Hsu C P, Hanke I, Douglas J M
Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
Ann Surg. 1995 Nov;222(5):626-31. doi: 10.1097/00000658-199511000-00004.
The authors evaluated the effectiveness and the limitations of video-assisted diagnostic thoracoscopy.
The initial successes achieved with the use of video-assisted diagnostic thoracoscopic techniques has lead to an enthusiastic propagation of its use by thoracic surgeons as well as by some pulmonologists. However, detailed analyses of the diagnostic yield and potential limitations of this technique in relation to the roentgenographic and pathologic presentations of the patients are necessary to ensure its safe and effective application.
From July 1991 to December 1993, 102 diagnostic video-assisted thoracoscopic procedures were performed. All patients received other preoperative diagnostic workups without a definitive diagnosis. The initial roentgenographic presentations of these patients included 42 pulmonary nodules, 23 interstitial processes, 11 parenchymal infiltrates, 6 pleural effusions, 10 mediastinal tumors, and 10 mediastinal lymphadenopathies. If the procedure was completed without minithoracotomy or extension of any port site, then it was defined as an exclusive thoracoscopic biopsy (ETB); if the procedure was completed with the assistance of minithoracotomy (4-6 cm), then it was defined as a supplementary thoracoscopic biopsy (STB).
Ninety-two of the pathology reports (90.2%) were interpreted as conclusive. Of these, 35 tumors were malignant and 67 benign. Ten pathology reports were inconclusive and on initial roentgenography had presented as pulmonary infiltrates (4 cases), pulmonary nodule (2), pleural effusion (2), interstitial process (1), and mediastinal lymphadenopathy (1). Seventy-six procedures (74.5%) were completed thoracoscopically and were classified as ETB. The remaining 26 procedures (25.5%) were completed with minithoracotomy and were classified as STB. The underlying diseases in the STB group were carcinoma (8 cases), Hodgkin's lymphoma (3), sarcoidosis (3), tuberculosis (2), interstitial pneumonitis (2), organizing pneumonia (2), mesothelioma (1), and miscellaneous disease (5). The reasons given for minithoracotomy were diffuse intrapleural adhesion (10 cases), technical inexperience (8), inability to localize the lesion (5), problems with anesthesia (1), poor patient tolerance (1), and unknown (1). Four patients (3.9%) experienced complications and three (2.9%) died while in the hospital.
Diagnostic thoracoscopy provides high diagnostic yield with very low risk. However, 25.5% of the procedures require minithoracotomy to obtain adequate tissue for definitive diagnosis. This finding supports the assertion that diagnostic thoracoscopy should be performed only by experienced thoracic surgeons who can extend the procedure when indicated.
作者评估了电视辅助诊断性胸腔镜检查的有效性及局限性。
电视辅助诊断性胸腔镜技术取得的初步成功，使得胸外科医生以及一些肺科医生热衷于应用该技术。然而，为确保其安全有效应用，有必要详细分析该技术在诊断方面的效果以及与患者影像学和病理学表现相关的潜在局限性。
1991年7月至1993年12月期间，共进行了102例电视辅助诊断性胸腔镜检查。所有患者术前均接受了其他诊断性检查但未获明确诊断。这些患者最初的影像学表现包括42例肺结节、23例间质性病变、11例实质性浸润、6例胸腔积液、10例纵隔肿瘤和10例纵隔淋巴结病。若手术在未行小开胸或未扩大任何切口部位的情况下完成，则定义为单纯胸腔镜活检（ETB）；若手术在小开胸（4 - 6厘米）辅助下完成，则定义为补充胸腔镜活检（STB）。
92份病理报告（90.2%）被判定为结论性的。其中，35例肿瘤为恶性，67例为良性。10份病理报告结论不明确，最初的影像学表现为肺部浸润（4例）、肺结节（2例）、胸腔积液（2例）、间质性病变（1例）和纵隔淋巴结病（1例）。76例手术（74.5%）通过胸腔镜完成，被归类为ETB。其余26例手术（25.5%）在小开胸辅助下完成，被归类为STB。STB组的基础疾病包括癌（8例）、霍奇金淋巴瘤（3例）、结节病（3例）、结核病（2例）、间质性肺炎（2例）、机化性肺炎（2例）、间皮瘤（1例）和其他疾病（5例）。行小开胸的原因包括广泛胸膜粘连（10例）、技术不熟练（8例）、无法定位病变（5例）、麻醉问题（1例）、患者耐受性差（1例）和原因不明（1例）。4例患者（3.9%）发生并发症，3例（2.9%）在住院期间死亡。
诊断性胸腔镜检查诊断率高且风险极低。然而，25.5%的手术需要小开胸以获取足够组织进行明确诊断。这一发现支持了仅应由经验丰富的胸外科医生进行诊断性胸腔镜检查，且他们应在必要时扩大手术范围的观点。
