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Ann Thorac Surg 2005;80:2013-2019
© 2005 The Society of Thoracic Surgeons

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Original article: General thoracic

Comparative Study of Subxiphoid Versus Video-Thoracoscopic Pericardial "Window"

^a Section of General Thoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania USA
^b Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania USA
^c Department of Surgery, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania

Accepted for publication May 18, 2005.

^_* Address correspondence to Dr Shrager, Hospital of the University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA19104 (Email: joseph.shrager{at}uphs.upenn.edu).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: It remains undefined whether surgical subxiphoid drainage or thoracoscopic pericardial "window" is the optimal operative approach to pericardial effusion. We hypothesized that the true window into the pleural space created by the latter might improve the duration of freedom from recurrent effusion.

METHODS: We conducted a retrospective chart review of indications, preoperative and intraoperative variables, morbidity, recurrence, and survival.

RESULTS: Fifty-six patients underwent the subxiphoid procedure and 15 underwent the thoracoscopic procedure. Echocardiographic evidence of tamponade was present before 8 of 10 thoracoscopic procedures (80%) and 43 of 56 subxiphoid procedures (81%) for which descriptions of hemodynamics were available. In addition, non-pericardial procedures were performed in 10 (67%) and 18 (32%) patients, respectively (p = 0.020). Anesthesia time was longer at thoracoscopy (117.1 ± 32.4 vs 81.1 ± 25.5 minutes; p < 0.001). Procedural morbidity was higher after thoracoscopy (4 [27%] vs 1 [2%]; p = 0.006), but was generally minor. Hospital mortality tended to be higher after the subxiphoid procedure (7 [13%] vs 0 [0%]; p = 0.332), but none of the deaths was procedure-related. Follow-up was complete for 65 patients (92%). Recurrence occurred in 1 thoracoscopy patient (8%) and 5 subxiphoid patients (10%) (p = 1.000). Mean time to recurrence by Kaplan-Meier analysis trends were longer after thoracoscopy (36.1 vs 11.4 months; p = 0.16), and multivariate analysis identified the thoracoscopic approach as an independent predictor of freedom from recurrence (relative risk, 0.41; p = 0.014).

CONCLUSIONS: Operative time and minor procedural morbidity are higher with thoracoscopic pericardial window, but long-term control of effusion seemed to be better than after subxiphoid surgical drainage.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Pericardial effusion complicates many disease processes, both benign and malignant. A variety of treatments are available, ranging from observation, to anti-inflammatory or anti-neoplastic chemotherapy, to pericardiocentesis with or without percutaneous catheter drainage, and finally to surgical procedures. We believe that there are two surgical options most commonly used today: (1) subxiphoid drainage (SXD) and (2) video-thoracoscopic pericardial "window" (TPW). We are unaware of any available data to guide the choice between these approaches.

The most common operation is likely SXD, which as generally performed amounts to placing a large-bore tube from an upper abdominal incision through the site of a pericardial biopsy [1]. Symphysis between the epicardium and pericardium develops after several days of drainage [2]. Because it is done in the supine position, access is readily available to perform pericardiocentesis if instability occurs after induction.

A pericardial window is a larger biopsy or partial pericardiectomy that creates a passage presumably allowing longer-term drainage into an adjacent space, usually the pleural space. Pericardial resection creating such a window can be performed through a limited anterior thoracotomy, formal thoracotomy [3], or since the 1990s, thoracoscopy [4–10]. The subxiphoid drainage procedure is often erroneously referred to as a "window," when in fact no such connection to an adjoining space is made during standard SXD.

Thoracoscopic pericardial window does create a true window, but it requires one-lung ventilation and two or three intercostal incisions. The thoracoscopic access allows concurrent performance of additional procedures, such as biopsy of the lung, pleural, or mediastinal masses, or management of a concomitant pleural effusion [4–10]. However, need for single-lung ventilation and the preference by some surgeons for lateral positioning, which impedes easy access for an emergent drainage, may limit the role of TPW in patients with hemodynamically significant effusions [5, 6, 10]. Although TPW is minimally invasive when compared with thoracotomy, it may in fact be more invasive than SXD.

The choice among the surgical approaches to the management of pericardial effusion must be based mainly on (1) the effectiveness of the procedure in preventing recurrent effusion, and (2) the morbidity and mortality of the procedure. Other considerations include the relative simplicity of the technique and cost. Published recurrence rates have ranged from 2.5% to 16% after SXD [1, 2, 11–21] and 0% to 8% after TPW [4–6, 8–10, 22, 23]. However, duration and intensity of follow-up, as well as definitions of recurrence have been variable. The only study directly comparing a subxiphoid with a thoracoscopic approach [24] does not clearly describe whether a true window was created by the former procedure, and does not focus on surgical morbidity or other issues of surgical importance.

We reviewed our experience with SXD and TPW at a single institution, comparing preoperative and intraoperative variables, morbidity, and recurrence. Our goal was to provide data that might guide the choice between the two approaches. A central hypothesis was that the creation of a true window by TPW would confer an improvement in freedom from recurrent pericardial effusion.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Data was collected from the inpatient and outpatient records of patients who underwent SXD or TPW procedures between 1992 and 2002. These procedures were performed by 5 surgeons at three different hospitals within the University of Pennsylvania Health System. The study was granted an exemption from the requirement for informed consent from the Institutional Review Board of the University of Pennsylvania.

A total of 76 patients underwent SXD or TPW procedures. Five patients were excluded because the medical record of the index admission was not available. The remaining 71 patients are the subjects of this review. A thoracoscopic pericardial window procedure was performed in 15 patients (21%), and the SXD procedure was performed in 56 patients (79%).

Echocardiographic data prior to surgical drainage were reviewed for effusion size and the presence of tamponade physiology as indicated by right atrial compression or right ventricular diastolic collapse, or both [25, 26]. In cases in which echocardiography was unavailable, size was graded according to computed tomography. In cases in which percutaneous drainage was performed prior to surgical drainage, echocardiographic data after the percutaneous procedure was used if it existed; otherwise, the data was omitted.

We recorded any adverse event after the procedure that occurred during the same hospitalization, but was not preoperatively present as morbidity. We recorded any adverse event that clearly would not have taken place had the patient not undergone the procedure as a procedural morbidity; in this category we searched the records specifically for wound infections or wound healing problems, intraoperative technical complications, intraoperative or postoperative bleeding, and drainage tube-related complications (eg, pneumothorax).

Follow-Up
Length of stay was calculated from the day of the surgical procedure until discharge or in-hospital death. Recurrence was defined as an effusion on postoperative echocardiography that was either moderate or greater, or hemodynamically significant, regardless of the need for further therapy. In the case of patients who were not followed-up at the University of Pennsylvania Health System, the treating physician was contacted by telephone. The follow-up period was calculated until recurrence, death, or last clinical contact. Additional survival data was obtained from the Social Security Death Index.

Operative Techniques
The choice of operative procedure was made by the surgeon. All patients were hemodynamically stable when brought to the operating room, although many had tachycardia or mild pulsus paradoxus, or both. In several instances in both groups, preoperative percutaneous drainage by the cardiology service had been performed for a hemodynamically significant effusion to urgently stabilize a patient. One patient had hemodynamic instability develop with the induction of general anesthesia. This patient improved after urgent pericardiocentesis and an SXD procedure was immediately performed. General anesthesia was used in all cases. Anesthesia time was calculated as time from induction until extubation, or until skin closure if the patient was not extubated or if additional procedures were to be performed at a separate site.

Our technique of SXD is made through a 5-cm upper midline incision. Blunt extraperitoneal dissection is carried out (usually with resection of the xiphoid) to expose the pericardium. After excision of an approximately 3 x 3 cm piece of pericardium, and after drainage of the effusion, a single thoracostomy tube (20 to 32 FF) is placed and left to drain for at least 96 hours. A closed-system silastic drain was placed in 3 patients. During SXD, no attempt was made to create a true window to either the pleural or peritoneal space.

For TPW, single-lung ventilation using a double-lumen endotracheal tube was used in all of our cases. Thoracoscopy was performed through a 10-mm camera port, typically in the seventh intercostal space in the mid-axillary line, and the procedure was completed through one or two working incisions. Nine of the TPW procedures were done from the right side and six from the left. A piece of pericardium approximately 4 cm in diameter was resected from anterior to the phrenic nerve, creating a window into the pleural space. A single chest tube (20 to 32 FF) was placed into the operative pleural space in all instances; a second chest tube was placed directly into the pericardium in 2 patients. A thoracoscopic window had been planned for 2 patients who ultimately underwent subxiphoid drainage. This conversion was due to preoperative deterioration in 1 patient and inability to place a double-lumen endotracheal tube in the other patient. All other planned TPWs were successfully accomplished by that technique.

Pericardial and pleural tube management, including the use of sclerosants, was at the discretion of the surgeon. The duration and amount of postoperative drainage were calculated for the pericardial drain in cases of SXD and for all drains (pleural and pericardial) placed on the operative side in cases of TPW.

Statistical Methods
Two-sample t test and two-tailed Fisher's exact test were used to compare continuous and dichotomous variables between groups, respectively. Differences were considered statistically significant at p < 0.05. Time to recurrence and time to death were modeled using the Kaplan-Meier method. Risk of recurrence and risk of death were estimated using Cox proportional hazards models.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Demographics
Table 1 lists the demographic characteristics of all patients. A history of malignancy was present in 50 patients (70%). The most common primary malignancies were lung (23), breast (9), and lymphoma or lymphoproliferative disorders (8). Prior pericardial drainage had been performed in 19 patients (27%), either by pericardiocentesis (17) or by pericardiocentesis with subsequent indwelling catheter (2). Two patients had undergone more than one percutaneous procedure. The effusion was proven malignant in 16 patients (22%) (ie, by preoperative cytology in 3 patients [4.2%], operative cytology in 9 [13%], and pericardial biopsy in 10 [14%]).

Data shown in Table 2 demonstrates that there was no significant difference between the TPW and SXD groups in any of the demographic factors or echocardiographic characteristics.

Instillation of a sclerosing agent (talc or doxycycline) into the pericardial space was performed in 5 patients (7%), all in the SXD group (intraoperatively in 4 and postoperatively in 1). Instillation of sclerosants into the pleural space was done in 8 patients (10%), including 6 TPW patients (intraoperatively in 4 [including 2 contralateral to the TPW through a chest tube] and postoperatively in 2), and 2 SXD patients (both postoperatively through an additional chest tube placed at the time of surgery).

Operative time
Anesthesia time could be calculated in 67 patients (94%). Not unexpectedly, there was a statistically significantly longer anesthesia time for TPW (117.1 ± 32.4 minutes) versus SXD (81.1 ± 25.5 minutes) (p < 0.001).

Sensitivity of pericaridal biopsy
Pericardial biopsies were done in all patients in the TPW group and in 45 in the SXD group, including 9 patients with a history of malignancy among the former and 34 such patients among the latter. Biopsy was positive for malignancy in 4 of 9 patients (44%) and 6 of 34 (18%), respectively, a difference that did not achieve statistical significance (p = 0.177). No patients without a history of malignancy had positive pericardial cytology or biopsy.

Postoperative data and morbidity
All of the TPW patients were extubated in the operating room, excluding 2 patients who were intubated preoperatively for ongoing respiratory failure; 49 of 54 SXD patients (91%) were extubated, a difference that did not achieve statistical significance.

Duration of tube drainage ranged from 1 to 10 days. The duration was similar in the groups (p = 0.117). The total amount drained was significantly higher in the TPW group (735 ± 742 mL vs 433 ± 417 mL), but recall that this drainage included pleural tubes in the former. Length of stay was similar in the two groups, 12.4 ± 22.8 days (range, 2 to 94; median, 7 days) in the TPW group and 10.4 ± 12.2 days (range, 1 to 76; median, 7 days) in the SXD group.

Morbidity occurred in 36 patients (ie, 7 TPW patients [47%] and 29 SXD patients [52%]), and it was primarily related to coexisting medical problems in these complex patients that were unrelated to the procedure. Specific procedural morbidity was greater after TPW procedures (p = 0.006), although the morbidities were considered minor. Procedural morbidity occurred in 4 patients (27%) in the TPW group and in 1 in the SXD group (2%). Of the 4 TPW patients, 2 required additional chest tubes for pneumothorax after chest tube removal, 1 was discharged home with a Heimlich valve for ongoing air leak from injury to a trapped lung, and 1 was readmitted for drainage from a chest tube site that was self-limited. In the SXD patient with procedural morbidity, a pleural chest tube was placed intraoperatively for a clinical tension pneumothorax after pericardial drainage. There were no cases of postoperative pneumothorax or wound-related problems in the SXD group.

There were no direct procedure-related mortalities (deaths due to procedural morbidity or early failure to control effusion). Seven patients died within 30 days or prior to discharge, all in the SXD group (13%), a difference that did not achieve statistical significance. All 7 deaths were due to either advancing malignancy or worsening of an underlying medical illness in the absence of recurrent effusion.

Recurrence of Effusion and Survival
Crude follow-up, effusion recurrence, and survival data is shown in Table 4.

There was one recurrence (8%) in the TPW group and five (10%) in the SXD group (p = 1.000). None of the recurrences required invasive therapy. The sole recurrence after TPW occurred in a 72-year-old man with a recurrent idiopathic effusion that recurred again 18 months after TPW; he expired 1 month later of congestive heart failure. Two of the recurrences in the SXD group occurred early; each patient was found to have a moderate residual effusion at the time of discharge that was not treated further. The three late SXD recurrences were noted at a mean of 3.2 months.

From the Social Security Death Index data, we find that a total of 52 patients had died (ie, 9 in the TPW group [60%] and 43 in the SXD group [77%]) at a mean of 28.1 ± 35.9 months. Median overall survival was 70.5 months. Crude, median survival was not statistically significantly different between the groups (ie, 59.2 months after SXD and 79.7 months after TPW p = 0.68). In patients with a history of malignancy and documented malignant effusions, median survival was 79.7 months and 23.6 months, respectively.

Kaplan-Meier Analysis
The Kaplan-Meier curves of freedom from recurrent effusion after SXD and TPW are shown in Figure 1. Median time to recurrence was 8.0 months after SXD and 21.7 months after TPW, and mean time to recurrence was 11.4 and 36.1 months, respectively, but the difference did not achieve statistical significance (p = 0.16).

View larger version (16K): [in this window] [in a new window]   Fig 1. Kaplan-Meier curves of freedom from recurrent effusion. (SXD = subxiphoid drainage; VATS = thoracoscopic pericardial window.)

None of the variables achieved significance in the survival model (Table 6). Documented malignant effusion nearly achieved significance, with a relative risk of 7.7 (p = 0.051; 95% confidence interval, 0.99 to 60.77).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
When an operation is required for the management of pericardial effusion, there are two main options in recent years that have been considered reasonable: (1) surgical SXD and (2) video TPW. If it could be shown that there was a clear difference in morbidity, mortality, diagnostic accuracy, recurrence of effusion, or cost between these approaches, then this information would be useful to surgeons who are trying to decide between the two options. Therefore we reviewed our experience with the two procedures to compare them with respect to these outcomes. The importance of these issues is highlighted by the fact that there is an ongoing discussion at a national level to organize a multicenter, prospective, randomized study to address this question.

In this series, patients who underwent SXD and those who underwent TPW had effusions that were similar in terms of the percentage that were (1) moderate or greater in size and (2) associated with echocardiographic abnormalities suggesting tamponade physiology. General anesthesia was well tolerated in both groups, with only 1 patient who had urgent needle decompression performed in the operating room for instability after induction. Also, single-lung ventilation was well tolerated in the TPW group. In our practice and in many series [3–5], patients who are clinically unstable from tamponade are often temporized with percutaneous, echocardiographic-guided drainage prior to any surgical procedure to avoid instability associated with the induction of general anesthesia. In clinically stable patients, our data suggest that effusion size and presence of mild tamponade on echocardiography do not prohibit TPW.

One potential benefit of TPW in comparison with SXD is that it allows certain intrathoracic procedures to be performed simultaneously with the pericardial procedure. In this review, the percentage of patients having additional procedures was twice as high as in the TPW group. Most of these were intrapleural procedures accomplished thoracoscopically. However, whether there is any benefit to the patient having a thoracoscopic pleurodesis for pleural effusion combined with a TPW rather than a tube thoracostomy under the same anesthetic as SXD, and subsequent pleurodesis, is questionable.

In this series, follow-up was available in 92%, and recurrence was confirmed by echocardiography. Recurrence was uncommon, occurring in 8% and 10% of TPW and SXD patients, respectively, comparable with previous series [1–24].

We had hypothesized that the creation of a true pericardial window into the pleural space might produce a lower recurrence rate in the TPW group. Although the crude recurrence rate and time to recurrence were not significantly different between the two groups, Cox proportional hazards models determined that TPW conferred a statistically significant reduction (relative risk, 0.41) in the risk of recurrent effusion. In addition, this model confirmed the previous findings of others that patients with a history of malignancy and especially those with documented malignant effusions have a greater risk of recurrence.

Procedural morbidity was low overall, but it was significantly higher in the TPW group and related mainly to complications associated with accessing the pleural space (particularly pneuomothoraces). In that sense, the higher overall morbidity seems to reflect the greater complexity of the procedure and the fact that the surgeon is entering an additional cavity. Several series of SXD report complication rates of less than 4% [15, 18, 20], but higher rates have been reported [16, 17]. Most series of TPW report no complications [4–7, 10]; however Geissbuhler and colleagues [8] reported a 12% incidence. In our study, hospital mortality was 13% among patients having SXD, which is similar to rates reported in other series [1, 2, 11–20], and zero among TPW patients. However, because none of the mortality was specific to the procedure, we interpret this as reflecting that patients with greater comorbidities were selected for the SXD procedure, which was perceived by the surgeons to be less invasive. Patients with concomitant critical illness or very advanced malignancy, and those who otherwise seemed not to be clinically suited to the somewhat more complex TPW procedure were likely offered SXD as the simplest option.

Anesthesia time was dramatically longer in the TPW group, a finding that we had anticipated given the added time necessary for (1) placement of a double-lumen endotracheal tube, (2) lateral decubitus positioning, and (3) concomitant thoracoscopic procedures. Mean operative times have ranged from 27 to 57 minutes in previous series [8, 9, 22] that presumably measured "skin-to-skin" time. We elected to measure anesthesia time to reflect the total time invested by the care team and as the best reflection of operating room costs.

The only other study we are aware of that reported a concurrent series of subxiphoid and thoracoscopic surgical procedures for drainage of pericardial effusion focused not on the type of procedure but on other prognostic factors [24]. In that publication, the authors found that morbidity was not dependent on which procedure was performed. A careful reading of their publication allows one to glean that crude recurrence rates were similar according to procedure (ie, 2 of 14 after the subxiphoid procedure and 1 of 30 after the thoracoscopic procedure), but this study did not report recurrence data according to procedure by multivariate analysis as in our study.

We did not measure postoperative pain in this study. However, we believe it is likely that the small, upper midline incision for SXD is less painful than the two to three intercostal incisions required for TPW. Certainly the abdominal incision confers no risk of the prolonged intercostal neuralgia that can occur after a thoracoscopic operation [27]. We also did not measure costs, but one would expect that the documented longer anesthesia times and the use of thoracoscopic disposables would favor SXD in this regard, particularly with the finding that the length of stay was similar between the groups.

Regarding diagnostic accuracy, it might be expected that the opportunity to provide a larger biopsy of pericardium at TPW would afford improved diagnostic capability. However, our data do not clearly establish this, as there was no significant difference in the rate of biopsies positive for malignancy obtained by the two methods.

Limitations of this series include its retrospective design, the small sample size in the thoracoscopic group, and the lack of routine surveillance echocardiograms. Although a follow-up echocardiogram was available in 56%, routine surveillance might have picked up more recurrent effusions. However, if such undetected recurrences were asymptomatic or occurred in an end-stage patient, their clinical significance is likely to be small. We cannot exclude the possibility though that some patients died of recurrent tamponade that went undiagnosed. In general, our conclusions must be tempered by all of the biases inherent in a retrospective study.

To summarize this retrospective series, TPW and SXD were both reasonably effective in controlling pericardial effusions. However, when adjusted for confounding variables, TPW conferred a significantly lower risk of recurrent effusion. The thoracoscopic procedure was associated with a longer operative time and higher rate of minor, procedure-related morbidity. Echocardiographic evidence of mild tamponade did not render the thoracoscopic approach unsafe, and TPW was more likely to be used when concomitant intrapleural procedures were required.

We conclude from these results that because it is simpler, faster, and slightly less morbid, SXD should be the preferred approach in the surgical management of pericardial effusion if a patient's life expectancy is likely to be extremely limited due to major comorbidities or extensive metastatic disease. Patients with benign disease, those with malignancy that has not metastasized extensively or is exquisitely responsive to chemotherapy and thus may enjoy prolonged survival, and those requiring concomitant intrapleural procedures should be considered for TPW. We look forward to a prospective, randomized trial that may shed further light on this question.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The authors thank Julien Bonifacio for database work that made this publication possible.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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