further by the inclusion of patients whose diagnoses had previously been made by CT scan, needle cytology and/or biopsy histology alone. This approach needs to be evaluated with a cost-benefit analysis and ought to be the basis of a randomized prospective trial with the cost of earlier and more frequent thoracoscopic intervention by physicians as an important parameter. What, therefore, is the future of surgical thoracoscopy? Surgical colleagues need not fear for the threatened loss of a part of their practice as we stand on the threshhold of exciting new horizons. New developments in optics, electronics and instrumentation have laid the foundations for increasingly extensive surgical procedures to be carried out using a thoracoscopic approach visualized on a television monitor. This concept of minimally invasive surgery follows close on the heels of video-assisted laparoscopy and procedures such as laparoscopic cholecystectomy. Similar dividends are to be expected for thoracic patients with a reduced length of hospital stay and hence reduced costs, less discomfort for the patient and a concomitant earlier return to a normal lifestyle, including work. Several affordable visualization systems are already available, with others on their way. Developments in stapling and suturing devices are advancing hand-inhand with laser and electrocautery. Initial experiences are already being published with respect to the management of spontaneous pneumothoraces (5) and wedge resection of pulmonary nodules and coin lesions (6). Other more adventurous procedures are being carried out, such as excision of posterior mediastinal neural tumours, bronchogenic and foregut cysts, thymic lesions and pericardial resections. Others are working experimentally on still more extensive procedures such as lobar pulmonary resections, oesophageal procedures and the treatment of giant bullous emphysema. The stapling of sub-pleural blebs and bullae with friction pleurodesis, or pleurectomy is becoming commonplace (7). Patients are left with three relatively painless 1.5 cm incisions and often a hospital stay of less t~aan 3 days duration. This paves the way for © 1992 Baillitre Tindall
366
Editorial
much earlier definitive treatment of spontaneous pneumothorax supporting some of the arguments regarding the timing of surgical intervention rehearsed recently in an editorial of this journal (8). These procedures must stay within the domain of the surgeon, as anyone practicing them must be able to deal with the potential complications which may often involve a thoracotomy. It is likely that with such minimally invasive surgery our physician colleagues will lower their resistance to referral for surgical help in lung and pleural biopsies and a host of other situations. In conclusion, it appears therefore, that of the two areas of use for thoracoscopy, diagnostic and therapeutic, the extensive growth area is once again in therapy. Once physicians are aware of the exposure and visualization available with the new techniques I suspect flexible fibre-optic thoracoscopy, carried out in the clinic or on the ward, will once again be placed in context and disavowed for the more effective videoassisted systems. The capability for diagnosis and treatment at one sitting, especially if hospital stay may be only 1-3 days, will firmly place the new videoassisted surgical thoracoscope approach as the gold standard once again. Time will tell. F. C. WELLS* S. W. H. KENDALL Surgical Unit Papworth Hospital
Papworth Everard Cambridgeshire CB3 8RE U.K. *To whom correspondence should be addressed.
References
I. JacobaeusHC. ~berdieM6ghichkeit, dieZystoskopiebei Untersuchung Ser6ser H6hlungen anzuwenden. Miinch Med Wschr 1910;57: 2090-2092. 2. Jacobaeus HC. The practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922; 34: 289-296. 3. Page RD, Jeffrey RR, Donnelly RJ. Thoracoscopy: a review of 121 consecutive surgical procedures. Ann Thorac Surg 1989;481: 66--68. 4. Davidson AC, George RJ, Sinha G. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988;43: 327-332. 5. Wakabayaski A, Brenner M, Wilson AF, Tadir Y, Berus M. Thorascopic treatment of spontaneous pneumothorax using carbon dioxide laser. Ann Thorac Surg 1990; 50: 786-790. 6. Landreneau RJ, Herlan DB, Johnson JA, Boley TM, Nawarawong W, Ferson PF. Thorascopic neodymium: yttrium-aluminium garnet laser-assisted pulmonary resection. Ann Thorac Surg 1991;52:1176-1178. 7. Natharson LK, Shimi SM, Wood RAB, Cuschieri A. Videothorascopic ligation of bulla and pleurectomy for spontaneous pneumothorax. Ann Thorac Surg 1991; 52: 316-319. 8. Parry GW, Juniper ME, Dussek JE. Surgical intervention • .t in spontaneous pneumothorax. Respir Med 1992;86: 1-2.
