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Ann Thorac Surg 1996;62:1000-1002
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Talc Pleurodesis: Talc Slurry Versus Thoracoscopic Talc Insufflation in a Porcine Model

Division of Cardiothoracic Surgery, Department of Surgery, University of Southern California School of Medicine, Los Angeles, California; and Ethicon Endo-Surgery Institute, Cincinnati, Ohio

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Pleurodesis using both talc slurry and thoracoscopic talc insufflation has been shown to be clinically effective. This study compares these two modalities of pleural talc instillation in an animal model.

Methods. Eleven immature pigs underwent general endotracheal anesthesia. On one side, a slurry of 5 g sterile United States Pharmacopeia talc in 50 mL of saline solution was instilled through a thoracostomy tube. On the other side, the lung was deflated and 5 g of dry talc was insufflated under thoracoscopic visualization. The animals were sacrificed 30 days later, and the quality of pleural adhesions was graded from 0 to 2 (0 = absent; 1 = light; 2 = dense) in each of six regions of each hemithorax. The distribution of adhesions on each side was graded from 0 to 6, according to the number of areas that contained adhesions.

Results. One animal died of anesthetic complications. Among the survivors, adhesions produced by both methods were dense and diffuse in 8 of 10 animals, and light and diffuse in 1 animal. One animal had light or absent adhesions on the talc slurry side, and dense and diffuse adhesions on the thoracoscopic talc insufflation side. There was no difference between the techniques for density of adhesion scores (talc slurry, 9.9 ± 2.2; thoracoscopic talc insufflation, 10.0 ± 2.5) or distribution of adhesion scores (talc slurry, 5.5 ± 1.0; thoracoscopic talc insufflation, 5.8 ± 0.4) (p > 0.1).

Conclusions. Effective pleurodesis in a porcine model can be obtained with either talc slurry or thoracoscopic talc insufflation.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1003.

Talc pleurodesis is extremely effective for the treatment of chronic pleural effusions and selected cases of recurrent pneumothorax [1]. Whereas talc can be instilled successfully into the pleural space in slurry form through a thoracostomy tube, administration by thoracoscopic insufflation recently has become popular [2, 3]. Though effective, the thoracoscopic approach frequently requires general anesthesia and single-lung ventilation, with the potential for increased morbidity and mortality as well as increased cost [4]. This study compares the effectiveness of pleurodesis resulting from thoracoscopic talc insufflation (TTI) with that obtained by talc slurry (TS) through a thoracostomy tube in a porcine model.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All animals received humane care in accordance with the "Guide for the Care and Use of Laboratory Animals" published by the National Institutes of Health (NIH publication 85-23, revised 1985).

Eleven immature pigs (weight 35 to 50 kg) underwent bilateral talc pleurodesis under general endotracheal anesthesia. In each animal, TTI was randomly assigned to be performed on one side and TS on the other.

We performed TS first. On this side, a 2-cm incision was made and the pleural space was entered in the fifth or sixth intercostal space. A 10-mm thoracoscope was placed through the incision without deflating the lung, and the pleural space was explored to exclude existing adhesions or pleural disease. The scope was removed, and a 28F thoracostomy tube was placed through the same incision. A slurry of 5 g talc (magnesium silicate) in 50 mL of sterile saline solution was instilled into the pleural space through the tube with a catheter-tipped syringe. The tube was flushed with another 50 mL of saline and clamped. The animal was then rotated into the dorsal, sternal, and right and left decubitus positions every 15 minutes for 2 hours. The thoracostomy tube was unclamped and placed to 20 cm suction. To ensure that the TS side was indistinguishable from the TTI side, we made a second incision and closed it 5 cm anterior and superior to the thoracostomy tube site.

Identical skin incisions were made on the contralateral hemithorax. After selective deflation of the lung on this side, a 10-mm thoracoscope was inserted through a port in the inferior incision. The pleural space was explored to confirm that the lung was collapsed and to exclude preexisting pleural disease or adhesions. Using a bulb syringe, 5 g of dry sterile talc was then insufflated into the pleural space through the superior incision under thoracoscopic vision. After the thoracoscope was replaced with a 28F thoracostomy tube in the inferior incision, we reexpanded the lung and obtained a chest roentgenogram to ensure that the lungs were inflated bilaterally. The animals were then allowed to recover, and both chest tubes were removed. Buprenorphine, 0.01 to 0.05 mg/kg, was administered as an analgesic every 8 to 12 hours postoperatively for 72 hours.

Thirty days later, a second chest roentgenogram was obtained. The animals then were sacrificed and autopsied by an investigator who was blinded to which hemithoraces received TS and which ones were treated with TTI. The ventral chest wall and sternum were removed, and the pleural spaces were evaluated for the distribution of adhesions (DA) by assigning one point for each of six areas of the pleural space in which substantial adhesions were present (apical, diaphragmatic, mediastinal, anterior, lateral, and posterior). The maximum possible DA score was 6. A rating of "diffuse" was given for a DA score of 5 or greater on a given side.

The quality of adhesions (QA) in each of six areas was also determined, by grading on a scale of 0 to 2 as follows: 0 = absent; 1 = light (able to dissect bluntly without tearing the lung); and 2 = dense (lung tears with blunt dissection; sharp dissection required to take down adhesions). The maximum QA score was 12. An overall rating of "dense" was given for a QA score of 10 or greater on a given side, and "light" for a QA score of 4 to 10. Pleurodesis was considered to have failed if the QA score was less than 4 or if the DA score was less than 5. Sections of the lung and chest wall containing adhesions were submitted for histologic examination.

Data were expressed as mean ± standard deviation. The paired Student's t test was used to determine the differences between each group. A p value less than 0.05 was considered statistically significant.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Twenty-two pleurodesis procedures were performed on 11 animals (11 TS, 11 TTI). One animal died immediately postoperatively of pneumothorax resulting from a malfunctioning chest tube. All other animals survived the procedure and recovered without complications. Chest roentgenograms obtained after pleurodesis and 1 month postoperatively showed full expansion of the lungs bilaterally in all animals.

Adhesions produced by both methods were dense and diffuse in 8 of 10 animals, and light and diffuse in 1 animal. One animal had light or absent adhesions on the TS side (DA = 3, QA = 5), and dense and diffuse adhesions on the TTI side. There was no significant difference between the techniques with respect to the quality of adhesion scores (TS, 9.9 ± 2.2; TTI, 10.0 ± 2.5) or the distribution of adhesion scores (TS, 5.5 ± 1.0; TTI, 5.8 ± 0.4) (p > 0.1). The localized absence of adhesions, when it occurred, was noted most frequently on the dorsal diaphragmatic surface. This was observed on both sides in 2 animals, on the TS side in 1 animal, and on the TTI side in 1 animal. In addition, a focal absence of adhesions tended to occur in areas where the collapsed lung was not lifted to allow exposure to insufflated talc on the TTI side.

Histologically, both sides showed obliteration of the pleural space by a florid foreign-body giant cell response and developing fibrosis.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The intrapleural instillation of talc for producing pleural adhesions was first described in the laboratory and clinical setting by Bethune [5] in 1935, who used it as a preliminary to lobectomy. Since then, talc has been discussed extensively regarding its mechanism of action, mode of administration, effectiveness, and potential toxicity as a pleural sclerosing agent.

Animal studies have shown that the intrapleural application of talc by either slurry or poudrage causes visceral pleural thickening with macrophage infiltration, foreign-body reaction, and fibroblast proliferation, with subsequent pleural fibrosis [1, 6, 7]. These findings were also present in this study, although only mild to moderate fibrosis was seen. This latter result may be due to the short follow-up (30 days) in this study as compared with other studies.

The effectiveness of talc for pleurodesis has been documented both clinically and in the laboratory. Bresticker and associates [8] found that talc was equal to mechanical abrasion and superior to tetracycline, the argon beam coagulator, and the Nd:YAG laser in producing pleural adhesions in dogs. Hartman and colleagues [9] compared insufflated talc with tetracycline and bleomycin pleurodesis in patients with malignant pleural effusions and found consistently superior results with talc. Kennedy and Sahn [1] reviewed the literature from 1958 to 1994 and calculated a cumulative success rate of 91% among 723 patients undergoing talc pleurodesis for pleural effusions. The success rate for TS in the reviewed studies ranged from 80% to 100%, compared with 90% to 100% for talc poudrage. This fairly extensive clinical experience is consistent with our laboratory findings, which showed comparable results between these modes of talc delivery. Both the quality and distribution of adhesions seem to be acceptable with both techniques. We found an occasional lack of adhesions on the dorsal diaphragms of animals in our porcine model, possibly because this is one of the most remote and least dependent areas of the pleural space in an upright quadriped. However, this explanation is only speculative. When insufflating talc through a thoracoscope, we have found that talc distribution can be improved by manually lifting the collapsed lung to apply talc to the posterior aspects of the pleural space, including the posterior diaphragm. For TS, we used the technique of Webb and associates [2] of rotating the patient after instillation of the talc to improve distribution. Whether this is necessary is not proven. Some surgeons add iodide to the talc when performing pleurodesis because it is thought to cause a more effective pleuritis; however, this also has not been proven. In fact, Singer and co-workers [10] found no difference in the pleural reaction to talc in rabbits with or without iodine. One interesting note regarding the use of iodized talc is that the iodine makes the talc visible on chest roentgenogram, which may aid in determining whether it has been distributed throughout the pleural space [2].

Serious toxicity with talc pleurodesis is unusual. Cardiovascular complications such as arrhythmias, cardiac arrest, myocardial infarction, and hypotension have been reported. However, their actual relation to the talc is difficult to ascertain [1]. Respiratory insufficiency, including adult respiratory distress syndrome, also has been reported with both TS and talc poudrage [11, 12]. The mechanism of respiratory insufficiency is unclear, but may be dose related [1]. Minor side effects of talc pleurodesis include pain, which is usually mild [13], and fever, which occurs 4 to 12 hours after talc instillation and may last for 2 to 3 days [1].

Considerable controversy exists regarding the most suitable technique for talc pleurodesis. Recently, video-assisted thoracoscopic surgery with talc poudrage has become popular with many surgeons. Proposed advantages of this technique include the opportunity to explore the pleural space and to biopsy suspicious lesions if necessary, and the ability to take down adhesions and drain loculated areas of effusion. Furthermore, this technique allows excellent distribution of a fine layer of insufflated talc under direct visualization. Disadvantages of video-assisted thoracoscopic surgery for talc insufflation are the frequent requirements of a general anesthetic in the operating room and double-lumen endotracheal tube intubation. Morbidity and mortality can be substantial in this group of often debilitated patients, as demonstrated by Ohri and colleagues [4], who reported a mortality rate of 5% in patients who underwent thoracoscopic talc poudrage under general anesthesia. The single death in our animal model was due to a pneumothorax, which a malfunctioning chest tube failed to evacuate.

In addition to the increased morbidity and mortality associated with general anesthesia and talc pleurodesis, the use of the operating room with its staff and expensive equipment (both disposable and reusable) may increase the cost of talc pleurodesis dramatically. In response to the increased morbidity and cost associated with TTI under general anesthesia, many practitioners have resorted to performing TTI under local anesthesia, using a simple 7- to 10-mm thoracoscope, with excellent results [14, 15].

Advantages of TS through a simple thoracostomy tube include its high success rate, safety, low cost, and simplicity. There is no need for expensive equipment, general anesthesia, or the operating room. If, as demonstrated in this study, comparable pleurodesis is obtainable with this technique, it would seem to be the procedure of choice for most patients with chronic pleural effusions and for selected patients with pneumothorax. Exceptions would include patients who also require thoracoscopy for other reasons, such as the need to make a diagnosis in the case of a pleural effusion or to stop an air leak in a patient with persistent or recurrent pneumothorax.

In summary, effective pleurodesis in a porcine model can be obtained with either TS through a thoracostomy tube or TTI. In light of the cost and morbidity of video-assisted thoracoscopic surgery when compared with a simple thoracostomy tube, TS may be the preferred clinical approach in patients with chronic pleural effusions and in selected patients with recurrent pneumothorax who do not require thoracoscopy for other reasons. This study emphasizes the need for a prospective clinical study comparing these techniques.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29–31, 1996.

Address reprint requests to Dr Cohen, USC Healthcare Consultation Center, 1510 San Pablo St, #415, Los Angeles, CA 90033.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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4. Ohri SK, Oswal SK, Townsend ER, Fountain SW. Early and late outcome after diagnostic thoracoscopy and talc pleurodesis. Ann Thorac Surg 1992;53:1038–41.[Abstract]
5. Bethune N. Pleural poudrage: a new technic for the deliberate production of pleural adhesions as a preliminary to lobectomy. J Thorac Surg 1935;4:251–61.
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9. Hartman DL, Gaither JM, Kesler KA, Mylet DM, Brown JW, Mathur PN. Comparison of insufflated talc under thoracoscopic guidance with standard tetracycline and bleomycin pleurodesis for control of malignant pleural effusions. J Thorac Cardiovasc Surg 1993;105:743–7.[Abstract]
10. Singer JJ, Jones JC, Tragerman LJ, Sherman L. Aseptic pleuritis experimentally produced. J Thorac Surg 1941;10:251–83.
11. Rinaldo JE, Owens GR, Rogers RM. Adult respiratory distress syndrome following intrapleural instillation of talc. J Thorac Cardiovasc Surg 1983;85:523–6.[Abstract]
12. Todd TRJ, Delarue NC, Ilves R, Pearson FG, Cooper JD. Talc poudrage for malignant pleural effusion [Abstract]. Chest 1980;78:542–3.
13. Walker-Renard P, Vaughn L, Sahn SA. Chemical pleurodesis for the treatment of malignant pleural effusions. Ann Intern Med 1994;120:56–64.[Abstract/Free Full Text]
14. Aelony Y, King R, Boutin C. Thoracoscopic talc poudrage pleurodesis for chronic recurrent pleural effusions. Ann Intern Med 1991;115:778–82.[Abstract/Free Full Text]
15. Davidson AC, George RJ, Sheldon CD, Sinha G, Corrin B, Geddes DM. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988;43:327–32.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robbin G. Cohen Jeffrey A. Hagen Tom R. DeMeester Vaughn A. Starnes Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cohen, R. G. Articles by Starnes, V. A. Search for Related Content PubMed PubMed Citation Articles by Cohen, R. G. Articles by Starnes, V. A. Related Collections Related Article