Day Case Local Anaesthetic Thoracoscopy: Experience from 2 District General Hospitals in the United Kingdom

Our plain-English summary of Day Case Local Anaesthetic Thoracoscopy: Experience from 2 District General Hospitals in the United Kingdom, by M. Turner, F. Craighead, J.D. MacKenzie, et al (Medical Sciences, 2023).

The study

• Authors: M. Turner, F. Craighead, J.D. MacKenzie, A. Aujayeb
• Journal: Medical Sciences
• Published: 2023;11(1)
• Cited by: 10 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Local anaesthetic thoracoscopy (LAT) can be a vital procedure for diagnosis of unexplained pleural effusions. Traditionally, poudrage for pleurodesis and insertion of a large bore drain necessitated admission. There has been a shift towards performing LAT as a day case procedure with indwelling pleural catheter (IPC) insertion. This was advocated during the COVID pandemic by the British Thoracic Society (BTS). To determine the feasibility of such pathways, continuous evaluations are required.

Methods: All day case LAT procedures with IPC insertion, performed in theatre, were identified at two large district general hospitals (Northumbria HealthCare in the North East of England and Victoria Hospital, NHS Fife, in Scotland). Rapid pleurodesis with talc was not performed due to local staffing problems. All patients had their LAT in theatre under conscious sedation with a rigid scope. Demographics, clinical, radiological and histopathological characteristics and outcomes were collected.

Results: 79 patients underwent day case LAT. The lung did not deflate, meaning biopsies were not enabled, in four of the patients. The mean age was 72 years (standard deviation 13). Fifty-five patients were male and twenty-four were female. The main diagnoses were lung cancers, mesotheliomas and fibrinous pleuritis with an overall diagnostic sensitivity of 93%. Other diagnoses were breast, tonsillar, unknown primary cancers and lymphomas. Seventy-three IPCs were simultaneously placed and, due to normal macroscopic appearances in two patients, two large bore drains were placed and removed within one hour of LAT termination. Sixty-six (88%) patients were discharged on the same day. Seven patients required admission: one for treatment of surgical emphysema, four because they lived alone, one for pain control and one for control of a cardiac arrythmia. Within 30 days, there were five IPC site infections with two resultant empyemas (9%), with no associated mortality. Two patients developed pneumonia requiring admission and one patient required admission for pain management. The median number of days for which the IPCs remained in situ was 78.5 days (IQR 95). The median length of stay (LoS) was 0 days (IQR 0). No patients required further interventions for pleural fluid management.

Conclusions: Day case LAT with IPC insertion is feasible with this current set up, with a median stay of 0 days, and should be widely adopted. The health economics of preventing admission are considerable, as our previous analysis showed a median length of stay of 3.96 days, although we are not comparing matched cohorts.

In plain English

This retrospective quality-improvement project reviewed patients having day case local anaesthetic thoracoscopy, a sedated camera examination and biopsy of the chest lining. Patients were treated at two UK hospitals, in Fife and Northumbria, between March 2020 and June 2022. The article does not discuss asbestos exposure. Of 79 patients, four could not have biopsies because of adhesions, so 75 were analysed. Seventy-three received a long-term chest drain (indwelling pleural catheter) at the same procedure; two instead had large-bore drains removed after the procedure. Diagnoses included chronic fibrinous pleuritis (28), lung cancer (22) and mesothelioma (18). Four labelled fibrinous pleuritis were later found by surgery to have mesothelioma. The procedure gave the diagnosis in 70 cases, a sensitivity of 93%. Sixty-six patients (88%) went home the same day. Seven were admitted, four of them because they lived alone. Within 30 days there were five catheter site infections, two leading to empyema, and no associated deaths; the authors put their overall complication rate at 9%. The authors concluded the approach was feasible, noting there was no matched comparison group and patients were pre-selected.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective, non-randomised observational quality-improvement project (case series) reviewing patient notes
• Who was studied: Consecutive patients having day case local anaesthetic thoracoscopy at Victoria Hospital, NHS Fife (Scotland) and Northumbria Healthcare NHS Trust (England), March 2020 to June 2022. 79 underwent the procedure and 75 were analysed after 4 could not have biopsies. Mean age was 72 years (standard deviation 13).
• Exposure: No asbestos or other environmental exposure was studied. The study examined a procedure: day case local anaesthetic thoracoscopy with simultaneous indwelling pleural catheter insertion, without talc pleurodesis.
• Main results:
  • Of 79 patients who underwent day case LAT, the lung could not be deflated in 4 because of significant adhesions, so 75 patients were analysed.
  • Seventy-three indwelling pleural catheters were placed at the time of LAT. In two patients, large-bore drains were placed instead and removed post-operatively.
  • Among the 75 analysed patients, diagnoses from thoracoscopic biopsies were: chronic fibrinous pleuritis 28 (37%), lung cancer 22 (29%), mesothelioma 18 (24%), breast cancer 2 (3%), cancer of unknown primary 2 (3%), lymphoma 2 (3%) and tonsillar cancer 1 (2%).
  • Four patients with chronic fibrinous pleuritis later underwent video-assisted thoracoscopic surgery (VATS) and were diagnosed with mesothelioma.
  • LAT provided the diagnosis in 70 cases, a diagnostic sensitivity of 93%.
  • Sixty-six patients (88%) were discharged on the same day. Seven required admission: four because they lived alone, one for pain control, one for a cardiac arrhythmia and one for progressive surgical emphysema.
  • Within 30 days there were five catheter site infections, with two resulting empyemas, and no associated deaths. Two patients were admitted with community-acquired pneumonia and one for tumour-related pain.
  • The authors described their overall complication rate as 9%.
  • The mean length of stay was 0 days (standard deviation 0.2), and no patients needed further procedures for pleural fluid.
  • Because aggressive drainage was not used, the median time the catheters stayed in place was nearly 80 days.
• The authors' conclusion: The authors concluded that, while awaiting randomised evidence, day case LAT with catheter insertion can be performed with a reduced length of stay while preserving diagnostic sensitivity. They added that complication rates and any health economic savings need study in much larger datasets.
• Limitations the authors state:
  • The study was non-randomised and observational.
  • There was no matched control group, and no formal health economics were possible.
  • There was clear selection bias, because patients were pre-selected as suitable for a day case procedure.
  • Aggressive drainage was not pursued, so catheters stayed in place for a long time.
  • The number of district nurse visits needed for drainage, and their cost, were not counted.

Topics

Medical terms in this study, explained in our Lexicon: Thoracoscopy, Pleural Effusion, Pleurodesis, Indwelling Pleural Catheter, Talc, Lung Cancer, Mesothelioma, Emphysema.

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