Role of medical thoracoscopy and closed-blind pleural biopsy in undiagnosed exudative pleural effusions: a single-center experience of 348 patients.

BACKGROUND

Medical thoracoscopy (MT) performed either with rigid or the semirigid thoracoscope has been shown to have diagnostic accuracy superior to closed-blind pleural biopsy (CBPB) in exudative pleural effusions (EPE), which remain undiagnosed after thoracentesis. However, in resource-constrained settings, CBPB continues to be performed. In this study, we compare the outcome of thoracoscopy with CBPB.

METHODS

This was a retrospective analysis of data collected over a 10-year period (2004 to 2014) of patients who underwent pleural biopsy for the evaluation of undiagnosed EPE. We report the comparative procedural yield and safety of CBPB and MT.

RESULTS

During the study period, 84 and 264 patients (mean age, 49.8 y) underwent CBPB and MT, respectively. No clinical or radiologic finding could predict the correct histologic diagnosis with reasonable certainty in patients with undiagnosed EPE. The procedural yield of MT was significantly higher than CBPB (93.2% vs. 84.5%, P=0.02). The yield of MT significantly improved when chest ultrasound was used to guide the choice and point of entry of the thoracoscope (98.7% vs. 90.6%, P=0.04). Thoracoscopy was associated with mortality and complication rates of 0.37% and 5.6%, respectively, whereas the complication rate with CBPB was 8.3% with no mortality.

CONCLUSIONS

MT is the procedure of choice in the evaluation of undiagnosed EPE, due to its higher success rate and an acceptable safety profile. However, in centers where thoracoscopy is not feasible, CBPB should be performed in preference to initiating empiric treatment.