WHAT WE NEED FOR THORACOSCOPY

Transcription

1 WHAT WE NEED FOR THORACOSCOPY Medical School Marios Froudarakis, MD Department of Pneumonology University Hospital of Alexandroupolis Democritus University of Thrace Dedicated Course on Thoracoscopy & Pleural Techniques. Marseille

2 What we need: easy! Business plan Few money Some skills-training A place to do Lot of enthousiasm

3 Few money Few or more Support by friends Support by industry Photo - JPEG Photo - JPEG

4 Equipment Trocar 5, 7, 9, 11mm Optics Direct or oblique vision Diameter 2, 5, 7, 9mm Biopsy forceps connected to the optic Set pleurodesis Set drainage

5 Thoracoscopy: which tool? Rigid: classic Semi-flexible: modern

6 Rigid the classic tool Advantages Large biopsies Adhesionlysis Parenchyma biopsies Limitations Need some experience Pain at the port of entry Troubles with the surgeons

7 Flex-Rigid: advantages-limitations Advantages Looks like bronchoscope Compatible with electrocauthery, laser Rx, NBI Interfaces well with existing processor (CV-160) and light source (EVIS EXERA 160, EVIS 100, 140) Flexbility and therefore ability to investigate difficult areas Limitations Small size of biopsies Adhesionlysis difficult

8 Flex-rigid YUV420 codec

9 Diagnostic accuracy of flex and flex-rigid in malignant PE Series Patients (n) Thoracoscopy (n) Accuracy (%) Benign (n) Non specific (n) Gwin et al, 1975 (flexible) 9 9 4/4(100%) 4 1 Kerby et al 1975 (flexible) /11 (72.2%) 2 6 Davidson et al 1988 (flexible) /24 (83.3%) 6 4 Edmondstone 1990 (flexible) /20 (65%) 8 7 Robinson et al 1995 (flexible) /4 (100%) 1 7 Emad &Rezaian 1998 (flexible) /20 (85%) Total flex /83 (79.5%) 36/144 (25%) 42/144 (29%) McLean et al 1998 (flex-rigid) /16 (81%) 8 - Ernst et al 2004 (flex-rigid) /14 (28.5%) - - Lee et al 2007 (flex-rigid) /36 (94%) 13 2 Munavvar et al 2007 (flex-rigid) /37 (86.5%) 17 5 Wang et al, 2008 (flex-rigid) /21 (90.5%) 6 2 Total flex-rigid /124 (82.2%) 44/178 (24.7%) 9/132 (6.8%) Froudarakis M, review

10 Series Patients (n) Thoracoscopy (n) Diagnostic accuracy of rigid in malignant PE Accuracy (%) Benign (n) Non specific De Camp et al /50 (94%) Canto et al /137 (94%) Weissberg et al /70 (98.5%) 49 8 Boutin et al /128 (88%) Boutin et al /150 (87%) Enk & Viskum /137 (69%) 78 1 Page et al /91 (99%) Wu et al /74 (96%) 72 9 Hucker et al /76 (80%) 5 21 Menzies et al /44 (96%) 53 9 Ohri et al /38 (97%) 11 7 Harris et al, /98 (94.9%) 58 (31.8) 26 (14.2) Colt /12 (100%) 14 2 Hansen et al /103 (88%) Janssen et al /349 (91%) Ferrer et al /56 (89%) Simpson /73/ (94.5%) 12 4 Fletcher et al /42 (95%) 4 4 Medford et al /63 (95.2%) Total /1811 (91.4%) 1811/3120 (58%) (n) 976/3120 (31.3%) 415/3120 (8.3%) Froudarakis M, review

11 Cost of instruments Rigid: 15-20,000 euros Total equipment Optics Trocarts Forceps Camera and processor Multi adaptor light source Flex-rigid: 20-50,000 Device 20,000 Excera system +

12 If you have more buy both! (Like Paco says) Yet, RIGID Larger biopsies Mesothelioma Molecular techniques Adhesionlysis Empyema treatment Lower cost Porsche Mahindra Reva

13 Thoracoscopy: How to get skills ERS Course on Medical Thoracoscopy, Marseille and Alexandroupolis

14 Get skills by studying with the experts Yo Aeloni Dedicated books Henri Colt Philippe Astoul Marc Noppen F. Rodriguez- Panadero (Paco) Fellowships Yo Aeloni GF Tassi JM Tschopp

15 Enthousiasm To convince the boss TIFF (Uncompressed) To convince collegues of work Good relation with thoracic surgeons

16 Time from initial symptoms to thoracoscopic diagnosis of pleural effusion Year duration in months (mean ± SD) ± ± ± ± Overall p= Data on file

17 After meet the basic conditions Photo - JPEG Nice assistants Happy personnel Place to do

18 Endoscopy suite Cardiovascular monitoring Respiratory monitoring Rescusitation devices A procedure table Oxygen supplementation Aspiration equipment to drain and collect fluid Overhead lighting Chest tube with seal, light surgical instrumentation

19 Instrumentation Needles and syringes Scalpels Boutin needle Scissors, forceps and clamps Trocars Chest drain and sutures Soap and warm saline Betadin Gauge Formol On-site evaluation?

20 Trained and dedicated personnel Time saving Important for the outcome Know how to react when trouble (automatisms) Always happy

21 Find the patients Congratulations: you made it Photo - JPEG Photo - JPEG Photo - JPEG

22 The day before the procedure: Review the patient Full history and physical examination Be sure of no contraindications History/examination Blood results Anaesthetic review/ ECG/ ECHO Review radiology Explain the procedure Consent (in some countries mandatory)

23 Patients selection When starting carefully selection of patients Make the right choice: young, rich, healthy, handsome and smart Good PS Long Survival Undiagnosed pleural effusions Talc poudrage After diagnosis

24 Preparation Lateral decubitus position Arm fully extended overhead Port of entry: mid axillary line

25 Standardize the method Photo - JPEG Photo - JPEG Technique Indications Undiagnosed pleural effusions Talc poudrage After diagnosis Photo - JPEG Photo - JPEG Photo - JPEG Photo - JPEG

26 Flex-rigid

27 Diagnostic thoracoscopy and staging Thoracoscopy When lung cancer is associated to pleural effusion we must prove malignancy 47-year old, male, non-smoker Lung adenocarcinoma

28 Pleurodesis: aim Improvement of quality of life Symptoms improvement Maintain the Performance Status H year old, female, non-smoker breast adenocarcinoma

29 Collect your data Data base of your patients Think of research Simple questions Simple answers Participate to protocols

30 Thoracoscopy and clinical research Simple question: Fever of Talcage vs Diagnostic Thoracoscopy Froudarakis M, Klimathianaki M, Pougounias M. Chest 2006;129:356-61

31 Thoracoscopy and clinical research Evolution of inflammatory cells CRP WBC PN LP Froudarakis M, Klimathianaki M, Pougounias M. Chest 2006;129:356-61

32 Thoracoscopy in COPD with PNO 41 Patients with PSP due to COPD were recruited for pleuroscopy and talc poudrage under local anaesthesia Pain scores, safety and outcome Lee P, et al. Chest 2004; 125:

33 Thoracoscopy in COPD with PNO Deaths due to Respiratory status Comorbidities

34 Why increased mortality in such patients Froudarakis M et al, Respiration 2010

35 Why increased mortality in such patients Froudarakis M et al, Respiration 2010

36 European Association of Bronchology and Interventional Pulmonology (EABIP) Article of the month

37 Participate to protocols Safety Of Talc poudrage In Malignant pleural effusion (SOTIM study) Safety Of Talc poudrage In Pneumothorax (SOTIP study) Participating Centers Astoul Philippe, Marseille France Bolliger Chris, Cape Town South Africa Driesen Peter, Turnhout Belgium Froudarakis Marios, Heraklion Greece Janssen Julius, Nijmegen the Netherlands Loddenkemper Robert, Berlin Germany Marquette Charles Hugo, Lille France Noppen Marc, Brussels Belgium Rodriguez-Panadero Francisco, Sevilla Spain Tassi Gianfranco, Brescia Italy Tschopp Jean-Marie, Montana Switzerland ERS Berlin 2001 Group on Medical Thoracoscopy Study Coordinators Jean Marie Tschopp Julius Janssen Data Collection Center Julius Janssen Janssen J et al, Lancet 2007;369:1535-9

38 WHAT WE NEED Enthousiasm

39 ERS course, 2008 Αλεξανδρούπολη Ευχαριστώ