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TAPS 2024 Ep 7- Pleuroscopy and its role in Thoracic Medicine — Transcript

by The Australasian Pleural Seminars · 5,025 words · 719 segments · language en · Watch on YouTube

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0:05all right looks like we're ready so good
0:07morning or good afternoon depending on
0:09where you are uh welcome to the AUST
0:12version of the austral plural seiners
0:16today we're delighted to have Dr Sur guy
0:20who is a Interventional palmary
0:22consultant in Sydney at the mcari and
0:24concort hospital to talk to us about
0:27medical fosc toy something that office
0:30all very interested or have been
0:31involved in um just a reminder that you
0:35need to uh type in the questions uh on
0:39chat so that we can actually see it um
0:42and feel free to put in all the
0:43questions that you want to ask this is
0:45the best time to ask the expert and our
0:48next version is will be in the first
0:51Wednesday of September and that will be
0:53Dr fisho from Ireland to talk about why
0:56people are breathless with a Ki fusion
0:59and other interesting topic so I'm just
1:02going to hand over the the the zoom to
1:05Dr s guy and uh welcome and thank you
1:09very much for talking to us
1:12today excellent thank you uh thank you
1:15Gary uh thanks for the invitation and
1:17thanks for the opportunity to um um you
1:21know having included me in in these um
1:24excellent
1:26seminars um
1:30I've been I've been very much looking
1:31forward to this uh myself as well and
1:34specifically um I'm trying to angle this
1:3715minute talk to sort of as an
1:39introduction to Medical
1:41pleuroscopy hoping to have some q&as and
1:45discussions at the end uh but as
1:48you when you when you say um um the
1:52expert um I I kind of thought to myself
1:56why why am I doing this why am I the one
1:58who's who's giving this talk and I I
2:00really owe this to uh uh obviously
2:03yourself and and people like Matthew
2:05Peters who uh really supported me to uh
2:09pick up uh the medical proscope service
2:11at Concord Hospital um uh more than 10
2:15years ago um and um I I came over to
2:18Perth and joined a course the ca course
2:22that you were running with Martin uh and
2:24that was that was really the turning
2:26point for me because I met uh David
2:28there and and he he became my mentor uh
2:31kind of a remote mentor and and and I've
2:33I've learned a lot of the stuff that I
2:35do these days from um from these guys so
2:38acknowledgements to
2:40them um just a little bit about what I
2:43do in in relation to this talk I am um I
2:47do medical pleuroscopy in a procedure
2:49room at Concord Hospital using a
2:53semi-rigid um
2:57pleuroscopy it's the ltf
3:00160 uh model um as you can see it is a
3:04steroid procedure and um this is this is
3:08how we we set up and do it um obviously
3:11I use um forceps um for for sampling the
3:15plal space but I I also use cryo probes
3:19as well for that
3:22purpose um I'm I'm trying to keep it as
3:25you say you know Punchy and and and to
3:28the point um aiming for about 15 minutes
3:32of of of my slides so I'm going to go
3:34through a little bit of History because
3:36I think that's important and kind of
3:38clarifies a few things about how we uh
3:41see medical perioscopy today and and
3:45then sort of try to clarify uh what it
3:47is and how how it compares to um the
3:51surgical
3:54options so uh this is I'm sure I'm sure
3:57a lot of us and uh a lot of the audience
3:59have heard this before that this is a
4:01very old procedure that was invented or
4:04introduced by a Swedish inist more than
4:08a 100 years ago in 1910 uh Jacobus
4:13um described um this procedure alongside
4:17uh laparoscopy and he named it
4:20thoracoscopy and and the initial
4:22indication was for treatment of TV by
4:25introducing numo thorax and then uh a
4:28few more papers came out in the um
4:31following decade um on expansion of its
4:35indications uh specifically talking
4:37about
4:39sampling um things started fading away
4:42uh after chemotherapy for TB drugs for
4:46TB were invented and and uh in
4:50introducing or inducing anumal thorax
4:52was um not done anymore uh for treatment
4:56of
4:58TB um
5:00the term pleuroscopy starts popping up
5:03uh in North American um literature uh
5:08when um some people started using
5:11bronchoscopes
5:12um uh inside the plural space and as you
5:16can imagine they struggled with it um a
5:19couple of years later the first semi-
5:21rigid plos scope was made in Japan
5:27um however it it really
5:30um feels like there there were two sort
5:34of Pathways that were U moving along
5:38parallel to one another one was in
5:39Europe and the other one was outside
5:42Europe and and Europe kind of stuck to
5:44the rigid um thoracoscopy that was
5:47invented uh there and and kept that
5:50going and in the 80s with bhuton and a
5:53few others um had a had a bit of a
5:55Renaissance they had uh two meetings uh
5:58and tried to train more people uh to
6:01continue this uh procedure and uh things
6:06started changing after video assist
6:08thoracoscopic surgery was uh introduced
6:13in the 90s and and pretty much took over
6:16uh some of that stud specifically
6:18outside
6:20Europe however I think in 2003 we had um
6:25the um I think Olympus made made the Sim
6:28to
6:29later in 2007 um the model that was
6:34autoclavable was made as well and this
6:36is pretty much what is used these
6:38days um pretty much what I have now
6:42these days as well but the question is
6:44what is medical proscope
6:47um is it a procedure that I you know the
6:51referrer would ask for when they can't
6:52find the
6:54surgeon um is it the second choice when
6:57the patient is too sick to tolerate V
6:59and it's seen as that you know we can't
7:02have bats might as well settle for the
7:04second
7:06best or is it a a poorly done
7:09thoracoscopy pretty much surgery that is
7:12done by a physician in a bad
7:16way or really is it an alternative to
7:18Vats which in some cases in selected
7:21cases could be superior to it to be
7:23honest with you I think it's all the
7:25above and it really um depends on
7:30how you uh Define it and and and how you
7:33how you establish your own service and
7:35your referral Base by definition though
7:38medical proscope also known as medical
7:41thoracoscopy or just pleuroscopy is a
7:44minimally invasive procedure that allows
7:46direct visualization and access to the
7:49plural
7:52space so really need to sort of clarify
7:55this no man's land this kind of turf war
7:58between Surgical oscopy and medical
8:00perioscopy not just because we want to
8:02kind of see which referral goes to whom
8:04but also to um highlight and understand
8:09what the advantages of medical peroscope
8:15are I've made that um this slide uh this
8:20table to highlight a few things but I
8:22would like to acknowledge the fact
8:25that uh things are very variable um not
8:29not much on this surgical side of things
8:32because uh surgeons do things in a in a
8:34much um more controlled and Ne way that
8:38than than we do as Interventional
8:40pulmonologists or or or PR Specialists
8:43um there is you don't see a lot of
8:45variability in how um Vats is done in
8:48different hospitals by different
8:50surgeons or in different countries even
8:52but you do see a lot of that with
8:54medical perioscopy and and I'll try to
8:56sort of touch on that as well because I
8:58think these variations are where we uh
9:01either succeed or fail in in
9:03highlighting the advantages of a a niche
9:05procedure like medical
9:07perioscopy uh one is in indications um
9:10obviously Vats uh can access and operate
9:13and does access and operate on lung and
9:16plura both therapeutically and
9:18diagnostically however the advantage of
9:20medical pleuroscopy is mainly in the
9:22plural space and specifically also uh in
9:25the parial pra and not visceral pra
9:28again I acknowled the fact that in
9:30Europe for example they do even lung
9:32biopsies um doing medical
9:35pleuroscopy the setting um surgeries are
9:39done in operating theaters medical
9:41proscapes are uh done usually done in
9:44procedures uh uh procedure rooms or
9:47broncoscopy rooms again uh I'm aware of
9:50um in some centers that they uh The
9:53Physician would do their medical
9:54peroscope in theater uh with an anst and
9:58sometimes with an LMA deep sedation and
10:00that that kind of pretty much um defeats
10:05the purpose um of its
10:09Advantage um Again Medical perioscopy is
10:12done usually under local anesthesia and
10:15Conscious Sedation if required um
10:18surgery is done under general anesthesia
10:20and often paralysis because patients are
10:24tubed with a double Lumin and single
10:28lung ventilation um with pleuroscopy
10:31they hold their own Airway and
10:32spontaneously breathe medical proscope
10:35is usually done with one port uh
10:38surgical thoracoscopy at least three
10:40sometimes four again uh in some centers
10:43they would do medical perioscopy with
10:45more than one again it kind of breaches
10:48that um that that line um we use
10:54semi-rigid Scopes as I mentioned before
10:57or sometimes rigid scopes um to do
11:00pleuroscopy medical pleuroscopy uh as
11:02you know surgical thoracoscopy is done
11:04with uh rigid thoracoscopies video
11:07cameras and rigid instruments in
11:09different ports recovery is usually very
11:12quick with pleuroscopy either same day
11:14or overnight uh surgical thoracoscopy
11:16needs multiple days the cost is lower
11:19both in terms of equipment and per head
11:23with medical pleuroscopy so I I think it
11:26this slide paints a picture of where the
11:28differences are and and why um there may
11:31be selected cases that medical peroscope
11:34would be uh even Superior to surgical
11:39thoracoscopy um one question that I I
11:41really uh enjoy kind of exploring with
11:44uh my regist and fellows is uh about um
11:49how is it that that even an elderly or a
11:51comorbid patient can tolerate mil
11:54coproscopy so well um and
11:56physiologically it really is about the
11:58depend Depend and lung getting the best
12:01of ventilation and perfusion um in in
12:06terms of perfusion um it's quite obvious
12:08because gravity will will direct
12:10profusion towards uh the uh the
12:13dependent lung but in terms of
12:16ventilation uh it really is because at a
12:18lower volume um the dependent lung sits
12:21at a better part of the volume pressure
12:25curve the compliance curve and therefore
12:27for uh a certain amount of changing
12:29pressure uh you would have better
12:32ventilation or more ventilation so uh
12:35ventilation is is better in the
12:37dependent lung perfusion is better and
12:39there therefore VQ is better as well so
12:42that's why they can tolerate um an
12:44induction of pneumothorax in the
12:47contralateral lung uh and a procedure
12:50that could sometimes even last for an
12:55hour uh how about anesthesia U again
13:00local anesthetics is really the main
13:02stay of medical perioscopy and and often
13:04even by that and a bit of sedation they
13:08um the patient your patients can go
13:10through a medical prosc opy procedure
13:12quite
13:14um
13:16comfortably um the pitfalls of uh and
13:20the principles of of using local ndia in
13:23in any invasive procedure has had to
13:26have have to be adhered to however um
13:29dosing is very important knowing the
13:30maximum dose and using it uh reasonably
13:33knowing where the pain is mostly felt uh
13:37obviously in medical perioscopy that
13:39would be on the surface of skin and also
13:41at at level of plur and using your local
13:43aesthetic in those areas and one of the
13:46most common mistakes that that trainees
13:50make is that they give the local
13:51anesthesia um somewhere because the
13:53angle is different then they start
13:55dissecting in another space and that's
13:57obviously going to be painful um one of
14:00the things that we we have in fact
14:02worked on and published and it's a part
14:04of our um routine practice now is using
14:08inhal metox Florine uh as an anesthetic
14:12agent uh in not just medical
14:15prosop um but also in ipcs um as well uh
14:20very well tolerated uh really no side
14:23effects we exclude people with uh severe
14:25renal impairment um uh or liver
14:29impairment U and uh in fact in in that
14:33setting we only use um sedation in
14:36people who cannot have um methoxy
14:41Florine and it's been very
14:45successful um so now the question is how
14:48does medical prosc opy compared to
14:50Surgical thoracoscopy and this is a list
14:52of um you know a summary
14:55of like morbidities and complications uh
14:58that are reported with Vats versus
15:00medical peroscope and you can see
15:01medical peroscope does really well in a
15:04lot of things including pain bleeding um
15:07infection NE thoses um pretty much
15:11everything but um I think the reality
15:14there is that this is not a fair
15:17comparison and the reason is because
15:19obviously you're including all the more
15:21invasive uh procedures that are done
15:24with thats and comparing all of those
15:26complications with medical perioscopy
15:31um on this table I've got a comparison
15:35um in yield or success rate when it
15:38comes to medical perioscopy versus
15:41Vats um I think the important Point here
15:43is that there are limitations uh with
15:47medical horoscopy that stops us from
15:48using it
15:50successfully uh in reaching for example
15:52Min masses or um lung biopsies lung
15:57parent caral biopsies or doing doing
16:00resections uh and that's where the
16:02advantage of bats is but when it's um
16:06just about
16:08um diagnosing for example for an uh
16:12undiagnosed recurrent
16:15exhalative plural Fusion then uh the
16:18success rate or the yield of medical
16:20prosc opy is very similar to
16:23that uh again limitations I'm going to
16:26skip through that in in the um
16:29um because of time but again limited
16:32access um of course the scope is going
16:35to be
16:37U limited with medical horoscopy as well
16:42uh and um experti are not
16:47widespread um so in summary uh medical
16:52perioscopy is an old but useful
16:54technique that provides visualization
16:56and access to the plural space in a
16:58minimally in a um invasive way and uh we
17:02can provide that under local anesthesia
17:04maybe with Conscious Sedation from time
17:06to time if needed spontaneous breathing
17:08single
17:10port and
17:12uh
17:13it's well tolerated and compared to
17:16surgical thoracoscopy medical
17:18pleuroscopy has its specific role in
17:20some clinical scarios as it provides a
17:25comparable yield or success rate uh
17:28which are uh with a much more favorable
17:31safety profile and also cost benefit
17:35ratio as well so it really is about
17:37choosing the right
17:40indication It is Well tolerated even in
17:42the elderly and comorbid patients and um
17:46I'm sure I've I've heard this quote from
17:49um one of our Australian colleagues I
17:51think it's Luke Luke garski but uh
17:54because I don't um I wasn't sure I
17:57didn't put his name down here so shout
17:59out to him but um this this quote I love
18:03says medical perioscopy is really just
18:05an extended version of chest rization by
18:08dissection
18:11um so I might stop there these are my
18:14references and um um happy to
18:19um come back to you Gary
18:22and um answer any
18:26questions right thank you Chach that's a
18:29very good uh rundown of the um medical
18:32foric ccop and pros and cons um I might
18:35just start with very specific questions
18:38but uh in the in the meantime I
18:40encourage the audience if you can put
18:41your questions in chat and we can
18:43discuss it quickly um so you show in
18:46your pictures that you using semi- rigid
18:48uh Scopes and I think a lot of our Asian
18:52audience uh will use that as well but if
18:54you're trained in the UK you're probably
18:56more likely to do rid Scopes and that is
18:59almost like an eternal argument uh do
19:02you use apple or do you use Microsoft um
19:05so what's your take on that uh look it's
19:09it's um I think at the end of the day
19:11it's it's back to access and what you
19:13have and what you have access to um I I
19:17think they both have their uh pros and
19:19cons um to be fair I think rigid
19:23thoracoscopy is is is a skill that I
19:25don't do I don't do that procedure but I
19:28I do understand that you you have access
19:30to rigid forceps for sampling of the
19:32protop plura and that will give you
19:34deeper and larger specimens uh there
19:37could be an argument that by using cryo
19:40probes and doing Crysis which is now
19:42routinely uh done uh you can kind of
19:44overcome that um while using semi-
19:48rigids um I guess um it could also be
19:52fair to say that on the other hand um
19:57rigid plos or thoros Scopes don't have
20:00that flexibility that you get with the
20:03flexi rigid um and
20:06then visualization of the plora is
20:09probably a little bit better access to
20:12coris for example to the Apex sometimes
20:14a little a little bit better
20:18um I I think that's um the pain probably
20:22a bit better as well because you don't
20:24require that big of a port uh with a
20:27semi- rigid you could can you can get
20:29away with a 0.5 to 0.8 cm Port but you
20:34really need something at at 1 to 2 cimet
20:36port for uh for a rigid so there are
20:39there are pros and cons I I'm not sold
20:42to one way or another and I think it's
20:43it's a matter of access I think a true
20:46Interventional person would say the best
20:48is to have both isn't it yeah absolutely
20:52it will be now about training I think
20:55there's a lot of people in the in the
20:56audience who want to say you know some
21:00of the
21:01oldfashioned um Pioneers they just
21:04taught themselves how to do it um but I
21:07think nowadays there's always training
21:08pathway for everything what what do you
21:11think if someone if your traines want to
21:14start what is your recommendation to to
21:17get training or accreditation yeah I I I
21:22learned from the ctech course and and
21:24the the the beauty of that was um uh not
21:27just well obviously talks and and
21:29learning about the physiology and
21:30anatomy and um your we around the plural
21:33but we we spend uh a full day uh with
21:36live
21:37animals um uh doing doing pleuroscopy
21:40and that was really helpful um I think
21:44one of the very important uh factors
21:47here in any training is um of a of a new
21:51uh technique is to make sure that um
21:54shortly after the training course is
21:57done you do have access to have some
21:59supervised work as well and that's
22:02that's how I was lucky to go back to
22:05Concord and do a few with Matthew
22:07supporting me or or supervising me and
22:09then uh and that would be that's that's
22:12what I would recommend to
22:13everyone and um a lot of people may not
22:17have surgical people on site as a backup
22:22and that's always one question as to do
22:24we do you need to have surgery foric
22:27surgery onsite to be safe to do medical
22:30fetoscopy what's your
22:32view uh look I
22:35I'm my my view may be a bit
22:38controversial I I I don't think surgeons
22:41are of uh of um much help in the
22:45immediate um um situ in the acute
22:49situation to be honest with you in fact
22:51one of the reasons that H cour hospital
22:53and and we we do probably about 15 to 20
22:57uh a year on average
22:59um maybe more in some years um less
23:02during covid uh the reason that we have
23:04that service is because we don't have
23:06surgeons
23:07outside um and it's been work working
23:10well uh if there there are complications
23:13uh there are ways to manage them while
23:16you seek a surgical opinion yeah uh in
23:20your picture you you are doing it
23:22solo on your um Concord or mcari picture
23:27do you normally have a syst and what
23:29kind of assistance do you need yeah yeah
23:32I do have an assistant um we usually
23:35start on either side of the bed uh while
23:37uh we're dissecting but when we uh have
23:41the port in and I've sucked the fluid
23:43out we we go on the same side looking at
23:46the uh the monitor on the uh the other
23:48side and um the person assisting usually
23:53handles the the probes and forceps yeah
23:57so there's a couple of questions online
23:59one
24:00is do you need to have a minimal amount
24:02of Pro Fusion for you to go and do the
24:06to the um procedure and I guess that
24:10would lead to what do you do if there's
24:12no
24:13infusions uh very good question um I I
24:17would answer that question in a
24:18different way I don't think it's about
24:20the uh amount of infusion you have I
24:22think it's about uh the possibility the
24:26physiological ability of the two layers
24:28of plard to separate um so my my um when
24:33I do ultrasound before the procedure I'm
24:35not looking for having uh a big pocket
24:39to get in uh it would be nice it will be
24:42easy uh but I'm I'm more after um seeing
24:46the sliding of the two layers because
24:48that that basically tells me that if I
24:50induce a numo thorax there they would
24:52separate and I have a space to get in um
24:55if they're
24:56fused not going to anywhere so um if if
25:00there is no Fusion then you can actually
25:01introduce it by using a bhuton uh a
25:05needle which pretty much of just
25:07basically putting that I'm going to ask
25:09you a much more tougher question the the
25:12Bhutan though has been taken out of
25:13production you can't buy anymore so what
25:17what would you do oh um so um
25:20controversial again maybe you can
25:23dissect you can dissect carefully and
25:25put your finger in there and uh the try
25:28itself is blunt so when you put it in
25:32and open into the atmosphere is a um the
25:36other the other is that uh Abram
25:38needle that's a bit sharp though so
25:41you've got to be very careful with that
25:42but that again the side port into this
25:45air into the plural space yeah and just
25:48for the audience the the surgeons that's
25:50how they would enter the chest for Sayo
25:52back toy for lung cancer when that's dry
25:54so it's not an uncommon things to do at
25:57all yeah so another question was any
26:00tips on how to get the foric surgeon on
26:03side on your
26:05side look I think I think it's important
26:08to explain to them where um medical
26:12thoracoscopy uh medical prosop fits in
26:16uh in that Spectrum exactly how I was
26:19trying to sort of angle my talk is is to
26:23um avoid this uh concept that medical
26:27prosc opy is a substitute for vs um
26:31or in fact it has its own role it has
26:35its own indication and and just like
26:38anything else uh if when when you and
26:41your surgeon are collaborating looking
26:44at a big cohort uh of patients with
26:49plural conditions it actually creates
26:52more cross referrals so you're
26:54supporting one another rather than
26:55competing with one another if if you can
26:57kind of
26:58create that understanding I think that
27:00works very well yeah and just for the
27:03audience you don't really need
27:04permission from the surgeons to do
27:08this uh and and also at least in the
27:11Public Services it takes any amount of
27:13work low you take from them is actually
27:16a win-win situation um what do you do
27:20when the pur is tough I mean obviously
27:22you mentioned about cryo proof but I
27:24doubt if many of the audience has got
27:27access to that or feels entirely
27:29comfortable of using cryo in the plal
27:32space um what other options have we
27:36got um so I um I think you're referring
27:40to where the plur is kind of those kind
27:43of fibros
27:45or thick plid and it's very hard
27:49to biopsy um so my um approach is to use
27:56uh cryo it is even in those sometimes
27:59cryo is also very hard I often start
28:02with the forceps and I try to create a
28:04dent uh by peeling and go a bit deeper
28:08and usually deeper levels have have more
28:10water content and I can I can I can
28:13stick my cry probe there and then
28:16vibsing from there uh at at every uh
28:20procedure I mean obviously I have
28:22already thought about why I'm doing it
28:26um do I actually need
28:28a deep biopsy or not is this a case that
28:31I'm considering for misoa if that's the
28:33case Absolutely I'll go for it
28:37um obviously I'm going to be careful
28:39that I'm on the rib I'm not in between
28:40the rib and if I'm on the rib I feel
28:43reasonably comfortable to go as deep as
28:45I can layer by layer and try to sort of
28:48stick to one
28:50spot so another question is how many
28:53biopsies do or how many sites would you
28:56biopsy and how many biopsies per side is
28:59there usual rule of
29:02thumb oh look it is a um I I suspect
29:06there's going to be a very uh wide
29:08variation if you ask that question from
29:10from all pleuroscopy from uh from here
29:13and there I I often stick to if it's a
29:15diffuse uh obviously if you've got
29:17abnormalities you biopsy the
29:19abnormalities if it's a um diffuse
29:22process I I often do two sides and I
29:26include the posterior recess because
29:28seris is often often where things gather
29:31around pathology gathers around yeah
29:34someone wants to ask what's the
29:35indication for croscopy I I I presume um
29:40I I'll modify the question a little bit
29:42as as the when you would consider that
29:45and when you would actually consider s
29:47percutaneous say ound guided or CT
29:49guided biopsy
29:51instead right uh look ultrasounded
29:54guided um biopsy
29:58directly visualized biopsy is is a great
30:01technique when you have can
30:03identify um the abnormality on
30:06ultrasound um and in fact I would prefer
30:09that if I can see that there are studies
30:11as you I'm sure you're aware and and a
30:13few other um colleagues in Australia are
30:17involved in that as well the the yield
30:19seems to be reasonably comparable to
30:21thoros scopic or opos scopic as well so
30:25um when you if if you have access to
30:27that Techni
30:28and when you're doing your ultrasound if
30:31you can see enough thickness uh to allow
30:34for a biopsy uh needle biopsy I I would
30:38uh I would prefer that to troscopy
30:41however um there are often cases that
30:44that you not just doing that procedure
30:46for um for the biopsy for sampling uh
30:51for example you've got someone with
30:52malignant per refusion you know it's
30:54probably going to be malignant and
30:55you're going to make it a One-Stop shop
30:57uh um have a look um have a look at the
31:00visceral pra do your assessment about
31:02expansion maybe even try expansion uh
31:06whether you want to tal it or not or
31:08just go into IPC and get it done uh and
31:11that that some often it actually um
31:16speeds up the recovery for for patients
31:19so
31:20um that that that's my practice I try to
31:24um in most of these patients with plural
31:27disease you want to minimize the number
31:29of procedures you do and their time in
31:31hospital so another question is um if
31:35you find yourself in the middle of a
31:37locki once you get in how confident you
31:40are to break the adhesions or should we
31:43avoid doing that because it is not a
31:45surgical foric costop look it depends uh
31:49there are adhesions that are chronic and
31:51we see that um often sometimes they have
31:53actually blood vessels as well I would
31:55avoid them and and that's that's based
31:57on your your assessment and your direct
31:59vision and with experience that comes uh
32:02however in in um you know fibrin kind of
32:06locules it depends on your tool I
32:08actually use my cryo probe I use a 2.4
32:11cryo probe uh with uh in the three 3.2
32:15Channel or the 2.8 channel of my semi-
32:19rigid uh it's brilliant it's blunt uh
32:23and it also has rigidity enough to be
32:25able to puncture through um these webs
32:29of um of locules and when you can poke
32:32through and see on the other side
32:34usually fluid comes and you can see more
32:35holes then you feel comfortable to go
32:37through with your scope and start
32:39dissecting
32:41them and um another question is about
32:44after care um I think do you keep them
32:48overnight or um or you discharge them on
32:51the same day I think in the UK there's a
32:53strong push to to do day stay uh Medical
32:57horoscopy but it's not very common in
32:59Australia don't think no that's right I
33:01mean it it may be possible um but but my
33:05practice is to keep them over night yeah
33:08so am
33:09I I think you need to be uh doing it
33:12very early in the day and just make sure
33:14that the patient is stable and there's
33:16needs to be enough home support and so
33:18on and so forth yeah so I don't think
33:21there's any more questions I think
33:24everybody has learned a lot today so
33:26thank you very much TSH and thank you
33:28for the audience for joining us today
33:30and just a reminder that our next one
33:32will be on September 4th and de FIS who
33:35used to work in Australia who's Now in
33:37Ireland will be talking about uh why
33:40patients get breathless with PR Fusion
33:42which is a very important topic and
33:44there's a lot of new data on it so thank
33:47you everyone I look forward to see you
33:48next time

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