Ali Muhammad Sajawal, Light Richard W, Maldonado Fabien
Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Wauwatosa, WI 53226, USA.
Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN 37235, USA.
J Thorac Dis. 2019 Jul;11(7):3207-3216. doi: 10.21037/jtd.2019.03.86.
Exudative pleural effusions, such as malignant and tuberculous pleural effusions, are associated with notable morbidity and mortality. Unfortunately, a significant number of these effusions will remain undiagnosed despite thoracentesis. Traditionally, closed pleural biopsies have been the next best diagnostic step, but the diagnostic yield of blind closed pleural biopsies for malignant pleural effusions is insufficient. When image-guided targeted biopsies are not possible, both pleuroscopy and video-assisted thoracoscopic surgery are reasonable options for obtaining pleural biopsies, but the decision to select one procedure over the other continues to raise much debate. Pleuroscopy (aka. medical thoracoscopy, local anaesthetic thoracoscopy) is a relatively common procedure performed by interventional pulmonologists in the bronchoscopy suite with local anesthesia, often as an outpatient procedure, on spontaneously breathing patients. Video-assisted thoracoscopic surgery, on the other hand, is performed by thoracic surgeons in the operating room, on mechanically ventilated patients under general anesthesia, though admittedly considerable overlap exists in practice. Both pleuroscopy and video-assisted thoracoscopic surgery have reported diagnostic yields of over 90%, although pleuroscopy more often leads to the unsatisfactory diagnosis of 'non-specific' pleuritis. These cases of 'non-specific' pleuritis need to be followed up for at least one year, as 10-15% of them will eventually lead to the diagnosis of cancer, typically malignant pleural mesothelioma. Both procedures have their pros and cons, and it is therefore of paramount importance that all cases be discussed as part of a multidisciplinary approach to diagnosis within a "pleural team" that should ideally include interventional pulmonologists and thoracic surgeons.
渗出性胸腔积液，如恶性和结核性胸腔积液，与显著的发病率和死亡率相关。不幸的是，尽管进行了胸腔穿刺术，仍有相当数量的此类积液无法确诊。传统上，闭式胸膜活检是接下来最好的诊断步骤，但盲目闭式胸膜活检对恶性胸腔积液的诊断率不足。当无法进行影像引导下的靶向活检时，胸腔镜检查和电视辅助胸腔镜手术都是获取胸膜活检的合理选择，但选择一种手术而非另一种手术的决定仍引发诸多争议。胸腔镜检查（又称内科胸腔镜检查、局部麻醉胸腔镜检查）是介入肺科医生在支气管镜检查室对自主呼吸的患者进行的一种相对常见的手术，通常在局部麻醉下进行，常作为门诊手术。另一方面，电视辅助胸腔镜手术是由胸外科医生在手术室对全身麻醉下机械通气的患者进行的，尽管实际上存在相当大的重叠。胸腔镜检查和电视辅助胸腔镜手术的诊断率均报告超过90%，尽管胸腔镜检查更常导致“非特异性”胸膜炎的诊断结果不理想。这些“非特异性”胸膜炎病例需要至少随访一年，因为其中10%-15%最终会被诊断为癌症，通常是恶性胸膜间皮瘤。这两种手术都有其优缺点，因此，作为“胸膜团队”多学科诊断方法的一部分，对所有病例进行讨论至关重要，该团队理想情况下应包括介入肺科医生和胸外科医生。
