Lung Cancer 66 (2009) 355–358
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A local anaesthetic video-assisted thoracoscopy service: Prospective performance analysis in a UK tertiary respiratory centre A.R.L. Medford ∗ , S. Agrawal, C.M. Free, J.A. Bennett Department of Respiratory Medicine, Allergy and Thoracic Surgery, Institute for Lung Health, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester LE3 9QP, Leicestershire, UK
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Article history: Received 10 December 2008 Received in revised form 1 February 2009 Accepted 25 February 2009 Keywords: Local anaesthetic thoracoscopy VATS Audit Pleurodesis Pleural malignancy Lung cancer
a b s t r a c t Introduction: Local anaesthetic video-assisted thoracoscopy (LAVAT) is a safe, reliable and therapeutic procedure used by respiratory physicians in the management of pleural disease, especially pleural malignancy. We describe a prospective analysis of a UK LAVAT service set up in a tertiary respiratory centre to complement an existing large surgical video-assisted thoracic surgery (VATS) service. Methods: A prospective analysis of 125 LAVAT procedures over a 34-month period was performed looking at a variety of quality control endpoints comparing them to national thoracic surgical VATS standards. Results: Talc pleurodesis was effective in over 86% of cases and this did not significantly lengthen bed stay (median 4.5 days). Bed stay was also unchanged between the ages of 60–89 years. Over 77% of the 48 patients with proven metastatic pleural lung malignancy or mesothelioma received either surgical decortication or oncological treatment (palliative chemotherapy in 57%). In only 6% were biopsies not possible because of technical factors. LAVAT biopsies had a diagnostic accuracy of 97.4%, sensitivity 95.4%, specificity 100%, positive predictive value 100%, and negative predictive value 94.7%. Our complication rate was 4% and mortality rate 0.8%. Discussion: Our LAVAT service meets surgical VATS standards for diagnosis and safety with a good pleurodesis efficacy rate. It complements our surgical VATS service, offering a pleural diagnostic service for patients with non-complex pleural exudates or too frail for VATS. Our data demonstrate there is a demand and potential for respiratory physicians dealing with pleural malignancy to develop LAVAT and enhance their local lung cancer and pleural diagnostic pathway. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Local anaesthetic video-assisted (“medical”) thoracoscopy performed using a single port under conscious sedation (LAVAT) allows drainage of a pleural effusion, multiple biopsies of the parietal pleura under direct vision achieving a high diagnostic yield and effective talc pleurodesis during one procedure [1]. It avoids the risks of general anaesthesia in patients, many of whom have comorbidities and reduced performance status. Thus it offers several advantages in the investigation of simple unilateral pleural effusion of unknown cause but particularly in suspected malignant pleural disease. However, it is not a substitute for video-assisted thoracoscopic surgery (VATS) in the investigation and treatment of complex pleural effusions. UHL NHS Trust has a thoracic surgical unit with considerable expertise in VATS. With thoracic surgical support, we started a LAVAT service in 2005 in response to the need to develop a com-
∗ Corresponding author. Tel.: +44 1162502766; fax: +44 1162502787. E-mail address:
[email protected] (A.R.L. Medford). 0169-5002/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2009.02.023
plementary pleural diagnostic service for patients with simple unexplained pleural exudates (and most commonly pleural malignancy). We prospectively audited our LAVAT service from 2005 to 2008 and conducted a cost analysis.
2. Methods Prospective audit of all LAVAT procedures registered onto a database on the date the procedure was performed. Data were analysed using Graph Pad Prism version 4 software. Normality testing was assessed by the Ryan-Joiner test. Means and standard error (S.E.) in parentheses are quoted for normal data. Medians and interquartile range (IQR) in parentheses are quoted for nonparametric data. Box and whisker plots show median, IQR and extreme ranges. Two column data were analysed with either Mann–Whitney (nonparametric data) or t-test (normal data); multiple comparisons were analysed with either Kruskal–Wallis (nonparametric data) with Dunn’s post-test correction or ANOVA (normal data) with Bonferroni post-test correction. In all cases, a p value less than 0.05 was deemed significant.
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A.R.L. Medford et al. / Lung Cancer 66 (2009) 355–358 Table 1 Histological breakdown of positive malignant LAVAT biopsies. Histology (n = 60)
Sub-subtype number (%)
Malignant mesothelioma Epithelioid Sarcomatoid Biphasic Unclassified Metastatic lung cancer NSCLC (total) Lung adenocarcinoma Unclassified SCLC
Fig. 1. Box and whisker plot of median length of stay according to pleurodesis and age in decades (20–39 age group not included as only 3 patients). Medians (IQR) and extreme ranges shown.
3. Results 125 procedures were performed over a 34-month period, equating to 3.7 thoracoscopies per month or 44 annually. There was a male preponderance (75.2%) with mean (S.E.) age 69.9 (1.12) ranging from 27 to 88. The 10th–90th age percentiles were 54.8, 61, 66.2, 69, 71, 75, 77.8, 81 and 84, respectively. Talc pleurodesis was performed in 66 (52.8%) of cases. Pleurodesis was effective (confirmed by failure of recurrence of the effusion on subsequent imaging or requiring further pleural drainage for at least 1 month) in 57 cases (86.4%). Available imaging was not available for all patients for longer time periods but at least 37 of these cases (64.9%) had an effective pleurodesis confirmed at 3 months (this is a conservative estimate as some patients died within 3 months and others had follow-up chest X-rays out of region). Median (IQR) bed stay was 4.5 (4) days. Talc pleurodesis at LAVAT did not significantly alter median (IQR) bed stay (4.5[5] days without talc versus 5[3] days with talc, p = 0.38, Mann–Whitney) (see Fig. 1). Age had a minimal effect on median length of stay varying from a minimum median (IQR) of 3(4.5) days for 50–59 year olds to a maximum median (IQR) of 6(10) days for 80–89 year olds (see Fig. 1). Median lengths of stay were significantly different on overall initial analysis (p = 0.03, Kruskal–Wallis), but, on post-test analysis, only the 50–59-year-old and 80–89-year-old groups differed (p < 0.05, Dunns). There was no difference in median length of stay between the commonest decades (60–69 years, 70–79 years and 80–89 years), p > 0.05 (Kruskal–Wallis). In 117 patients (93.6%) drainage of fluid and parietal pleural biopsies were obtained. 60 patients had malignant pleural effu-
Subtype number Total number (%) (%) 29 (48.3) 21 (72.4) 2 (6.9) 2 (6.9) 4 (13.8) 19 (31.7) 14 (73.7)
11 (78.6) 3 (21.4) 5 (26.3)
Metastatic (non-lung) cancer Kidney Breast Colorectal Oesophagus Pancreas Unknown site (non-lung)
3 (33.3) 2 (22.2) 1 (11.1) 1 (11.1) 1 (11.1) 1 (6.7)
9 (15)
Miscellaneous Unclassified Synovial sarcoma
2 (66.7) 1 (33.3)
3 (5)
sions confirmed on biopsy (Table 1). Of the 48 patients with either malignant mesothelioma or metastatic lung cancer, 77.1% were offered specific cancer treatment, either radical surgery (decortication) or chemo- and/or radiotherapy (Table 2). Most patients (89.6%) with a malignant diagnosis had talc pleurodesis at LAVAT, having had suspicious abnormal macroscopic pleura noted at LAVAT. The remaining 10.4% were not pleurodesed because of technical factors (loculations, trapped lung or adhesions unsuspected prior to LAVAT on imaging). For the 8 patients with no biopsy at LAVAT, 50% had a CT-guided lung biopsy and the other 50% VATS. Three patients (2.6%) with non-malignant LAVAT parietal pleural biopsies had a subsequent malignant diagnosis: one from VATS biopsy (epithelioid malignant mesothelioma) and two from abdominal and omental biopsies (although likely to have been pseudo-Meigs’ syndrome [2]). All three cases have been included as false negatives. No other patients with benign LAVAT pleural biopsies (Table 3) have had a malignant diagnosis made during follow up (range 1–33 months). In 8 patients (6.3%), LAVAT pleural biopsies were not performed (4 cases multi-loculated, 3 cases unable to define pleural space, 1 case trapped lung). LAVAT achieved a positive diagnosis in 91% of patients. Of the 117 cases where biopsies were possible, LAVAT achieved an accuracy of 97.4%, sensitivity 95.4%, specificity 100%, positive predictive value 100%, negative predictive value 94.7%. Major complications (according to the national thoracic surgical guidelines for VATS [3]) were rare, occurring in only 5 cases (4%). One death occurred (0.8% mortality rate) due to postoperative MI in a patient with known coronary disease. In the other 4 cases, the problem was rectified without requiring thoracic surgery (drainage of post-LAVAT empyema in 2 cases, electrocautery to minor intercostal bleed at time of LAVAT, drainage of post-LAVAT
Table 2 Subsequent intended treatment following LAVAT showing malignant mesothelioma or metastatic lung cancer (n = 48). Treatment
Subtype number (%)
Surgical (radical decortication) Oncological Chemotherapy Radiotherapy
9 (18.8)
Additional comments 4 patients declined surgery
28 (58.3) 16a (33.3) 12a (25.0)
Palliative care (active symptom control) a
Number (%)
Includes 2 patients in each group having chemo-radiotherapy.
2 too ill for chemotherapy 11 (22.9)
A.R.L. Medford et al. / Lung Cancer 66 (2009) 355–358 Table 3 Histological breakdown of non-malignant LAVAT biopsies. Histology (n = 54)
Subtype number (%)
Pleuritis Chronic inflammatory Fibrosing Reactive with pleural plaque
24 (50) 19 (39.6) 5 (10.4)
TB
Number (%) 46 (85.2)
8 (14.8)
air leak and surgical emphysema). Adhesions, loculations, trapped lung and an inability to define the pleural space occurred in only 38 cases (30.4%) in total. Ultimately these prevented biopsies being taken in only 8 cases (6.4%). 4. Discussion Our data confirm that our LAVAT service is safe and effective. LAVAT has a high diagnostic yield (91%) which fulfils the national thoracic surgical guidelines for VATS (90–95% yield for previously uninvestigated effusions) [3] and a high pleurodesis success rate (86.4%) which is better than for talc slurry in a recent prospective study [4] although a recent larger North American randomised trial of 501 patients failed to show any overall superiority for talc poudrage over slurry [5]. Our pleurodesis success rate is also only just below the standard (90%) for VATS talc pleurodesis [3]. We would not expect LAVAT to perform as effectively as VATS pleurodesis due to limitations in breaking down adhesions and locules and to decorticate visceral pleura. The procedure was performed promptly and all of our patients except one (VATS diagnosis of malignant mesothelioma) had a diagnosis and treatment within 62 days of referral and 31 days of the decision to treat, thereby fulfilling current NHS cancer targets. Previously some patients with unilateral pleural effusions had a delay in making malignant histological diagnoses due to the limited utility of blind pleural biopsies [6] resulting in multiple procedures which impacted on 62 and 31 day targets. We selected patients for LAVAT if their functional status was likely to be a WHO performance status of 2 or less post-complete drainage of pleural fluid at LAVAT. Using physiological rather than chronological age as a selection criterion, we have shown that LAVAT can be performed in an elderly population with no significant change in inpatient stay for patients aged 60–89 years old (>80% of our total cohort). Our median length of stay is good at 4.5 (4) days, which compares favourably to a recent UK thoracic surgical centre VATS audit [7] indicating a median (IQR) stay of 8 (4.5) days (p < 0.0001, Mann–Whitney); and it is unaffected by the administration of talc for attempted pleurodesis. In particular, our length of stay data is likely to be an overestimate as the procedures are performed on a Friday afternoon, extending patient stay over the weekend. Our mortality data (0.8%) are within national guidelines for VATS (
