7    Clinical Prerequisites for Medical Thoracoscopy/Pleuroscopy

Medical thoracoscopy/pleuroscopy (MT/P) should be considered an invasive procedure that the chest physician should use only when other, simpler methods fail to yield a diagnosis or when less-invasive therapeutic measures are not available or are less promising. For each individual, the risk/benefit ratio must be considered. Therefore, a careful evaluation of the patient a well as of the indications and contraindications to the procedure is mandatory. MT/P is safe if the patient is evaluated carefully, the thoracoscopist is adequately trained, the contraindications are observed, and complications are prevented.

The history of the patient reveals information about the acute or chronic evolution of the disease, effort intolerance, and possible underlying previous or concomitant pulmonary or extrapulmonary disease such as tumor, asthma, COPD, deep venous thrombosis, coagulation disorders, congestive heart failure, myocardial infarction, renal insufficiency, liver cirrhosis, pancreatitis, diabetes mellitus, HIV, or rheumatoid arthritis. It is well known that the lung and pleura may be involved in many of these diseases. The patient’s history may also provide important information on possible risk factors. For example, in case of idiosyncratic or allergic sensitivities to local anesthetics, general anesthesia should be planned.

There should be knowledge of the preceding drug therapy, in particular of anticoagulant treatment, which may be an absolute or relative contraindication to the investigation. Systemic immunosuppressive treatment, especially with corticosteroids, may cause a delayed closure of biopsy sites of the lung. It is important to notify the pathologist about previous therapy with cytostatic agents or radiotherapy as well as about occupational exposures, e.g., to asbestos. The microbiologist needs information on previous antibiotic therapy.

Besides a detailed history a thorough physical examination is a vital component of any preoperative evaluation. Routine posteroanterior and lateral chest radiography has frequently to be supplemented with a CT scan, bilateral decubitus films, or ultrasonography, which also provide the basis for determining the optimum point of insertion of the thoracoscope. They often also prove or exclude the presence of pleural thickening, which points to a possible symphysis by adhesions. This could be a contraindication for MT/P, since the presence of an adequate pleural space is an absolute prerequisite. However, neither CT scan (Mason et al. 1999) nor ultrasonography (Sasaki et al. 2005) provides 100% accuracy in excluding adhesions.

The respiratory status is evaluated, at a minimum, with blood gas analysis and, if necessary, with pulmonary function tests. An electrocardiogram should be obtained to exclude a recent myocardial infarction or significant arrhythmia. The clinical laboratory will provide the coagulation parameters, serum electrolytes, serum creatinine, glucose, liver function studies, and a complete blood count as well as a blood group typing.

If convinced, by applying strict criteria, that MT/P is indicated, the physician should have little difficulty explaining the need for the procedure to the patient and obtaining informed consent. To be certain that the patient fully understands what is to be done and why the procedure is necessary, a hand-out with detailed explanations of the procedure should be provided, followed by verbal explanation and discussion. This includes an explanation of the planned technique, the management of postoperative pain and other possible, so-called typical complications, as well as the expected diagnostic or therapeutic results. It is only then that the patient can truly provide informed consent.

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