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Andreas H. Diacon - One of the best experts on this subject based on the ideXlab platform.
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An image-guided diagnostic pathway for undiagnosed pleural exudates
European Respiratory Journal, 2013Co-Authors: Coenraad F N Koegelenberg, Florian Von Groote-bidlingmaier, Johannes W. Bruwer, Enas Batubara, Chris T. Bolliger, Elvis M. Irusen, Andreas H. DiaconAbstract:Background: We assessed the efficiency and safety of an image-guided diagnostic pathway with ultrasound (US)-assisted closed pleural biopsy as an alternative to thoracoscopy as first-line investigation in undiagnosed pleural exudates. Methods: Patients with non-diagnostic Thoracocentesis were prospectively stratified on imaging as having (A) an associated mass lesion (>10mm) abutting the chest wall; (B) diffuse pleural thickening (>10mm) and/or nodularity or (C) insignificant/no pleural thickening. US-assisted repeat Thoracocentesis and transthoracic fine-needle aspiration were performed on patients stratified to (A), and if non-diagnostic on on-site analysis, a Tru-Cut biopsy was performed in the same session. US-assisted Thoracocentesis and Abrams needle biopsies were performed on all others aiming at the region(s) of interest (B) or low supra-diaphragmatic pleura (C). Thoracoscopy was reserved for cases not diagnosed by repeat thoracentesis and biopsy. Results: Final diagnoses in 78 consecutive patients included malignancy (n=42), TB (n=30), and other causes (n=6). Accurate diagnoses were obtained in 69 (88.5%) with US-assisted Thoracocentesis and biopsy. The yield was high for TB (93.3%) and malignancy (88.1%). Complications included mild haemoptysis (n=1) and pneumothorax (n=1, no intervention required). Thoracoscopy was performed in 13 cases (16.7%), including all 4 cases correctly diagnosed on closed biopsy as non-specific pleuritis, and yielded diagnoses in 12. Conclusion: A diagnostic algorithm based on pleural morphology, US-assisted Thoracocentesis and biopsy has a high diagnostic yield and offers an efficient and safe alternative to thoracoscopy as a first-line investigation in undiagnosed exudates.
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image guided pleural biopsy
Current Opinion in Pulmonary Medicine, 2013Co-Authors: Coenraad F N Koegelenberg, Andreas H. DiaconAbstract:Purpose of reviewThe most efficient and cost-effective approach to pleural exudates not diagnosed by means of Thoracocentesis remains uncertain. Both closed pleural biopsy and thoracoscopy may be utilized for the acquisition of pleural tissue. This review will focus on the developments in image guid
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The diagnostic yield of ultrasound-assisted closed pleural biopsy in pleural effusions following non-diagnostic Thoracocentesis
European Respiratory Journal, 2012Co-Authors: Coenraad F N Koegelenberg, Florian Von Groote-bidlingmaier, Chris T. Bolliger, Elvis M. Irusen, Pawel T. Schubert, Mercia Louw, Colleen A. Wright, Andreas H. DiaconAbstract:Background: Unaided (“blind”) pleural biopsy is prone to sampling error and has a modest yield. We assessed the safety and yield of ultrasound (US)-assisted closed pleural biopsy in the setting of undiagnosed effusions, and investigated how pleural morphology could guide the selection and execution of closed pleural biopsy. Methods: Patients with an exudative effusion who had had a non-diagnostic Thoracocentesis were prospectively stratified on imaging as having (A) an associated mass lesion (>10mm) abutting the chest wall; (B) diffuse pleural thickening (>10mm) and/or nodularity or (C) insignificant/no pleural thickening. US-assisted repeat Thoracocentesis and transthoracic fine-needle aspiration (TTFNA) were performed on patients stratified to (A),and if non-diagnostic on on-site analysis, followed by a Tru-Cut biopsy. US-assisted Thoracocentesis and Abrams needle biopsies were performed on all others aiming at the region(s) of interest (B) or low supra-diaphragmatic pleura (C). Results: Final diagnoses in 41 consecutive patients (30 males, 47+/-18 years) included pleural TB (n=21), malignancy (n=16) and other causes (n=4). Accurate diagnoses were obtained in 34 (82.9%) with US-assisted biopsy; thoracoscopy (n=6, 14.6%) or bronchoscopy (n=1) were required in the rest. The yield of US-assisted biopsy was higher for TB (19/21, 90.48%) than malignancy (12/16, 75.0%, p=0.37). One patient experienced mild haemoptysis following TTFNA. Conclusion: A diagnostic algorithm based on pleural morphology and US-assisted pleural biopsy has a high diagnostic yield and offers a safe first-line approach in the setting of undiagnosed pleural exudates.
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pleural controversy close needle pleural biopsy or thoracoscopy which first
Respirology, 2011Co-Authors: Coenraad F N Koegelenberg, Andreas H. DiaconAbstract:The most efficient and cost-effective approach to the diagnosis of pleural exudates remains controversial. Important considerations include the respective diagnostic yields of Thoracocentesis, closed pleural biopsy and thoracoscopy; the incremental gain in diagnostic yield when sequentially combining these investigations; and the role of various image modalities. The diagnostic yield of Thoracocentesis is in the order of 60% for malignancy and >90% for tuberculosis. A second aspiration may increase the yield for malignancy, but a third is generally superfluous. Many authorities consider thoracoscopy the investigation of choice in exudative pleural effusions where a Thoracocentesis was nondiagnostic and particularly when malignancy is suspected. It allows for the direct inspection of the pleura and for talc poudrage. Thoracoscopy has a diagnostic yield of 91–95% for malignant disease and as high as 100% for pleural tuberculosis. Access to thoracoscopy is, however, limited in many parts of the world, as significant resources and expertise are required. Blind closed pleural biopsy has a yield of 80% for tuberculosis and <60% for pleural malignancy. Recent studies suggest that CT and/or ultrasound guidance may improve the yield, particularly for malignancy, where it may be as high as 88% and 83%, respectively. A second Thoracocentesis combined with an image-assisted pleural biopsy with either an Abrams needle or cutting needle, depending on the setting, may therefore be an acceptable alternative to thoracoscopy. With such an approach, thoracoscopy may potentially be reserved for cases not diagnosed by means of closed pleural biopsy.
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Pleural controversy: close needle pleural biopsy or thoracoscopy-which first?
Respirology (Carlton Vic.), 2011Co-Authors: Coenraad F N Koegelenberg, Andreas H. DiaconAbstract:The most efficient and cost-effective approach to the diagnosis of pleural exudates remains controversial. Important considerations include the respective diagnostic yields of Thoracocentesis, closed pleural biopsy and thoracoscopy; the incremental gain in diagnostic yield when sequentially combining these investigations; and the role of various image modalities. The diagnostic yield of Thoracocentesis is in the order of 60% for malignancy and >90% for tuberculosis. A second aspiration may increase the yield for malignancy, but a third is generally superfluous. Many authorities consider thoracoscopy the investigation of choice in exudative pleural effusions where a Thoracocentesis was nondiagnostic and particularly when malignancy is suspected. It allows for the direct inspection of the pleura and for talc poudrage. Thoracoscopy has a diagnostic yield of 91–95% for malignant disease and as high as 100% for pleural tuberculosis. Access to thoracoscopy is, however, limited in many parts of the world, as significant resources and expertise are required. Blind closed pleural biopsy has a yield of 80% for tuberculosis and
Coenraad F N Koegelenberg - One of the best experts on this subject based on the ideXlab platform.
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An image-guided diagnostic pathway for undiagnosed pleural exudates
European Respiratory Journal, 2013Co-Authors: Coenraad F N Koegelenberg, Florian Von Groote-bidlingmaier, Johannes W. Bruwer, Enas Batubara, Chris T. Bolliger, Elvis M. Irusen, Andreas H. DiaconAbstract:Background: We assessed the efficiency and safety of an image-guided diagnostic pathway with ultrasound (US)-assisted closed pleural biopsy as an alternative to thoracoscopy as first-line investigation in undiagnosed pleural exudates. Methods: Patients with non-diagnostic Thoracocentesis were prospectively stratified on imaging as having (A) an associated mass lesion (>10mm) abutting the chest wall; (B) diffuse pleural thickening (>10mm) and/or nodularity or (C) insignificant/no pleural thickening. US-assisted repeat Thoracocentesis and transthoracic fine-needle aspiration were performed on patients stratified to (A), and if non-diagnostic on on-site analysis, a Tru-Cut biopsy was performed in the same session. US-assisted Thoracocentesis and Abrams needle biopsies were performed on all others aiming at the region(s) of interest (B) or low supra-diaphragmatic pleura (C). Thoracoscopy was reserved for cases not diagnosed by repeat thoracentesis and biopsy. Results: Final diagnoses in 78 consecutive patients included malignancy (n=42), TB (n=30), and other causes (n=6). Accurate diagnoses were obtained in 69 (88.5%) with US-assisted Thoracocentesis and biopsy. The yield was high for TB (93.3%) and malignancy (88.1%). Complications included mild haemoptysis (n=1) and pneumothorax (n=1, no intervention required). Thoracoscopy was performed in 13 cases (16.7%), including all 4 cases correctly diagnosed on closed biopsy as non-specific pleuritis, and yielded diagnoses in 12. Conclusion: A diagnostic algorithm based on pleural morphology, US-assisted Thoracocentesis and biopsy has a high diagnostic yield and offers an efficient and safe alternative to thoracoscopy as a first-line investigation in undiagnosed exudates.
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image guided pleural biopsy
Current Opinion in Pulmonary Medicine, 2013Co-Authors: Coenraad F N Koegelenberg, Andreas H. DiaconAbstract:Purpose of reviewThe most efficient and cost-effective approach to pleural exudates not diagnosed by means of Thoracocentesis remains uncertain. Both closed pleural biopsy and thoracoscopy may be utilized for the acquisition of pleural tissue. This review will focus on the developments in image guid
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The diagnostic yield of ultrasound-assisted closed pleural biopsy in pleural effusions following non-diagnostic Thoracocentesis
European Respiratory Journal, 2012Co-Authors: Coenraad F N Koegelenberg, Florian Von Groote-bidlingmaier, Chris T. Bolliger, Elvis M. Irusen, Pawel T. Schubert, Mercia Louw, Colleen A. Wright, Andreas H. DiaconAbstract:Background: Unaided (“blind”) pleural biopsy is prone to sampling error and has a modest yield. We assessed the safety and yield of ultrasound (US)-assisted closed pleural biopsy in the setting of undiagnosed effusions, and investigated how pleural morphology could guide the selection and execution of closed pleural biopsy. Methods: Patients with an exudative effusion who had had a non-diagnostic Thoracocentesis were prospectively stratified on imaging as having (A) an associated mass lesion (>10mm) abutting the chest wall; (B) diffuse pleural thickening (>10mm) and/or nodularity or (C) insignificant/no pleural thickening. US-assisted repeat Thoracocentesis and transthoracic fine-needle aspiration (TTFNA) were performed on patients stratified to (A),and if non-diagnostic on on-site analysis, followed by a Tru-Cut biopsy. US-assisted Thoracocentesis and Abrams needle biopsies were performed on all others aiming at the region(s) of interest (B) or low supra-diaphragmatic pleura (C). Results: Final diagnoses in 41 consecutive patients (30 males, 47+/-18 years) included pleural TB (n=21), malignancy (n=16) and other causes (n=4). Accurate diagnoses were obtained in 34 (82.9%) with US-assisted biopsy; thoracoscopy (n=6, 14.6%) or bronchoscopy (n=1) were required in the rest. The yield of US-assisted biopsy was higher for TB (19/21, 90.48%) than malignancy (12/16, 75.0%, p=0.37). One patient experienced mild haemoptysis following TTFNA. Conclusion: A diagnostic algorithm based on pleural morphology and US-assisted pleural biopsy has a high diagnostic yield and offers a safe first-line approach in the setting of undiagnosed pleural exudates.
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pleural controversy close needle pleural biopsy or thoracoscopy which first
Respirology, 2011Co-Authors: Coenraad F N Koegelenberg, Andreas H. DiaconAbstract:The most efficient and cost-effective approach to the diagnosis of pleural exudates remains controversial. Important considerations include the respective diagnostic yields of Thoracocentesis, closed pleural biopsy and thoracoscopy; the incremental gain in diagnostic yield when sequentially combining these investigations; and the role of various image modalities. The diagnostic yield of Thoracocentesis is in the order of 60% for malignancy and >90% for tuberculosis. A second aspiration may increase the yield for malignancy, but a third is generally superfluous. Many authorities consider thoracoscopy the investigation of choice in exudative pleural effusions where a Thoracocentesis was nondiagnostic and particularly when malignancy is suspected. It allows for the direct inspection of the pleura and for talc poudrage. Thoracoscopy has a diagnostic yield of 91–95% for malignant disease and as high as 100% for pleural tuberculosis. Access to thoracoscopy is, however, limited in many parts of the world, as significant resources and expertise are required. Blind closed pleural biopsy has a yield of 80% for tuberculosis and <60% for pleural malignancy. Recent studies suggest that CT and/or ultrasound guidance may improve the yield, particularly for malignancy, where it may be as high as 88% and 83%, respectively. A second Thoracocentesis combined with an image-assisted pleural biopsy with either an Abrams needle or cutting needle, depending on the setting, may therefore be an acceptable alternative to thoracoscopy. With such an approach, thoracoscopy may potentially be reserved for cases not diagnosed by means of closed pleural biopsy.
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Pleural controversy: close needle pleural biopsy or thoracoscopy-which first?
Respirology (Carlton Vic.), 2011Co-Authors: Coenraad F N Koegelenberg, Andreas H. DiaconAbstract:The most efficient and cost-effective approach to the diagnosis of pleural exudates remains controversial. Important considerations include the respective diagnostic yields of Thoracocentesis, closed pleural biopsy and thoracoscopy; the incremental gain in diagnostic yield when sequentially combining these investigations; and the role of various image modalities. The diagnostic yield of Thoracocentesis is in the order of 60% for malignancy and >90% for tuberculosis. A second aspiration may increase the yield for malignancy, but a third is generally superfluous. Many authorities consider thoracoscopy the investigation of choice in exudative pleural effusions where a Thoracocentesis was nondiagnostic and particularly when malignancy is suspected. It allows for the direct inspection of the pleura and for talc poudrage. Thoracoscopy has a diagnostic yield of 91–95% for malignant disease and as high as 100% for pleural tuberculosis. Access to thoracoscopy is, however, limited in many parts of the world, as significant resources and expertise are required. Blind closed pleural biopsy has a yield of 80% for tuberculosis and
Carl Roobottom - One of the best experts on this subject based on the ideXlab platform.
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letter to the editor post Thoracocentesis chest radiograph is it time for a change in practice
British Journal of Radiology, 2011Co-Authors: B O Olubaniyi, Nanda Venkatanarasimha, Carl RoobottomAbstract:The Editor, It appears to be common practice and almost customary for clinicians to request a chest radiograph following diagnostic or therapeutic Thoracocentesis. Understandably, this is done to exclude complications that can occur as a result of the procedure; however, a critical look into this reveals a range of unresolved issues. Firstly, routine chest radiographs are usually requested to exclude the most likely complication following Thoracocentesis i.e. pneumothorax. It had a 6% incidence following Thoracocentesis in a recently published systematic review and meta-analysis [1] and an incidence of between 3% and 20% in a previous study [2]. 1.7% of all patients following Thoracocentesis and 34.1% of those with demonstrated pneumothorax require chest tube insertion [1]. A retrospective audit conducted in our institution (Derriford Hospital, Plymouth, UK) yielded similar results whereby the incidence of post-Thoracocentesis pneumothorax was 5% with none requiring tube drainage. The indication for a chest radiograph was to exclude pneumothorax in all cases (Table 1). Pneumothorax is a much feared complication; however, it does not occur in the majority of patients and, when it does occur, about two-thirds of patients will not require further intervention. Important factors that should be taken into consideration as possible predictors of pneumothorax include symptoms such as pleuritic chest pain, cough and shortness of breath during or after Thoracocentesis, aspiration of air during the procedure and patients undergoing mechanical ventilation. Table 1 Results of a retrospective audit of post-Thoracocentesis chest radiographs at Derriford Hospital, Plymouth, UK Secondly, Thoracocentesis under ultrasound guidance has been shown to be associated with lower occurrence of pneumothorax and is identified as the “most important strategy to reduce pneumothorax rates” [1]. Although it is safer to perform Thoracocentesis under image guidance, the feasibility and impact on service delivery cannot be ignored, leading to wider unresolved issues. If radiologists are expected to perform all ultrasound-guided Thoracocentesis, the pros and cons need to be carefully thought through. Apart from lowering the occurrence of pneumothoraces, there is also the opportunity for trainee radiologists to acquire generic skills such as familiarity with ultrasound scanning and image interpretation applicable to a career in general or interventional radiology. However, it will increase the current workload and will probably require service expansion. The possibility of delay before a diagnosis is made has to be entertained if this becomes a planned procedure, which might not be acceptable, especially for urgent cases such as cases of suspected malignancy where prompt diagnosis is crucial. If non-radiologists embrace this to reduce pneumothorax rates, adequate training of the use of ultrasound guidance has to be taken more seriously. There are currently no clinical guidelines, which has led to varying practices across various institutions. Recognition of patients who will benefit from routine chest radiographs will not only avoid unnecessary exposure to radiation but also foster a more efficient and cost-effective use of limited resources. On balance, routine chest radiographs is clearly not indicated in all patients following diagnostic or therapeutic Thoracocentesis. Results from various studies over the past decade do not support routine chest radiographs following all Thoracocentesis [3-5]. Ultrasound-guided Thoracocentesis is undoubtedly beneficial and needs to be incorporated into well designed clinical guidelines, which are long overdue to maintain efficient service provision.
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Letter to the editor: Post-Thoracocentesis chest radiograph – is it time for a change in practice?
The British journal of radiology, 2011Co-Authors: B O Olubaniyi, Nanda Venkatanarasimha, Carl RoobottomAbstract:The Editor, It appears to be common practice and almost customary for clinicians to request a chest radiograph following diagnostic or therapeutic Thoracocentesis. Understandably, this is done to exclude complications that can occur as a result of the procedure; however, a critical look into this reveals a range of unresolved issues. Firstly, routine chest radiographs are usually requested to exclude the most likely complication following Thoracocentesis i.e. pneumothorax. It had a 6% incidence following Thoracocentesis in a recently published systematic review and meta-analysis [1] and an incidence of between 3% and 20% in a previous study [2]. 1.7% of all patients following Thoracocentesis and 34.1% of those with demonstrated pneumothorax require chest tube insertion [1]. A retrospective audit conducted in our institution (Derriford Hospital, Plymouth, UK) yielded similar results whereby the incidence of post-Thoracocentesis pneumothorax was 5% with none requiring tube drainage. The indication for a chest radiograph was to exclude pneumothorax in all cases (Table 1). Pneumothorax is a much feared complication; however, it does not occur in the majority of patients and, when it does occur, about two-thirds of patients will not require further intervention. Important factors that should be taken into consideration as possible predictors of pneumothorax include symptoms such as pleuritic chest pain, cough and shortness of breath during or after Thoracocentesis, aspiration of air during the procedure and patients undergoing mechanical ventilation. Table 1 Results of a retrospective audit of post-Thoracocentesis chest radiographs at Derriford Hospital, Plymouth, UK Secondly, Thoracocentesis under ultrasound guidance has been shown to be associated with lower occurrence of pneumothorax and is identified as the “most important strategy to reduce pneumothorax rates” [1]. Although it is safer to perform Thoracocentesis under image guidance, the feasibility and impact on service delivery cannot be ignored, leading to wider unresolved issues. If radiologists are expected to perform all ultrasound-guided Thoracocentesis, the pros and cons need to be carefully thought through. Apart from lowering the occurrence of pneumothoraces, there is also the opportunity for trainee radiologists to acquire generic skills such as familiarity with ultrasound scanning and image interpretation applicable to a career in general or interventional radiology. However, it will increase the current workload and will probably require service expansion. The possibility of delay before a diagnosis is made has to be entertained if this becomes a planned procedure, which might not be acceptable, especially for urgent cases such as cases of suspected malignancy where prompt diagnosis is crucial. If non-radiologists embrace this to reduce pneumothorax rates, adequate training of the use of ultrasound guidance has to be taken more seriously. There are currently no clinical guidelines, which has led to varying practices across various institutions. Recognition of patients who will benefit from routine chest radiographs will not only avoid unnecessary exposure to radiation but also foster a more efficient and cost-effective use of limited resources. On balance, routine chest radiographs is clearly not indicated in all patients following diagnostic or therapeutic Thoracocentesis. Results from various studies over the past decade do not support routine chest radiographs following all Thoracocentesis [3-5]. Ultrasound-guided Thoracocentesis is undoubtedly beneficial and needs to be incorporated into well designed clinical guidelines, which are long overdue to maintain efficient service provision.
B O Olubaniyi - One of the best experts on this subject based on the ideXlab platform.
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letter to the editor post Thoracocentesis chest radiograph is it time for a change in practice
British Journal of Radiology, 2011Co-Authors: B O Olubaniyi, Nanda Venkatanarasimha, Carl RoobottomAbstract:The Editor, It appears to be common practice and almost customary for clinicians to request a chest radiograph following diagnostic or therapeutic Thoracocentesis. Understandably, this is done to exclude complications that can occur as a result of the procedure; however, a critical look into this reveals a range of unresolved issues. Firstly, routine chest radiographs are usually requested to exclude the most likely complication following Thoracocentesis i.e. pneumothorax. It had a 6% incidence following Thoracocentesis in a recently published systematic review and meta-analysis [1] and an incidence of between 3% and 20% in a previous study [2]. 1.7% of all patients following Thoracocentesis and 34.1% of those with demonstrated pneumothorax require chest tube insertion [1]. A retrospective audit conducted in our institution (Derriford Hospital, Plymouth, UK) yielded similar results whereby the incidence of post-Thoracocentesis pneumothorax was 5% with none requiring tube drainage. The indication for a chest radiograph was to exclude pneumothorax in all cases (Table 1). Pneumothorax is a much feared complication; however, it does not occur in the majority of patients and, when it does occur, about two-thirds of patients will not require further intervention. Important factors that should be taken into consideration as possible predictors of pneumothorax include symptoms such as pleuritic chest pain, cough and shortness of breath during or after Thoracocentesis, aspiration of air during the procedure and patients undergoing mechanical ventilation. Table 1 Results of a retrospective audit of post-Thoracocentesis chest radiographs at Derriford Hospital, Plymouth, UK Secondly, Thoracocentesis under ultrasound guidance has been shown to be associated with lower occurrence of pneumothorax and is identified as the “most important strategy to reduce pneumothorax rates” [1]. Although it is safer to perform Thoracocentesis under image guidance, the feasibility and impact on service delivery cannot be ignored, leading to wider unresolved issues. If radiologists are expected to perform all ultrasound-guided Thoracocentesis, the pros and cons need to be carefully thought through. Apart from lowering the occurrence of pneumothoraces, there is also the opportunity for trainee radiologists to acquire generic skills such as familiarity with ultrasound scanning and image interpretation applicable to a career in general or interventional radiology. However, it will increase the current workload and will probably require service expansion. The possibility of delay before a diagnosis is made has to be entertained if this becomes a planned procedure, which might not be acceptable, especially for urgent cases such as cases of suspected malignancy where prompt diagnosis is crucial. If non-radiologists embrace this to reduce pneumothorax rates, adequate training of the use of ultrasound guidance has to be taken more seriously. There are currently no clinical guidelines, which has led to varying practices across various institutions. Recognition of patients who will benefit from routine chest radiographs will not only avoid unnecessary exposure to radiation but also foster a more efficient and cost-effective use of limited resources. On balance, routine chest radiographs is clearly not indicated in all patients following diagnostic or therapeutic Thoracocentesis. Results from various studies over the past decade do not support routine chest radiographs following all Thoracocentesis [3-5]. Ultrasound-guided Thoracocentesis is undoubtedly beneficial and needs to be incorporated into well designed clinical guidelines, which are long overdue to maintain efficient service provision.
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Letter to the editor: Post-Thoracocentesis chest radiograph – is it time for a change in practice?
The British journal of radiology, 2011Co-Authors: B O Olubaniyi, Nanda Venkatanarasimha, Carl RoobottomAbstract:The Editor, It appears to be common practice and almost customary for clinicians to request a chest radiograph following diagnostic or therapeutic Thoracocentesis. Understandably, this is done to exclude complications that can occur as a result of the procedure; however, a critical look into this reveals a range of unresolved issues. Firstly, routine chest radiographs are usually requested to exclude the most likely complication following Thoracocentesis i.e. pneumothorax. It had a 6% incidence following Thoracocentesis in a recently published systematic review and meta-analysis [1] and an incidence of between 3% and 20% in a previous study [2]. 1.7% of all patients following Thoracocentesis and 34.1% of those with demonstrated pneumothorax require chest tube insertion [1]. A retrospective audit conducted in our institution (Derriford Hospital, Plymouth, UK) yielded similar results whereby the incidence of post-Thoracocentesis pneumothorax was 5% with none requiring tube drainage. The indication for a chest radiograph was to exclude pneumothorax in all cases (Table 1). Pneumothorax is a much feared complication; however, it does not occur in the majority of patients and, when it does occur, about two-thirds of patients will not require further intervention. Important factors that should be taken into consideration as possible predictors of pneumothorax include symptoms such as pleuritic chest pain, cough and shortness of breath during or after Thoracocentesis, aspiration of air during the procedure and patients undergoing mechanical ventilation. Table 1 Results of a retrospective audit of post-Thoracocentesis chest radiographs at Derriford Hospital, Plymouth, UK Secondly, Thoracocentesis under ultrasound guidance has been shown to be associated with lower occurrence of pneumothorax and is identified as the “most important strategy to reduce pneumothorax rates” [1]. Although it is safer to perform Thoracocentesis under image guidance, the feasibility and impact on service delivery cannot be ignored, leading to wider unresolved issues. If radiologists are expected to perform all ultrasound-guided Thoracocentesis, the pros and cons need to be carefully thought through. Apart from lowering the occurrence of pneumothoraces, there is also the opportunity for trainee radiologists to acquire generic skills such as familiarity with ultrasound scanning and image interpretation applicable to a career in general or interventional radiology. However, it will increase the current workload and will probably require service expansion. The possibility of delay before a diagnosis is made has to be entertained if this becomes a planned procedure, which might not be acceptable, especially for urgent cases such as cases of suspected malignancy where prompt diagnosis is crucial. If non-radiologists embrace this to reduce pneumothorax rates, adequate training of the use of ultrasound guidance has to be taken more seriously. There are currently no clinical guidelines, which has led to varying practices across various institutions. Recognition of patients who will benefit from routine chest radiographs will not only avoid unnecessary exposure to radiation but also foster a more efficient and cost-effective use of limited resources. On balance, routine chest radiographs is clearly not indicated in all patients following diagnostic or therapeutic Thoracocentesis. Results from various studies over the past decade do not support routine chest radiographs following all Thoracocentesis [3-5]. Ultrasound-guided Thoracocentesis is undoubtedly beneficial and needs to be incorporated into well designed clinical guidelines, which are long overdue to maintain efficient service provision.
Hiroyuki Daiko - One of the best experts on this subject based on the ideXlab platform.
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Postoperative pulmonary complications and Thoracocentesis associated with early versus late chest tube removal after thoracic esophagectomy with three-field dissection: a propensity score matching analysis.
Surgery today, 2018Co-Authors: Takuji Sato, Takeo Fujita, Naoya Okada, Hisashi Fujiwara, Takashi Kojima, Ryuichi Hayashi, Hiroyuki DaikoAbstract:To evaluate the safety of early chest tube removal after thoracic esophagectomy with three-field dissection. This prospective cohort study evaluated patients who underwent thoracic esophagectomy with three-field dissection during 2013–2015. Patients were divided into two groups according to whether they underwent early or late chest tube removal. Propensity score matching in a 1:1 ratio was applied. We compared the incidences of postoperative pulmonary complications and Thoracocentesis in the two groups. After propensity score matching, 89 patients in each group were analyzed. There was no significant difference between the groups in the incidences of pulmonary complications or Thoracocentesis. Significantly more patients achieved first mobilization within 15 h postoperatively in the early removal group (89.8%) than in the late removal group (52%, p
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postoperative pulmonary complications and Thoracocentesis associated with early versus late chest tube removal after thoracic esophagectomy with three field dissection a propensity score matching analysis
Surgery Today, 2018Co-Authors: Takuji Sato, Takeo Fujita, Naoya Okada, Hisashi Fujiwara, Takashi Kojima, Ryuichi Hayashi, Hiroyuki DaikoAbstract:To evaluate the safety of early chest tube removal after thoracic esophagectomy with three-field dissection. This prospective cohort study evaluated patients who underwent thoracic esophagectomy with three-field dissection during 2013–2015. Patients were divided into two groups according to whether they underwent early or late chest tube removal. Propensity score matching in a 1:1 ratio was applied. We compared the incidences of postoperative pulmonary complications and Thoracocentesis in the two groups. After propensity score matching, 89 patients in each group were analyzed. There was no significant difference between the groups in the incidences of pulmonary complications or Thoracocentesis. Significantly more patients achieved first mobilization within 15 h postoperatively in the early removal group (89.8%) than in the late removal group (52%, p < 0.01). Multivariate analysis revealed that early chest tube removal was not a risk factor for pulmonary complications or Thoracocentesis. Independent risk factors for pulmonary complications were a history of pulmonary disease (odds ratio: 0.81 [0.63–0.98]; p = 0.02) and neoadjuvant chemotherapy (odds ratio: 0.67 [0.32–0.96]; p = 0.04). Early chest tube removal is as safe and feasible as late chest tube removal after thoracic esophagectomy with three-field dissection.