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Single port videothoracoscopy under epidural anesthesia for undiagnosed pleural effusions. An alternative approach.

P effusion is a common medical problem and may occur due to various causes.1 Diagnostic investigations include thoracentesis, closed pleural biopsy, thoracoscopy (TC), video-assisted thoracic surgery (VATS), and thoracotomy.2 Thoracoscopy is a minimally invasive procedure that allows visualization of the pleural space and intrathoracic structures, allows obtaining pleural biopsies under direct vision, therapeutic drainage of effusions, and pleurodesis in one session.2 Pulmonologists usually perform TC under local anesthesia, regional anesthesia, and/or sedation with the use of a single port in a thoracoscopy suite.3 We planned to perform videothoracoscopy (VT) in the operation room under general anesthesia (GA) in our first patient. In order to avoid the disadvantages of GA in a 73 year-old female patient with hypertension and compensated cardiac failure referred to our department due to undiagnosed pleural effusion, we performed single port VT under thoracic epidural anesthesia (TEA) in September 2002. Following successful initial use in 3 consecutive patients in 2 months with a median age of 71 years, we started using the method as a standard procedure in patients presenting with undiagnosed pleural effusion. The anesthesiologist performed epidural anesthesia using an epidural catheter at the T4-T5 level. After the initial local anesthesia of skin using 2 ml of 2% lidocaine hydrochloride (Jetmonal ampoule 2%, Adeka Drug Co., Samsun, Turkey), the anesthesiologist placed the 18 G epidural catheter (Portex® Epidural Minipac, Smiths Medical ASD Inc., Keene, NH 03431, USA) and directed it approximately 2 cm downwards in the epidural space. Anesthesia was then administered using a combination of 6 ml of 0.05% bupivacaine (Marcaine 0.05% vial, AstraZeneca Drug Co., Istanbul, Turkey), 2 ml of fentanyl (Fentanyl-Janssen ampoule, Janssen Pharmaceutica N.V., Beerse, Belgium), and 2 ml of saline solution. Following the initial dose, we positioned the patient lying on the affected side. Once the anesthesia was effective, we positioned the patient with the affected side up. We monitored the patients for heart rate, blood pressure, and pulse oxymetry. The patients received O2 through a face mask at a rate of 3-5 l/min during the procedure. All patients were operated from the sixth or seventh intercostal space at the midaxillary line on the affected side. Iodine solution was used for skin preparation. After a 2 cm skin incision, we used blunt dissection to enter the pleural space. In order to exclude any adhesions, we used digital exploration. After placing the 12 mm Thoracoport, we introduced the conventional Hopkins straight forward telescope thoracoscope (Karl Storz Endoskope, Germany) with an attached CCD camera (Telecam DX PAL, Karl Storz Endoskope, Germany) to the pleural space for visual exploration and biopsy. Following biopsy, we placed a 32 Fr chest tube attached to an underwater seal drainage system. Before the patients were transferred to a bed, a final dose of 10 ml of the drug cocktail was administered, and the epidural catheter was withdrawn. All biopsy specimen were sent for pathologic examination. Between September 2002 and June 2011, 50 patients underwent VT under TEA. Following permission granted by the Local Ethical Committee for an archive study, the files of all these patients referred to the Thoracic Surgery Department of Bursa Yuksek Ihtisas Hospital for Education and Research due to undiagnosed pleural effusion were reviewed. The age, gender, affected side, time until anesthesia, duration of operation, complications (if any), diagnosis, additional procedures (if any), and length of hospital stay were noted from the charts. We used Microsoft Office 2007 Excel software in the data evaluation. There were 26 male (52%) and 24 female (48%) patients with an average age of 59.3 ± 10.9 years (range 36-83 years). Forty patients were more than 50 years old. Hypertension was noted in 38 (76%), cardiac dysfunction in 26 (52%), chronic pulmonary disease in 24 (48%), cardiac rhythm disorders in 15 (30%), and diabetes in 8 (16%) of the patients. The affected side was right in 30 (60%), and left in the remaining 20 (40%). The anesthesia was started at an average of 15 minutes (range 12-18 minutes), and the average operation time was 24 minutes (range 20-30 minutes). The diagnosis was pleural effusion due to infections other than tuberculosis in 20 (40%), pleurisy due to tuberculosis in 14 (28%) (Figure 1), malignant pleural mesothelioma in 7 (14%), and metastatic malignancy in 5 (10%) patients. In 4 patients (8%), no differential diagnosis could be made. In 12 patients with malignant pleural effusion, chemical pleurodesis with either talc slurry (n=8), or bleomycin (n=4) as an adjunct to drainage following diagnosis was performed. Patients were discharged from the hospital on the day of drain removal. The average length of hospital stay was 5.1 ± 2.3 days (3-11 days).