4    Medical Thoracoscopy/Pleuroscopy in Children

Indications for medical thoracoscopy/pleuroscopy (MT/P) in children are rare, and there are only a few publications. Rodgers and Talbert, pediatric surgeons, were the first who reported on their experience with thoracoscopy in nine children, ranging in age between 17 months and 16 years, which they used for diagnosis of various intra-thoracic lesions (Rodgers and Talbert 1976). In 1979 they published their results on 65 (medical) thoracoscopies in 57 children (Rodgers et al. 1979c); 34 procedures were performed in immunosuppressed patients to diagnose or rule out Pneumocystis carinii pneumonia with an accuracy of 100%. In 12 patients, the indications were persisting pulmonary infiltrates of undetermined origin, again with an accuracy of 100%; and in 15 cases the procedure was performed for the diagnosis of intrathoracic tumors. In four cases, a therapeutic thoracoscopy was performed, three times for pulmonary cysts and once for talc insufflation for malignant pleural effusion.

In additional publications, Rodgers and co-workers reported exclusively on their excellent results in 24 children with interstitial pneumonitis accompanying immunosuppression (Rodgers et al. 1979 a), and in 23 children with suspected intrathoracic neoplasms (Ryckman and Rodgers 1982). Also in 1982 another group published their positive experience with thoracoscopy in children, with a variety of localized or diffuse intrathoracic lesions (Janik et al. 1982).

Rodgers was invited to the Thoracoscopy Symposium in Marseille where he gave an impressive lecture on his thoracoscopic technique in children (Rodgers 1981). He also showed there a very exciting video on thoracoscopy in a horse! To the Atlas of Diagnostic Thoracoscopy he contributed an endoscopic photograph of a pneumocystis pneumonia in a 15-year-old patient (case 54 in Brandt et al. 1985).

The indications for the single-entry technique are similar to those in adults. However, there are differences in instruments and in anesthesia: the instruments have to be smaller, as manufactured by Storz Company, with trocars of 4.0 or 5.5 mm diameter. In addition, optics and instruments similar to those for infant rigid bronchoscopy can be used. Although Rodgers performed his first thoracoscopies under local anesthesia and with additional blockade of the stellate ganglion (to suppress the cough reflex during examination of the mediastinum), later he (and Janik) more often used general anesthesia with endotracheal intubation. The final decision on whether local or general anesthesia was used depended on the age, the ability to cooperate, and the pulmonary function of the children.

Successful thoracoscopic treatment has also been reported in children for pulmonary cysts and for talc poudrage in malignant pleural effusion (Rodgers et al. 1979 c) and in spontaneous pneumothorax due to cystic fibrosis (Tribble et al. 1986) as well as for empyema (Kern and Rodgers 1993; Stovroff et al. 1995) and sympathicolysis for essential hyperhidrosis (Noppen et al. 1996, 1998).

Today the technique has become adopted widely by pediatric surgeons and is currently considered to be the optimum technique for management of many intrathoracic disorders in children. The most common indications include pleural debridement for empyema, mediastinal lymph node biopsy, and pulmonary parenchymal biopsy for inflammatory infiltrates or nodules (Rodgers 2003).

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