Performing medical thoracoscopy safely in the outpatient setting: A case report

Abstract

BACKGROUND

Outpatient medical thoracoscopy offers a minimally invasive alternative to inpatient or surgical thoracoscopy for pleural biopsy, potentially reducing healthcare utilization while maintaining safety.

CASE SUMMARY

A 71-year-old man with metastatic epidermal growth factor receptor mutant lung adenocarcinoma developed progressive disease with an enlarging left pleural effusion requiring tissue biopsy for clinical trial enrolment. As no other site was readily accessible and the patient preferred ambulatory care, the patient underwent outpatient medical thoracoscopy under local anesthesia and light conscious sedation. After one liter of pleural fluid was drained, the proceduralist identified multiple pleural nodules and took twenty parietal pleural biopsies without complications. After three hours of clinical observation, the proceduralist removed the patient’s chest tube, allowing same-day discharge. Histology confirmed non-small cell carcinoma. At two-week follow-up, the patient remained well with a healed wound and no procedure-related complications.

CONCLUSION

In carefully selected stable patients, outpatient medical thoracoscopy can provide safe, effective pleural biopsy and drainage while avoiding hospitalization.

Key Words: Ambulatory care; Day-case procedure; Interventional pulmonology; Medical thoracoscopy; Outpatient procedure; Pleural disease; Pleural effusion; Pleuroscopy; Procedural safety; Case report

Core Tip: Medical thoracoscopy for pleural biopsy gives excellent yields exceeding 90% but patients may require hospitalization, which increases logistic and cost barriers. Case series are now available to support the effective and safe performance of outpatient medical thoracoscopy though these do not provide detailed principal considerations, procedural tips, and periprocedural recommendations. Using a case example, this paper aims to illustrate the principal periprocedural considerations for outpatient medical thoracoscopy and provide appropriate recommendations.

INTRODUCTION

Besides video-assisted thoracoscopic surgery, medical thoracoscopy with the flex-rigid or fully rigid pleuroscope has been established to be best method for pleural biopsy[1], with excellent yields exceeding 90% even when the associated pleural effusion is cytologically negative[2]. Targeted forceps biopsy or cryobiopsy under direct visualization enable such high diagnostic yields. However, patients may require hospitalization after thoracoscopy, which increases logistical and cost barriers.

Case series are now available to support the effective and safe performance of outpatient medical thoracoscopy[3-6], though these do not provide detailed principal considerations, procedural tips, and periprocedural recommendations. In addition, current guidelines do not provide details about outpatient (or day case) medical thoracoscopy[7].

Therefore, with a case example providing context, this paper aims to illustrate the principal periprocedural considerations for outpatient medical thoracoscopy and provide appropriate recommendations. The patient first provided written informed consent for the procedure and subsequently provided written informed consent for case report publication. The author has read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

CASE PRESENTATION

Chief complaints

A 71-year-old man with metastatic epidermal growth factor receptor (EGFR)-mutant lung adenocarcinoma.

History of present illness

As the patient’s lung cancer started to progress with increasing size of four small lung nodules and an enlarging left pleural effusion, his oncologist referred him to respiratory medicine for tissue biopsy to enable recruitment into a clinical trial. Apart from a moderately large left pleural effusion, no lung, lymph node, or other sites were readily accessible for biopsy. The patient was keen only for ambulatory or day case procedures, and agreed to outpatient medical thoracoscopy.

History of past illness

He was known to have metastatic lung adenocarcinoma with Exon 19 deletion, diagnosed from pleural fluid cytology and plasma EGFR mutation testing. He received treatment with osimertinib for the past two years.

Personal and family history

Comorbid conditions included hypertension, hyperlipidemia, and mild bilateral noise-induced sensorineural hearing loss.

Physical examination

Vital parameters in the clinic were normal (systolic blood pressure 146 mmHg, diastolic blood pressure 72 mmHg. pulse rate 85 beats per minute, room air oxygen saturation 99%). Physical examination in the clinic revealed absent breath sounds over the left hemithorax, with stony dullness to percussion. No enlarged cervical lymph nodes were palpable.

Laboratory examinations

Pre-procedural platelet levels, prothrombin time, partial thromboplastin time, and creatine were normal. Post-outpatient thoracoscopy, tissue and pleural fluid cultures were negative for bacterial growth, and molecular testing for tuberculosis was negative.

Imaging examinations

Point-of-care ultrasound in the clinic confirmed a complex, non-septated left pleural effusion with associated pleural thickening.

FINAL DIAGNOSIS

After one liter of pleural fluid was drained, the proceduralist identified multiple pleural nodules and took twenty parietal pleural biopsies without complications. Pleural histology confirmed the presence of non-small cell carcinoma (TTF-1 positive).

TREATMENT

Pre-procedural phase

He was eligible for outpatient medical thoracoscopy as the indication was only for pleural biopsy and not talc poudrage. A pre-procedure computed tomography (CT) thorax showed a moderately large left-sided pleural effusion (Figure 1A). With the patient in the right lateral decubitus position (i.e., left side of the body facing up), bedside ultrasound confirmed the presence of a non-septated pleural effusion with about 6 cm of fluid separating the parietal and visceral pleura at the left lateral chest wall.

Figure 1 Radiology images. A: Pre-procedural computed tomography scan image on 3 March 2026, showing a moderately large left-sided pleural effusion (asterisk); B: Post-procedure chest X-ray image on March 5, 2026, 2 hours after thoracoscopy, showing complete pleural fluid drainage, a left-sided chest tube in situ, and an unexpanded left lung (asterisk); C: Post-procedure chest X-ray image on March 20, 2026, 2 weeks after thoracoscopy, showing partial accumulation of pleural fluid, an air-fluid level (asterisk), and an unexpandable left lung.

Procedural phase

Following admission to the endoscopy center and peripheral intravenous cannulation, the patient lay in the right lateral decubitus position. Ultrasound confirmed the safest point of entry. Just like in the clinic, 6 cm of fluid separated the parietal and visceral pleura at the left lateral chest wall. The proceduralist marked the site of entry at the left mid-axillary line in the sixth intercostal space. One mg of intravenous midazolam and 25 mcg of intravenous fentanyl effected light sedation. Procedural nurses monitored the patient’s blood pressure, heart rate, level of consciousness, peripheral oxygen saturations, and respirations throughout the procedure.

Following sterile cleaning, draping, and instillation of 20 mL of 1% lignocaine local anesthetic into the skin, subcutaneous tissue, and parietal pleura, the proceduralist performed blunt dissection to enter the pleural space, inserted the trocar and then the flex-rigid pleuroscope. Intermittent aspiration of golden-yellow pleural fluid yielded a total of 1000 mL of serous fluid, and the patient felt comfortable throughout.

Upon fluid removal, systematic inspection of the thoracic cavity revealed multiple golden-yellow pleural nodules and pleural plaques over the visceral pleural, the parietal pleura and the diaphragm (Figure 2). After twenty parietal pleural biopsies, no significant bleeding occurred.

Figure 2 Thoracoscopy images. A: Parietal pleura over the diaphragm covered with patchy golden-yellow plaques and nodules (asterisk); B: Parietal pleura over the inner thoracic cavity covered with patchy golden-yellow plaques and nodules (asterisk). Histology confirmed the presence of non-small cell carcinoma (TTF-1 positive); C: Golden-yellow serous pleural fluid (asterisk) in the left costophrenic recess; D: Left lung and visceral pleura with golden-yellow nodules (asterisk).

After the removal of the medical thoracoscope, the proceduralist inserted a 20-French chest tube, directing it apically and posteriorly, and connected it to an underwater seal for free drainage without suction. A purse-string suture (nonabsorbable, monofilament synthetic suture made of polypropylene, size 2/0) applied around the chest tube would facilitate chest tube removal later. Two additional silk 2/0 sutures helped to close the wound around the chest tube. One of the silk sutures served as an anchor for the chest tube. Nurses then transported the patient on his trolley bed to the recovery area of the endoscopy center.

Post-procedural phase

At the recovery area of the endoscopy center, a portable chest X-ray two hours after thoracoscopy showed complete pleural fluid drainage and an unexpanded left lung (Figure 1B). At about three hours post-thoracoscopy, after confirming clinical stability and lack of complications (no bleeding or bubbling through the chest tube), the proceduralist removed the chest tube, secured the purse string suture, and applied the pressure dressing. The patient and his accompanying family members received advice to keep the pressure dressing for 24 hours, followed by daily cleaning with chlorhexidine and coverage with light dressing till review in clinic. The patient could then take orally and left the endoscopy center.

He returned for clinic review two weeks after thoracoscopy. A chest X-ray showed partial accumulation of the left pleural effusion, an unexpandable left lung and an air-fluid level indicative of hydropneumothorax (Figure 1C). He was otherwise well and felt better than before thoracoscopy. He had no pain or fever. The thoracoscopy site was clean and well-healed, which allowed suture removal.

OUTCOME AND FOLLOW-UP

He continued follow-up care with his oncologist, who had successfully enrolled him in the research trial with the possibility that a novel chemotherapy and immunotherapy regime would control his cancer and malignant pleural effusion better than standard chemotherapy.

DISCUSSION

Thoracoscopic pleural biopsy options include video-assisted thoracoscopic surgery under general anesthesia and one-lung ventilation, inpatient medical thoracoscopy, or outpatient medical thoracoscopy. Of these, outpatient medical thoracoscopy is the most convenient for patients and least resource-intensive, allowing invasive pleural biopsy without the need for hospitalization. Note that if pleural-based lesions are large or thick enough (those 10 mm or thicker)[8], ultrasound or CT-guided transthoracic needle biopsy may be another outpatient option potentially less resource-intensive than outpatient medical thoracoscopy.

Patient selection

The key consideration for outpatient medical thoracoscopy is avoidance of any necessity for hospitalization. This means that the patient needs to be medically stable, and the procedure itself should not confer elevated levels of risks or complications. One of the most important complications is major hemorrhage requiring blood transfusion or escalation for thoracic surgery.

To minimize the need for prolonged chest tube drainage requiring hospitalization post-thoracoscopy, one should exclude all cases of empyema or parapneumonic effusion, pre-existing pneumothorax, active traumatic pleural bleeding, or active atraumatic pleural bleeding. In addition, patients who need talc poudrage without indwelling pleural catheter insertion are unsuitable for outpatient medical thoracoscopy, because talc induces pleural fluid generation that requires drainage over at least 1-2 days to ensure pleural apposition. In the context of indwelling pleural catheter insertion immediately after thoracoscopy, talc poudrage will then be possible, as the catheter facilitates subsequent pleural fluid drainage[9]. In addition, although other therapies such as urokinase injection for empyema, medical glue spraying to close bronchopleural fistula, and thoracoscopic photodynamic therapy are being employed by experts[10], safety remains uncertain, and most proceduralists performing outpatient medical thoracoscopy should not attempt these.

Pre-procedural assessments

Pre-procedural assessments include testing for platelet levels, prothrombin time, partial thromboplastin time, and creatinine. Should emergency blood transfusion be potentially needed, one should also type and screen. Another major complication to avoid is damage to underlying organs including the lung, heart, liver, or spleen.

Pre-procedural ultrasound is essential for locating a safe space for entry of the thoracoscope[7,11], ensuring at least a 2-cm depth of pleural fluid. Dry space medical thoracoscopy, which is thoracoscopy performed in a patient without any pleural effusion, involves ultrasound assessment for lung sliding and lack of pleural adhesions, careful dissection to the pleural space without injuring the visceral pleura, with or without induction of pneumothorax to create a working space[12-14]. Although the introduction of optical trocars may increase its safety[15], dry space medical thoracoscopy is a more technically demanding method that conventional medical thoracoscopy, and most proceduralists pursing outpatient medical thoracoscopy should avoid this.

Role of prophylactic antibiotics

Surgical site infections after medical thoracoscopy are uncommon and do not decrease with prophylactic (pre-procedural) antibiotic use[16]. To avoid unnecessary use of antibiotics and antimicrobial resistance, clinicians should omit prophylactic antibiotics before medical thoracoscopy.

Thoracoscopic technique

Avoidance of complications is key to allowing early discharge from the endoscopy center. Avoiding biopsies over highly vascular areas or the intercostal vessels reduces the risk of active bleeding. Use standard forceps biopsy by default, as cryobiopsy may not increase diagnostic yield[17]. Make sure all bleeding has stopped by the end of the thoracoscopy. Use ultrasound to double check the entry point just before thoracoscopy, making sure that any pre-existing pleural fluid is still present, avoiding pneumothorax from visceral pleural puncture. Proceduralists should only take pleural biopsies from the parietal pleura over the inner thoracic cavity, not from visceral pleura (to avoid pneumothorax), and not from the diaphragmatic pleura (to avoid diaphragmatic perforation).

Re-expansion pulmonary edema may occur in some patients, and may be severe, necessitating assisted ventilation and intensive care unit admission[18]. As limiting the volume of fluid removal may not prevent re-expansion pulmonary edema, it is reasonable to then moderate the rate of lung re-expansion by using the minimal amount of suction pressure and allowing air to enter through the trocar around the pleuroscope. Furthermore, when patients develop chest discomfort, this may signify an excessively large drop of pleural pressure and increased transpleural pressures, and suctioning should be temporarily stopped[19].

Chest tube insertion and management

After pleural aspiration and biopsies, chest tube insertion through the thoracoscopy site aids further fluid or air drainage, and a purse-string suture applied around the chest tube facilitates wound closure after chest tube removal. As the thoracoscopy incision is usually wider than the chest tube diameter, apply additional sutures to close any gaping parts of the incision and help with wound healing after chest tube removal.

In general, clinicians can remove the chest tube at the end of the procedure (intra-procedure) or in the recovery area of the endoscopy center (post-procedure). The former may reduce discomfort[20]. However, delayed chest tube removal in the recovery area is better for several reasons: (1) It avoids subcutaneous emphysema by draining air that had entered the pleural space through the trocar during thoracoscopy; (2) It allows monitoring of delayed bleeding and pneumothorax (from inadvertent visceral pleura puncture) when connected to a chest tube collection bottle with an underwater seal; and (3) The additional discomfort is minimal, and analgesia is usually not required.

Chest tube removal

Chest tube removal or discharge does not require full re-expansion of the lung, as lung may not expand (42% in one series[20]), which may be due to visceral pleural fibrosis or malignant infiltration. In cases of unexpandable lungs, the main clinical clues include direct visualization of visceral pleura abnormalities during thoracoscopy and the lack of any bubbling in the chest tube bottle despite normal respiratory oscillation.

Post-thoracoscopy and removal of the chest tube, analgesia is usually unnecessary. Any significant pain is unusual and could mean excessive trauma to the soft tissue or ribs of the chest wall. Any significant dyspnea or desaturation is also unusual, and may be due to re-expansion pulmonary edema, which can manifest as lung crepitations and radiographic evidence of pulmonary edema. Re-expansion pulmonary edema may happen only after a few hours after thoracoscopy, and patients should thus be monitored for at least 3 hours before discharge from the endoscopy center[18].

Wound management

Upon removal of the chest tube, tighten and secure the purse-string suture. As the thoracoscopy tract can allow fluid and air to flow from the pleural space into the subcutaneous tissue, applying a pressure bandage for the next 24 hours can reduce the possibility of seroma formation and subcutaneous emphysema. After removal of the pressure bandage, daily cleaning and dressing circumvents wound site infection. In addition, the wound may take 10-14 days for complete healing and suture removal. As such, prescribe sufficient chlorhexidine, gauze swabs, and light dressings for daily dressing changes over two weeks.

Procedural training

Outpatient medical thoracoscopy operators must be skilled in medical thoracoscopy in general and avoid complications such as major bleeding that would require hospitalization. To achieve this level of competency, operators need not necessarily fulfil a certain minimum threshold of procedures but should have undergone supervised training on enough cases to demonstrate safe independent practice. The British Thoracic Society (BTS) does not recommend specific numbers that should be undertaken to demonstrate competency, though most of its surveyed experts suggest 16-20 procedures[21], which is in line with expert opinion elsewhere (at least 20 in the Indian Chest Society guidelines[11] and 20 in a United States expert commentary[22]). However, the BTS does recommend at least two summative direct observations confirming the ability to perform medical thoracoscopy with limited supervision, and another two confirming the ability to perform unsupervised[21].

CONCLUSION

Selected stable patients who need pleural biopsy, with or without drainage of pleural fluid or indwelling pleural catheter insertion, can undergo safe outpatient medical thoracoscopy with low rates of complications. Table 1 provides a concise clinical checklist for outpatient medical thoracoscopy. While thoracoscopic techniques and equipment may vary across clinical sites and operators, addressing these considerations would be important to minimize risks for patients. Also, while this is a solitary case report used to demonstrate safe use of outpatient medical thoracoscopy, Table 1 is based on reasonable practice, and its recommendations are likely to extend to most settings.

Table 1 Checklist for outpatient medical thoracoscopy.

Phase	Recommendations
Pre-procedure	Select stable patients with pleural effusion who need pleural biopsy only, with or without drainage of pleural fluid or indwelling pleural catheter insertion
	Exclude patients with the following conditions: Empyema or parapneumonic effusion; pneumothorax; active traumatic or atraumatic pleural bleeding; patients who need talc poudrage without indwelling pleural catheter insertion (as talc induces pleural fluid generation that requires drainage to ensure pleural apposition)
	Use ultrasound to locate a safe space for entry of the thoracoscope, ensuring at least a 2-cm depth of pleural fluid. Do not attempt pleural entry based on sliding pleura alone
During procedure	Avoid biopsy over highly vascular areas or the intercostal vessels. Use standard forceps biopsy by default and avoid cryobiopsy as far as possible. Make sure all bleeding has stopped by the end of the thoracoscopy
	Take biopsies only from parietal pleura over the inner thoracic cavity. Do not take biopsies from parietal pleura over the diaphragm or diaphragmatic pleura
	While suctioning, use the minimal amount of suction pressure and allow air to enter through the trocar around the pleuroscope to slow down lung expansion, especially if large volumes of pleural fluid are removed
	Insert a 20F chest tube through the thoracoscopy site, and apply a purse-string suture around it
	As the thoracoscopy incision is usually wider than the chest tube diameter, apply additional sutures to close any gaping parts of the incision
Post-procedure	Monitor vital signs hourly for 3 hours post-thoracoscopy. Watch for fresh blood in chest tube collection bottle
	Do a post-thoracoscopy chest X-ray at about 2-3 hours to check for pulmonary edema
	Confirm oscillation but no bubbling in the chest tube collection bottle before removal of the chest tube
	Upon removal of the chest tube, tighten and secure the purse-string suture. Then, apply a pressure bandage for the next 24 hours
	After the daily bath, remove dressing and clean with chlorhexidine. Then apply a small light bandage over the site
	Daily cleaning and dressing for 10 days to 14 days
At follow-up clinic appointment	Do a chest X-ray on the day of wound inspection and suture removal

By avoiding hospitalization, medical thoracoscopy saves resources and reduces costs compared to inpatient medical or surgical thoracoscopy. This could potentially increase the use of medical thoracoscopy and improve overall diagnostic yield for unexplained pleural effusion and disease, compared to outpatient thoracentesis alone[23].