Ann Thorac Surg 1997;64:592-593
© 1997 The Society of Thoracic Surgeons
6367 Caminito Estrellado, San Diego, Ca 92120
To the Editor:
I read with interest the recent article by Yim and associates  entitled "Thoracoscopic Talc Insufflation Versus Talc Slurry for Symptomatic Malignant Pleural Effusion," in which they found no difference in the good results obtained between talc poudrage by thoracoscopy and intubation with slurry instillation for neoplastic pleural effusion. I would like to mention a point that I believe is being overlooked. I began using slurry in the early 1950s (I published an article in 1958 ). My results throughout the years confirmed those of Yim and associates. I did not hesitate to use intubation and talc slurry in debilitated patients if I thought they had more than a month to live. Furthermore, I did not exclude patients with trapped lung or poor pulmonary function as usually these patients noted breathing improvement after drying up the effusion. Usually these patients (more than 80%) no longer required thoracentesis for difficulty in breathing. The space filled up with a coagulum that gradually scarred, thus accomplishing its purpose. Because palliation basically consists of preventing recurrence of the effusion to the point where thoracentesis is not necessary and shortness of breath from effusion subsides, some residual effusion atelectasis and trapped lung are often well tolerated. I believe that good palliation can be achieved in such patients and one should not deprive them of the benefit of intubation and slurry treatment. After all, if symptoms subside, who cares about the appearance of the chest roentgenogram?
In my own mind I believe that the so-called reexpansion pulmonary edema is no more than better bronchial toilet and reexpanding and reaerating atelectatic lung with accompanying resumption of blood flow to that portion of the lung, with improvement of symptoms.
It is satisfactory for me to see a treatment that I successfully used over a 40-year period achieve widespread acceptance as illustrated by the series reported by Yim and associates.
Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
Reply To the Editor:
I appreciate the comment from Dr Chambers and noted his extensive personal experience with talc slurry to treat malignant pleural effusion. My colleagues and I reported on a prospective, randomized trial comparing thoracoscopic talc insufflation under general anesthesia with talc slurry under local anesthesia. Therefore, patients who underwent talc slurry treatment in that report represent only a portion of patients in whom we would normally consider this therapy. This applies to the majority of patients with symptomatic effusion (including those with poor lung function). However, we remain hesitant in using this therapy in patients who are severely debilitated from the underlying malignancy, especially when dyspnea is not the main symptom, and in those with trapped lungs. The former group perhaps could be better served by the best supportive therapy (therapeutic thoracocentesis or simple drainage), whereas the latter group could be treated thoracoscopically to achieve lung reexpansion if the entrapment is mild, or considered for pleuroperitoneal shunting if it is severe. We believe that approximation of the visceral to the parietal pleura is a prerequisite for success in any form of sclerotherapy in the absence of carefully documented findings to the contrary.
Although talc slurry is generally safe, it is certainly not without complications. We have encountered a patient in whom acute respiratory distress developed after this treatment, and similar complications, even death, have been reported anecdotally. We do not believe any therapy, however excellent, is universally applicable to a condition without exceptions. One should always remember Primum non nocere.
"It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm."
Florence Nightingale (18201910) from
Notes on Hospitals, Preface
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