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

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

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)

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%

National Guidance

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?

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

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%)

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

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

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

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)

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 2012-2013)

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

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

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