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Ann Thorac Surg 2001;71:1809-1812
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Effective treatment of malignant pleural effusion by minimal invasive thoracic surgery: thoracoscopic talc pleurodesis and pleuroperitoneal shunts in 101 patients

^a Department of General and Thoracic Surgery, Christian-Albrechts-University Hospital, Kiel, Germany

Accepted for publication February 14, 2001.

Address reprint requests to Dr Schulze, Department of General and Thoracic Surgery, Christian-Albrechts-University, Arnold-Heller-Str 8, 24105 Kiel, Germany
e-mail: maren_schulze{at}hotmail.com

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. For effective palliation of patients with malignant pleural effusion due to advanced neoplastic disease, any proposed treatment should have low procedure-related mortality and morbidity.

Methods. The clinical outcome of 119 thoracoscopies in 101 patients (56 women, 45 men), from 42 to 91 years of age (mean, 68 ± 9 years) with malignant pleural effusions was evaluated in a retrospective study. Video-assisted thoracoscopy (VATS) talc pleurodesis was done in 105 instances, and a pleuroperitoneal shunt was performed 14 times as an alternative when complete expansion of the lung could not be achieved due to tumor implants on the visceral pleura.

Results. The VATS talc pleurodesis resulted in clinically significant improvement of dyspnea in 92.2% of the patients. Thirty-day mortality was 2.8% and morbidity was 2.8%. The mean duration of postoperative survival was 6.7 months. Recurrent pleural effusion occurred in 5.7% of patients after a mean interval of 6 months. Clinical relief of dyspnea was obtained in 73% of the patients treated with pleuroperitoneal shunts. Thirty-day mortality in this group was 21% and morbidity was 14.3%. The mean duration of survival was 4.2 months.

Conclusions. The VATS talc pleurodesis is appropriate for palliation of patients with malignant pleural effusions and should be performed once the diagnosis has been confirmed. Patients with lungs trapped by visceral carcinomatosis may benefit from placement of a pleuroperitoneal shunt as an alternative.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Dyspnea and reduction of physical capability severely affect the quality of life for patients with malignant pleural effusions. The mean survival of these patients is 13.5 months, ranging from 2.5 months for patients with bronchial carcinoma, up to 7 months for patients with metastatic breast cancer [1]. For patients with limited life expectancy, effective palliation requires a treatment with high probability of symptomatic improvement; low procedure-related mortality/morbidity, and a short hospital stay.

Drainage of the pleural cavity alone often does not result in significant palliation for patients with malignant pleural effusions; therefore, complete obliteration of the pleural space appears to be the procedure of choice [2]. Conventional irritant pleurodesis by instillation of talc slurry through tube thoracostomy has been modified using video-assisted thoracoscopy (VATS) with improved success. The VATS allows optimal preparation of the pleural surface and homogeneous distribution of the talc under visual control, maximizing the chances for complete pleurodesis.

We report a retrospective survey of 119 thoracoscopies in 101 patients suffering from malignant pleural effusion with follow-up as long as 3 years.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
In this retrospective study we have evaluated the clinical outcomes after treatment for malignant pleural effusion in 101 patients (56 women, 45 men) with a mean age of 68 years. All patients were treated at a single institution over a period of 36 months. The diagnoses are listed in Table 1.

The VATS was done under general anesthesia in all patients. For thoracoscopy, a 10.5-mm camera port and a 5.5-mm instrumentation port were inserted, pleural effusions were drained, and biopsies of the pleura were obtained [3]. The lungs were reexpanded under direct thoracoscopic vision by endotracheal insufflation. If complete reexpansion was accomplished, 2 to 4 g of talc powder were insufflated intrapleurally under direct vision and two chest tubes were positioned. If the lung appeared trapped by tumor involvement of the visceral pleura, a pleuroperitoneal Denver shunt (Denver Biomaterials, Surgimed Inc, Golden, CO) was inserted as an alternative to talc insufflation [3]. The draining portion of the shunt was positioned into the costodiaphragmatic angle and the opposite end of the shunt was placed into the free peritoneal space. Patients with bilateral effusions underwent sequential VATS to evaluate and treat both pleural cavities. Before hospital discharge patients were interviewed and examined and a chest roentgenogram was obtained. Outpatients were followed by telephone interviews of their attending oncologists. The effectiveness of talc pleurodesis was based on relief of symptoms and absence or reduction of pleural fluid by roentgenogram [3, 4]. Patients with symptomatic improvement and no detectable fluid on the roentgenogram before discharge were considered to have an excellent result. Those with symptomatic improvement, but residual fluid in the costophrenic angle, with no tendency for increase, were believed to have a satisfactory result. Patients whose pleural effusion recurred, or who had no symptomatic improvement, were classified as an unsatisfactory result.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
In 119 VATS procedures 105 talc pleurodesis and 14 pleuroperitoneal shunts were performed (Table 2). The average duration of VATS pleurodesis was 35 minutes (±14 minutes) and 55 minutes (±13 minutes) for insertion of a pleuroperitoneal shunt. All patients were weaned from mechanical ventilation in the operating theater.

Eight of the 14 patients who had pleuroperitoneal shunts experienced significant clinical improvement with 2 reporting marked relief of dyspnea and 6 experiencing moderate relief. Three patients had no improvement of their symptoms. Mean length of hospital stay after implantation of the shunt was 8.1 days (±1.9 days). Three patients (21%) died within 30 days of the procedure and 2 (14.3%) had procedure-related complications. Follow-up after pleuroperitoneal shunting ranged from 1 to 22 months, and the mean survival for these patients was 4.3 months (±1.9 months). Nine of the 14 patients succumbed to their disease during the follow-up period, and only 2 were alive at the time of this review (3 had died within 30 days of their procedure). Surgical reintervention for shunt dysfunction was required in 2 patients.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Simple drainage of the pleural cavity has not proven to be sufficient for treatment of malignant pleural effusion, as 90% of patients will develop recurrent effusions within 30 days [5]. In addition, drainage of large effusions may be accomplished by reexpansion of pulmonary edema [6]. Repetitive thoracentesis may be complicated by loculation of the pleural fluid, iatrogenic pneumothorax, or contamination with subsequent empyema [3]. Loss of fluid volume with a relatively high protein content may accentuate the patient’s tumor-related cachexia. Although tube thoracostomy often provides reliable drainage of the pleural space, more than 80% of patients experience recurrence of their effusion within 30 days after removal of the tube [7]. Drainage followed by obliteration of the pleural space has emerged as the procedure of choice for effective palliation of these patients [2]. Several methods and numerous sclerosing agents have been used (Table 3). Because of its effectiveness and the low incidence of side effects associated with its use, talc has proved superior to other commonly used sclerosing agents, particularly the irritant chemotherapeutic agents (Table 4) [4, 8–11]. The use of asbestosis-free talc minimized the risk of subsequent pleural mesothelioma, although this is not a major concern in these patients with such an extremely limited life expectancy.

Conventional pleurodesis by instillation of talc slurry through tube thoracostomy has been modified in this series of patients by using VATS. VATS provides optimal preparation of the pleural cavity by complete evacuation of all fluid, confirmation of complete lung expansion, and assurance of appropriate distribution of the insufflated talc under direct vision. If the lung is trapped by extensive tumor involvement of the visceral pleura and unable to expand sufficiently to obliterate the pleural space, a prerequisite for successful pleurodesis, a pleuroperitoneal Denver shunt may be implanted as alternative [14].

The VATS has been shown to be a safe procedure, with an operative mortality of 0.1% in a series of 1,365 patients [15]. In this series of 119 VATS procedures the operative mortality was 5.6%; however, this group of patients with advanced malignancy would seem to be at much higher risk than those on the series reported by Hurtgen and associates [15]. The operative mortality in our series is about the same as that previously reported by Ohri and associates [16] in a similar group of patients.

Because postoperative survival time is predictably short in this group of patients, successful palliation must be assessed in terms of effective relief of symptoms. Of our patients 93% experienced significant relief after VATS pleurodesis, a figure in agreement with those reported by other investigators using similar approaches [10, 14, 17].

Early recurrence of effusions after VATS pleurodesis was most likely due to advanced pleural disease. This is supported by the fact that the mean survival of patients with initial failure was only 8 weeks compared to 7.8 months in those successfully palliated. Therefore, it would seem that early pleurodesis in the course of malignant pleural effusion would more likely result in successful palliation. Of these patients 5.7% developed recurrent effusion after a mean of 6.6 months after initially successful pleurodesis. We consider this to indicate progression of their underlying malignancy. This is supported by the observation that only 1 patient survived longer than 6 weeks after late recurrence of effusion. Nevertheless, these patients experienced improved quality of life for at least 2 months after pleurodesis.

Pleuroperitoneal shunting has been previously described as effective in patients with extensive involvement of the visceral pleura with tumor [17]. Shunting allows ventilation of the diseased lung and affords some protection from mucous retention, atelectasis, and pneumonia. Although pleuroperitoneal shunting risks translocation of tumor cells into the peritoneal cavity [17], the improvement in respiratory function that may result makes the risks acceptable in this group of patients. We observed two shunt failures in our series. Other researchers [17] report similar problems with pleuroperitoneal shunts, a complication that may limit the widespread usefulness of these devices.

On the basis of this experience the following algorithm has been established for the management of malignant pleural effusion at our institution. Thoracentesis is performed with cytologic and microbiologic examination of the fluid. If the lung is completely reexpanded on chest roentgenogram, VATS pleurodesis is performed. If the lung fails to reexpand, a pleuroperitoneal shunt is placed. Patients who are believed to be incapable of having general anesthesia are treated with thoracentesis and instillation of talc slurry. Our experience suggests that more effective palliation is likely if pleurodesis is done early after the diagnosis of malignant pleural effusion.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The authors appreciate the supportive language editing by Dr William Gay.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) 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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schulze, M. Articles by Henne-Bruns, D. Search for Related Content PubMed PubMed Citation Articles by Schulze, M. Articles by Henne-Bruns, D. Related Collections Pleura