THE IMPACT OF THORACOSCOPY ON THE MANAGEMENT OF PLEURAL DISEASE
THE IMPACT OF THORACOSCOPY ON THE MANAGEMENT OF PLEURAL DISEASE
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DOI：
10.1378/chest.107.3.845
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发表时间：
1995-03-01
期刊：
影响因子：
9.6
通讯作者：
RICE, TW
中科院分区：
文献类型：
--
作者：
HARRIS, RJ;KAVURU, MS;RICE, TW
研究目的：描述胸腔镜检查的诊断功效、发病率和患者结局;量化胸腔镜检查对临床管理的直接影响;并确定与胸腔镜检查发现恶性肿瘤相关的术前变量，以帮助患者选择。设计：连续胸腔镜检查胸膜疾病病例的回顾性图表审查。设置：单个三级医疗中心。患者：1987年至1992年连续5年内（1987年至1992年）182例因胸膜疾病接受胸腔镜检查的患者，测量和结果：最终诊断为恶性98例（54%），良性58例（32%），特发性26例（14%）。胸腔镜检查对恶性肿瘤的诊断敏感性为95%，对良性疾病的诊断敏感性为100%。41例术前非诊断性闭合胸膜活检患者中有27例（66%）通过胸腔镜检查显示胸膜炎，35例术前至少有2份阴性胸膜细胞学标本的患者中有24例（69%）通过胸腔镜检查显示胸膜炎。通过预先制定的标准进行的图表审查显示，155例（85%）患者从胸腔镜检查中获得的信息直接影响了治疗。然而，37例（20%）患者至少有1例围手术期并发症（15%严重，8%轻微）。10例（6%）患者在进行胸腔镜检查的同一住院期间死亡，但无患者在48小时内死亡。有1例胸腔镜相关死亡。62例（34%）患者在胸腔镜检查后6个月内死亡（全因死亡）。47例（48%）胸腔镜检查时存在胸内恶性肿瘤的患者在6个月内死亡。胸腔镜检查发现有恶性胸膜疾病的患者更可能有术前恶性肿瘤病史（p=0.001）。年龄超过50岁与胸腔镜检查发现恶性肿瘤相关（p=0.04）。淋巴细胞和出血性积液与恶性肿瘤相关（p=0.004）。结论：（1）胸腔镜检查可提高胸腔穿刺和闭式胸膜活检不能确诊的良恶性胸腔积液的检出率; (2)胸腔镜检查直接影响85%患者的临床治疗。(3)接受三级护理的患者可能会发生严重的并发症。(4)对于可疑恶性胸膜疾病的评估，胸腔镜检查在有恶性肿瘤病史和淋巴细胞性、出血性、高LDH积液的老年患者中具有最高的诊断率。
Study objective: To describe the diagnostic efficacy, morbidity, and patient outcome of thoracoscopy; to quantify the direct impact of thoracoscopy on clinical management; and to determine preoperative variables associated with finding malignancy at thoracoscopy to aid patient selection.Design: Retrospective chart review of consecutive cases of thoracoscopy for pleural disease.Setting: Single tertiary medical center.Patients: One hundred eighty-two consecutive patients who underwent thoracoscopy for pleural disease over a 5-year period (from 1987 through 1992).Measurements and results: Final diagnoses were 98 (54%) malignant, 58 (32%) benign, and 26 (14%) idiopathic. Thoracoscopy had a diagnostic sensitivity of 95% for malignancy and 100% for benign disease. Malignancy was shown by thoracoscopy in 27 of 41 (66%) patients who had a preoperative nondiagnostic closed pleural biopsy, and in 24 of 35 (69%) patients who had at least 2 preoperative negative pleural cytologic specimens. Chart review by preestablished criteria showed information obtained from thoracoscopy directly influenced treatment in 155 (85%) patients. Thirty-seven (20%) patients, however, had at least one perioperative complication (15% major, 8% minor). Ten (6%) patients died during the same hospitalization in which a thoracoscopy was performed, although none died within 48 h. There was one thoracoscopy-related death. Sixty-two (34% patients died within 6 months of thoracoscopy (death by all causes). Forty-seven (48%) patients who had intrathoracic malignancy present at thoracoscopy died within 6 months. Patients found to have malignant pleural disease by thoracoscopy were more likely to have a preoperative history of a malignancy (p=0.001). Age more than 50 years was associated with finding malignancy at thoracoscopy (p=0.04). A combined lymphocytic and hemorrhagic effusion was associated with malignancy(p=0.004). Preoperative pleural data showed that idiopathic effusions had a significantly lower median lactate dehydrogenase (LDH) value (192, which was normal) compared with malignant or benign effusions.Conclusions: (1) Thoracoscopy increases yield for malignant and benign disease when thoracentesis and closed pleural biopsy are nondiagnostic. (2) Thoracoscopy directly affects clinical management in 85% of patients. (3) Significant complications can occur in patients receiving tertiary care. (4) For the evaluation of suspected malignant pleural disease, thoracoscopy has its greatest diagnostic yield in older patients who have a history of malignancy and who present with a lymphocytic, hemorrhagic, high LDH effusion.