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Ann Thorac Surg 2007;84:1367-1370
© 2007 The Society of Thoracic Surgeons
Institut Curie, Paris, France
Accepted for publication April 11, 2007.
* Address correspondence to Dr Kriegel, 26 rue d’Ulm, Cédex 05, Institut Curie, Paris, 75248, France (Email: irene.kriegel{at}curie.net).
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Abstract |
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Description: Prospective follow-up of 29 patients between August 20, 2005 and August 1, 2007 in a single center. Thirty-four pleural implantable access systems were placed in 29 patients (23 patients with breast cancers, 4 patients with bilateral placements, and 1 patient with a replacement) under sedation after the decision of a multidisciplinary meeting.
Evaluation: Twenty-eight patients obtained partial or complete relief of their dyspnea. Six patients underwent pleurodesis after a maximum of 2 months. Fifteen patients were receiving chemotherapy at the time of placement. Seven patients died at the Institut Curie or in a palliative care unit without returning home. The other 22 patients presented a total of 280 days of hospitalization for 2,717 days of catheter implantation. No placement failures were observed in this series. Two infectious complications (infectious pneumonia and skin infection over the puncture site) and two mechanical complications (expulsion of the port and disconnection between the port and the catheter) were observed and easily treated. One patient had loculation of the pleural cavity develop after 16 thoracenteses making further thoracentesis ineffective.
Conclusions: The pleural implantable access system is an interesting alternative in terms of efficacy and safety for the outpatient management of malignant pleural effusion. It presents a number of advantages in terms of comfort and infectious risk compared with tunnelled pleural catheters.
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Technology |
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Technique |
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A new approach to the management of malignant pleural effusion has been tested at the Institut Curie. We report our experience with the use of a pleural implantable access system. We believe that one similar experience has been reported in the literature on 6 patients [2].
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Clinical Experience |
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Pleural Implantable Access System Placement
Pleural implantable access system placement was performed after providing the patient with oral information and after the patient had given his or her informed consent. Implantable access system placement was performed under sedation with local anesthesia and with hospitalization on the evening of the procedure. We could only place the patient under local anesthesia, even at the bedside, but we chose sedation to privilege patient comfort.
A Celsite ST 305 H 8.5 F (B Braun Medical France, Boulogne, France) implantable port was used in every case. Orifices were drilled every 1.5 cm over the distal 18 cm of the catheter. The guidewire was inserted according to the Seldinger technique in the midaxillary line between the third and fifth intercostal spaces, then directed toward the base of the lung under image intensifier guidance. A subcutaneous compartment was then performed in the midaxillary line over the tenth rib (Fig 1). The sheath dilator was advanced over the guidewire and the catheter that was connected to the port was then introduced to a depth of 26 to 30 cm. Pleural fluid was removed with a Huber needle connected to a tube and a suction drainage bottle. A first thoracentesis was performed before the patient’s recovery to ensure correct functioning of the system. This thoracentesis was limited to a maximum of 1,500 mL of pleural fluid. Thoracentesis was performed in a closed system to reduce the risk of infection to a minimum.
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Results |
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Fifteen of the 29 patients were receiving chemotherapy at the time of placement of the implantable access system. Apart from the patient who died 11 days after placement, all other patients obtained partial or complete improvement of their dyspnea, which was the primary objective of this procedure.
Six patients were treated by pleurodesis with return of the lung against the chest wall after a mean interval of 1 month. These 6 patients were receiving chemotherapy for metastatic breast cancer. The first patient had spontaneous pleurodesis develop after three thoracenteses during the first fortnight after placement, and the device was easily removed 321 days after placement. The second patient who had pleurodesis develop 2 months after placement of the device and after five thoracenteses presented with recurrent malignant pleural effusion 291 days after placement. Thoracenteses through the pleural implantable access system were easily resumed.
The number of aspirations performed varied between 1 and 28 (mean, 4) during a time period of 11 to 330 days.
No complications were observed immediately after placement.
One patient had empyema with Propionibacterium acnes infection of the pleural fluid develop; this patient also had homolateral lobar pneumonia due to the same microorganism. The pleural implantable access system could not be directly implicated in this infection and was left in place. Adapted antibiotic therapy ensured rapid cure of the infection.
One implantable access system was removed due to secondary skin infection over the puncture site in a context of febrile aplasia 20 days after placement.
Two mechanical complications were observed:
Disobstruction procedures were required in 4 patients, but no permanent obstruction was observed in any of the patients. The removal of obstructions was always obtained by simple operations (ie, rinsing, heparinized serum).
In 1 patient, pleural loculation after 16 thoracenteses made subsequent thoracentesis ineffective. This patient did not need any further intervention.
No case of tumor seeding along the catheter or the port was observed [3].
On January 8, 2007, 21 of the 29 palliative care patients had died. Thirteen of these patients had a survival greater than 1 month (range, 30 to 330 days), 6 patients survived more than 6 months, and 8 died less than 1 month after implantable access system placement. Thoracentesis through the implantable access system was performed at least twice in 7 of these 8 patients.
Seven patients died at Institut Curie or in a palliative care unit without returning home. The other 22 patients presented a total of 280 days of hospitalization for 2,717 days of catheter implantation. In the great majority of cases, the reasons for hospitalization were a course of chemotherapy or alteration of the general state requiring assessment and renutrition. No hospitalization was related to a complication of the device.
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Comment |
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Twenty eight of the 29 patients obtained partial or complete improvement of their dyspnea after placement of the device. Our low spontaneous pleurodesis rate (ie, 6 of 29 patients) can probably be explained by the fact that thoracentesis was not systematically performed until complete drainage of the pleura, but according to the degree of respiratory distress experienced by the patient. In these palliative care patients, thoracentesis should only be performed at the patient’s request when he or she considers dyspnea to be disabling in order to limit repeated trips to the hospital.
Only one or two thoracenteses were performed in 5 of 29 patients who died less than 1 month after placement, which raises the question of the real benefit of the implantable access system in these patients compared with conventional repeated needle thoracentesis. Future studies should try to identify criteria allowing selection of patients with a very short life expectancy in whom useless invasive procedures should be avoided.
A phase II single-center study will be initiated shortly to evaluate the implantable access system in the management of malignant pleural effusion with improvement of dyspnea as the primary objective and to evaluate the capacity of repeated systematic thoracentesis during the first 2 weeks after placement of the device to induce pleurodesis as the secondary objective.
Later on, a subsequent study should focus on the difference between the two devices (tunnelled pleural catheter and port) in regard to comfort and infectious risk.
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Disclosures and Freedom of Investigation |
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Footnotes |
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