1. Day-case medical thoracoscopy
J. Fallon, J. Pepperell
Musgrove Park Hospital
Taunton & Somerset NHS Foundation Trust

2. Background Suspected malignant pleural effusion
Negative pleural cytology
Tissue required for diagnosis and staging
Medical thoracoscopy

5. BTS Pleural Disease Guideline 2010 Thorax, August 2010 Vol 65 Supplement II
CYTOLOGY
Malignant effusions can be diagnosed by pleural fluid cytology in about 60% of cases. (B)
The yield from sending more than two specimens (taken on different occasions) is very low and should be avoided. (B)
THORACOSCOPY
Thoracoscopy is the investigation of choice in exudative pleural effusions where a diagnostic pleural aspiration is inconclusive and malignancy is suspected. (C)

6. Local anaesthetic thoracoscopy
Safe and well tolerated procedure
Major complications (eg, empyema, haemorrhage and pneumonia) occur in only 2.3% and death is rare at 0.40%
It has a diagnostic sensitivity for malignant pleural disease of 92.6%

7. National Guidance

9. Aims of audit Is day-case thoracoscopy safe and efficient?
Does day-case thoracoscopy reduce number of bed days required in this cohort of patients?

10. Patient cohort Feb 2013 – Feb 2014
53 patients had medical thoracoscopy
31 patients admitted
22 day-case procedures
Data collection
number of bed days required
readmission rates
repeat procedures

11. Results Thoracoscopy patients (n=53) Elective admissions (n=31)
Day-case
(n=22)
Initial admission bed days (average)
3.8
Re-admission within 6 months
13 (42%)
9 (41%)
Re-admission bed days (average)
3.5
Total bed days (average)
7.3
Further pleural procedure(s) within 6 months
11 (35%)
11 (50%)

12. Results
Figure 1. Elective admission for thoracoscopy vs. day case thoracoscopy

13. Talc poudrage
21 of the 31 patients admitted for thoracoscopy underwent talc poudrage
7/21 (33%) required re-admission for pleural disease within 6 months
8/21 (38%) required a further pleural procedure
10 patients did not have talc poudrage
4/10 (40%) required re-admission for pleural procedure
5/10 (50%) required a further pleural procedure

14. Trapped lung Post-thoracoscopy hydropneumothorax
3/22 day-case procedures
2/3 required further procedure
4/31 inpatient procedures
3/4 required further pleural procedure

15. Further pleural procedures
Day-case patients (22)
Chest drain & pleurodesis (2)
Pleural aspiration (1)
Indwelling pleural catheter (2)
Further thoracoscopy if negative biopsy or TAPPS trial (5)
Surgical biopsy (1)
Inpatients (31)
Chest drain (4)
Pleural aspiration (5)
Indwelling pleural catheter (3)
Further thoracoscopy (2)

16. Bed days saved
Average inpatient stay for medical thoracoscopy patients = 3.8 days
One bed day average cost in the UK £273*
22 patients x 3.8 days = 83.6 bed days saved
£22,823 saved during this period
*(Department of Health Reference Costs )

17. Conclusions
Day-case thoracoscopy is a safe and efficient means of obtaining a tissue diagnosis in suspected pleural malignancy
It reduces the number of bed days required for this patient cohort
It does not lead to increased re-admission rates for this group
In combination with indwelling pleural catheter, this method could lead to full outpatient management of this cohort

18. Future prospects TAPPS trial outcomes
Day-case thoracoscopy outcomes from multi-centre database

19. Acknowledgments Thank you Any questions? Dr Justin Pepperell
Dawn Redwood & Tania Wainwright
Any questions?