To understand the application value of bendable electronic medical thoracoscopy in the diagnosis of unexplained pleural effusion. Methods From July 2005 to March 2007, a bendable electronic internal medicine thoracoscope was applied to perform thoracoscopy on 60 patients with unexplained pleural effusion in the respiratory ward of our hospital, of whom 36 were male and 24 were female. Internal thoracoscopy was performed on all patients whose causes of effusion could not be clarified by laboratory tests such as routine pleural fluid, biochemistry, microbiology and cytology or by diagnostic anti-tuberculosis treatment. The results of 60 patients with unexplained pleural effusion were examined in 32 cases (53.3%) with malignancy, 16 cases (26.7%) with tuberculosis, 5 cases (8.3%) with negative findings or chronic inflammation, 4 cases (6.7%;) with pneumonia combined with pleurisy, and 3 cases (5%) with severe adhesions failing to see the chest wall. Among the malignant tumors, adenocarcinoma of the lung was the most common. Postoperative complications wound pain was the most common and could be relieved by symptomatic treatment. There were no complications such as pulmonary edema, infection, or delayed extubation. Conclusion Bendable electronic endoscopic thoracoscopy is a simple, safe and effective examination method. In clinical practice, it can help us to further clarify the etiological diagnosis of pleural effusion, especially for the diagnosis of unexplained pleural effusion. Keywords bendable electronic thoracoscope, pleural effusion, diagnosis Pleural effusion is a common disease of the respiratory system, and there are usually few approaches for its etiologic diagnosis. Most clinical diagnoses are made using laboratory tests such as routine pleural fluid, biochemistry, microbiology and cytology combined with percutaneous pleural biopsy for etiological diagnosis. Even after these comprehensive examinations, the etiologic diagnosis is still not clear in about 25% or more of patients. Medical thoracoscopy (also known as Pleuroscopy) is an invasive technique, mainly used for the diagnosis and treatment of patients with pleural effusion whose etiology cannot be determined by non-invasive methods. The application of general rigid thoracoscopy for the diagnosis of pleural disease has been reported in China. However, the above two methods have certain limitations. Ordinary rigid thoracoscopy cannot observe pleural cavity lesions comprehensively, and there is a blind area under the scope, which may miss lesions; while bronchoscopy is easily bent and poorly positioned, and biopsy operation may encounter difficulties. In recent years, a new type of combined soft and rigid thoracoscope (Flexirigid thoracoscopy, or semi-rigid thoracoscopy) has been reported from abroad, whose rigid rod part has the ease of operation of an ordinary rigid thoracoscope, and the bendable part of the tip can observe changes in the thoracic cavity in multiple directions, and is compatible with It has a good prospect of application because it has the same light source monitoring system as the electronic tracheoscope. At present, there are no relevant reports in China. In this paper, we summarize the clinical data of 60 patients with unexplained pleural effusion diagnosed by Olympus LTF-240 electronic thoracoscope from July 2005 to March 2007, and initially discuss its application value. Subjects and methods I. Study subjects All 60 patients with pleural effusion were hospitalized in our hospital between July 2005 and March 2007. There were 36 male cases and 24 female cases, aged (19~86) years; among them, 29 cases had right pleural effusion, 25 cases had left pleural effusion, 3 cases had bilateral pleural effusion, 3 cases had obvious adhesions and no obvious pleural effusion. The time from the discovery of pleural effusion to thoracoscopy ranged from 6 days to 1.5 years. Combined underlying diseases included pulmonary embolism (two of the patients were taking oral warfarin), coronary atherosclerotic heart disease, cardiac insufficiency, hypertensive disease, chronic renal insufficiency, and diabetes mellitus. Preoperatively, three patients had a clear diagnosis of breast cancer and surgical resection, and one patient had a diagnosis of renal cancer and surgical resection. Except for these four patients, whose pleural effusion may be related to their tumor history, none of the other patients had a clear diagnosis of malignancy. For these patients, the cause of the effusion could not be clarified through routine laboratory tests such as pleural fluid, biochemistry, microbiology and cytology or through diagnostic antituberculosis treatment, internal thoracoscopy was performed. Methods 1. Internal thoracoscopy and related instruments and equipment The thoracoscope used for the examination was an Olympus LTF-240 electronic internal thoracoscope, including a rigid rod and a bendable tip (Figure 1). The accompanying instrumentation equipment included: EVIS-240 light source and TV system, chest puncture cannula, biopsy forceps, closed chest drainage chest wall cannula and closed drainage bottle, etc. 2.Pre-operative preparation Patients undergo ultrasound localization within 24 hours before the examination: in the healthy side lying position, ultrasound localization is performed on the chest wall at the anterior axillary or midline of the affected side to understand the volume of chest water and chest adhesions, and to select a suitable incision and access point. At the same time, preoperative assessment of coagulation function, cardiopulmonary function and surgical feasibility is completed. 3.Intraoperative anesthesia The operation is performed in the operating room, and the towel is routinely disinfected and laid according to the surgical requirements. 5-20 ml of local anesthesia of 2% lidocaine is given at the incision first, and intramuscular dulcolax or intravenous midazolam and fentanyl sedation can be given to those with obvious pain, and heart, electricity, blood pressure and oxygen saturation monitoring are performed to keep the patient breathing well on his own. 4.Operation procedure The patient is usually placed in the healthy side position, and the incision is chosen in the axillary chest wall between the 4th and 8th ribs, commonly between the 6th and 7th ribs. After local anesthesia, a 9-mm incision is made at the entry point, the subcutaneous layers are bluntly peeled to the pleura, a puncture cannula is placed, and the thoracoscope is delivered into the pleural cavity through the cannula, and most of the pleural fluid is first aspirated, and then, the visceral layer, the wall layer, the diaphragmatic pleura, and the peri-incisional pleura are observed in the order of internal, anterior, superior, posterior, lateral, and inferior. Because no lesions were found in the visceral layer in all patients, biopsy tissues were taken from the mural pleural tissue or lesion sites, and as many parts as possible were taken, ranging from 5 to more than 10 pieces of biopsy tissue as needed. After the operation, the puncture cannula was removed and a closed chest drainage tube was placed and connected to a closed drainage bottle to facilitate the drainage of gas and fluid from the chest cavity, and the drainage tube was generally selected to be 24-28F in size. Postoperative chest radiography was performed to understand the position of the tube and changes in the chest cavity. Results I. Etiology of pleural effusion Internal thoracoscopic findings: the nature of pleural effusion in patients included 25 cases of bloody effusion, 30 cases of straw-yellow effusion, 1 case of celiac-like effusion, 3 cases of obvious adhesions without obvious pleural effusion, and 1 case of small amount of effusion with pneumothorax. 60 patients with unexplained pleural effusion were examined, including 32 cases of malignant tumor (53.3%), 16 cases of tuberculosis (26.7%), and negative findings or chronic inflammation in 5 cases (8.3%), pneumonia combined with pleurisy in 4 cases (6.7%;), and adhesions severe failure to see the chest wall in 3 cases (5%). Among the malignant tumors, there were 11 cases of adenocarcinoma of the lung, 6 cases of squamous carcinoma, 1 case of lymphoma, 3 cases of small cell carcinoma, 3 cases of pleural mesothelioma, 3 cases of breast cancer metastasis, 1 case of kidney cancer metastasis, and 4 cases of unknown primary foci. Intraoperative and postoperative complications: 1. arrhythmia and pulmonary edema: 60 patients had intraoperative drainage of 350 ~ 2500 ml, and no arrhythmia or pulmonary edema occurred. 2. pain: 2 cases of pain during chest wall trocar placement, the first and second patients performed in this unit, probably related to inadequate anesthesia; 12 cases of minor pain during biopsy and 28 cases of postoperative wound pain. 3. subcutaneous Emphysema: 6 cases had subcutaneous emphysema, which was not treated and later absorbed on its own.4. Bleeding: 1 patient with heavy adhesions had intraoperative bleeding of about 150 ml, which was stopped after local injection of epinephrine saline, and vital signs were stable.5. Postoperative fever and wound infection: 6 cases of postoperative fever occurred on the second postoperative day, mostly within 38°C, only 1 case to 39°C, and the body temperature all dropped to normal level on the third day. No wound infection occurred. 6. Delayed extubation time: Extubation time ranged from 1 day to 8 days, with no delay in extubation. Most of the metastatic malignant tumor lesions were microscopically manifested as pleural nodular lesions of varying sizes. The patient was pathologically confirmed to have adenocarcinoma of the lung with pleural metastasis. Some of the lung adenocarcinoma and tuberculosis lesions showed diffuse small nodular shadows microscopically, which appeared to be benign lesions and were difficult to distinguish thoracoscopically, for example, in patient 3, whose CT changes were described in the later figure, the thoracoscopic features showed congestion and diffuse small nodular shadows in the mural pleura, and the patient was pathologically confirmed to have lung adenocarcinoma with pleural metastasis; while in patient 4, whose CT changes were described in the later figure, the thoracoscopic features also showed congestion and diffuse small nodular shadows in the mural pleura. The pathology confirmed that the patient had tuberculous pleurisy. Some of the tuberculous lesions showed microscopically as nodular lesions of varying sizes in the pleura, which resembled malignant changes, as in the case of patient 5, whose x-ray changes were described in the later figure, and the thoracoscopic features were nodular lesions of varying sizes in the mural pleura, and the pathological findings of which were tuberculous pleurisy. Microscopic manifestations of congestion and diffuse small nodular shadows with marked intracavitary segregation changes are mostly tuberculous pleurisy. Discussion Internal thoracoscopy is an invasive technique that can be performed by a respiratory physician, mainly for the diagnosis of unexplained pleural effusions, but also for the release of some pleural adhesions and pleural fixation of some refractory pleural effusions. Diagnostic thoracoscopy was mainly performed in this group of patients, and the results showed that among the unexplained pleural effusions, the first cause was malignant tumor accounting for 53.3%, among which adenocarcinoma was the most common. This was followed by tuberculosis in 26.7%, negative findings or chronic inflammation in 8.3%, pneumonia combined with pleurisy in 6.7%; and 3 cases (5%) with severe adhesions failing to see the chest wall, respectively. This is consistent with the report of Gao et al [2] in China, suggesting that the mid-major causes of unexplained pleural effusion are tumor and tuberculosis. Through 60 cases of medical thoracoscopy, we initially learned that there are three categories of patients with pleural effusion that often leave clinicians at their wits’ end, and the only and effective way is to actively perform medical thoracoscopy. First, patients with no lung shadow but slightly enlarged mediastinal lymph nodes and pleural effusion that is not absorbed by various tests and diagnostic antituberculosis treatment, who require general anesthesia and are relatively expensive to perform mediastinoscopy, may first undergo medical thoracoscopy to detect pleural lesions. In one patient in this study, pleural fluid persisted for up to 6 months and was finally diagnosed as non-Hodgkin’s lymphoma (small lymphocytic class NHL) by medical thoracoscopy. Second, lung shadows were considered as lung cancer, but the location of mass growth could not be diagnosed by tracheoscopy or percutaneous lung puncture biopsy, and no cancer cells were found in the pleural effusion, and pleural changes were often detected by internal thoracoscopy. Third, patients with fever with pleural effusion whose temperature has decreased after anti-inflammatory treatment and whose pleural fluid absorption is slow or even persistent may be considered for medical thoracoscopy excluding tuberculous pleurisy. In case 4, the patient was found to have caseous necrosis in the center of some granulomas in the pleural biopsy, so the diagnosis of tuberculous pleurisy was clear. The following aspects also need to be noted in the examination: 1. Although some scholars believe that endoscopic thoracoscopy can be performed in pustular chests within two weeks of onset, our experience is to avoid endoscopic thoracoscopy in patients with a high likelihood of clinically considered parapneumonic effusion and rapid pleural cavity adhesions. In our hospital, examination of a patient with 10 days of onset revealed significant adhesions, and no intrapleural cavity lesions could be visualized, and the patient was eventually referred to surgery for pleurodesis. Therefore, for patients with obvious pleural adhesions and no pleural fluid, medical thoracoscopy is generally not recommended, and surgical treatment should be considered.2. The possibility of necrosis of larger and softer tissues in the microscopic nodules is high, so take as many tissues as possible and avoid necrotic tissues to reduce the negative rate of thoracoscopy.3. Patients with large pleural volumes, lightly wrapped adhesions, and long presence of pleural fluid should be examined as early as possible, and the malignancy of such patients The possibility is high. In our group, one case of pleural fluid existed for 6 months and one case existed for 1.5 years, and the examination results were malignant. 4. For diffuse small nodular lesions seen under thoracoscopy may be benign or malignant, so we should biopsy as many parts as possible under the microscope, even if the results are negative, we should actively follow up to avoid misdiagnosis. In this group, one patient with postoperative pleural effusion of kidney cancer was found to have pleural nodular lesion under intraoperative observation, and the possibility of kidney cancer and pleural metastasis was clinically considered, while the biopsy result of pleural lesion was necrotic tissue and no tumor cells were seen, such patients should be persuaded to undergo re-examination. The complications of this group of patients with internal thoracoscopy were mainly pain at the postoperative placement of closed drains, which could be relieved by symptomatic treatment, and the pain generally decreased significantly 3 days after surgery; there were no serious complications. 2 patients with anticoagulation therapy for combined pulmonary embolism were given VitK intramuscularly in 1 case before the examination, and 1 case was discontinued with warfarin and changed to rapid wall coagulation therapy, and none of them had obvious bleeding tendency after surgery; 1 case with advanced age (86 years old) with coronary atherosclerotic heart disease and cardiac insufficiency completed the examination successfully in a semi-sitting position; only one patient with thoracic adhesions bled during biopsy and was stabilized after symptomatic treatment; in addition, there were subcutaneous emphysema (6 cases) and postoperative fever (6 cases), and there were no life-threatening serious complications or deaths. Consistent with foreign reports, serious complications were rare, with a mortality rate of 0.01-0.6%;. The indications and contraindications for medical thoracoscopy and the differences with surgical thoracoscopy have been described in the author’s previous publications and will not be repeated here. Through the medical thoracoscopy of 60 patients, we initially experienced that medical thoracoscopy, as a safe and effective minimally invasive diagnostic and therapeutic technique that can be operated by respiratory physicians, has important clinical applications for the diagnosis and treatment of pleural diseases such as pleural effusion and pneumothorax. Through endoscopy, malignant or tuberculous effusions can be clearly identified or excluded with an accuracy rate of almost 100%; it helps to clarify the etiology of pleural diseases and determine the prognosis of malignant effusions as well as to formulate corresponding treatment plans; in addition, it is also of great significance for the treatment of pus and spontaneous pneumothorax; through endoscopy, talcum powder is blown into the pleural cavity to treat malignant pleural effusions and recurrent benign effusions (e.g. celiac disease). ). It is believed that in the near future, medical thoracoscopy will become a must-have and practical treatment technique for respiratory physicians.