Fibrinolytic therapy during medical thoracoscopy: a single center experience

Background: In unilateral pleural effusions, medical thoracoscopy is a minimally invasive technique to access the pleural surface allowing both diagnostic and therapeutic procedures. The presence of adhesions may cause early interruption of the exam and failure in obtaining diagnostic biopsies. Fibrinolytic drugs have been used in both infective and malignant pleural diseases through chest drainage to break down septations and to improve radiologic outcome. Aim: The aim of this study was to assess the role of intrapleural fibrinolytic therapy during diagnostic medical thoracoscopy in patients with a unilateral loculated pleural effusion. Our primary outcome was the success rate of the procedure and its safety. We also compared the results with a similar population undergoing standard medical thoracoscopy without fibrinolysis. Methods: This is a monocenter retrospective descriptive study of patients affected by unilateral pleural effusion who underwent intrapleural fibrinolytic therapy under direct vision during diagnostic medical thoracoscopy admitted between January 1st, 2022 and November 30th, 2024 in the department of Pneumology, Ospedale di Bolzano (Italy). Data on procedural success and immediate or short-term complications (bleeding, subcutaneous emphysema, clinical data) were assessed. We compared the data with a control group of patients undergoing standard medical thoracoscopy between January 2018 and December 2024 in terms of procedural success rate, complications, quantity of sedation used during the procedure and time of drainage. Results: A total of 17 patients were included in this study (M=10, F=7). All the procedures could be successfully executed, and pleural biopsies were always possible. No complications (bleeding in particular) were seen during the procedure and until discharge. There was no significant difference compared with the control group in the quantity of sedation needed during procedure and in the time of drainage. Conclusions: This is the first study to describe the role of intraprocedural fibrinolytic therapy during medical thoracoscopy. It suggests that it is a safe and valid tool in selected cases to obtain a diagnosis even in loculated pleural effusions. A larger population is needed to support this evidence.