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      Early and late morbidity and mortality and life expectancy following thoracoscopic talc insufflation for control of malignant pleural effusions: a review of 400 cases

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          Abstract

          Background

          Malignant pleural effusion is a common sequelae in patients with certain malignancies. It represents a terminal condition with short median survival (in terms of months) and the goal is palliation. Aim of our study is to analyze morbidity, mortality and life expectancy following videothoracoscopic talc poudrage.

          Materials and methods

          From September 2004 to October 2009, 400 patients underwent video-assisted thoracic surgery (VATS) for malignant pleural effusion. The conditions of patients were assessed and graded before and after treatment concerning morbidity, mortality, success rate of pleurodesis and median survival.

          Results

          The median duration of follow up was 40 months (range 4-61 months). All patients demonstrated notable improvement in dyspnea. Intraoperative mortality was zero. The procedure was well tolerated and no significant adverse effects were observed. In hospital mortality was 2% and the pleurodesis success rate was 85%. A poor Karnofsky Performance Status and delay between diagnosis of pleural effusion and pleurodesis were statistically significant factors for in-hospital mortality. The best survival was seen in breast cancer, followed by ovarian cancer, lymphoma and pleural mesothelioma.

          Conclusions

          Video-assisted thoracoscopic talc poudrage is an effective and safe procedure that yields a high rate of successful pleurodesis and achieves long-term control with marked dyspnea decrease.

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          Most cited references13

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          Thoracoscopy talc poudrage : a 15-year experience.

          To review our experience with thoracoscopy and talc poudrage during the previous 15 years with regards to efficacy, side effects, morbidity, and mortality. Six hundred fourteen consecutive patients (58.6% female; mean age, 54.5 years) underwent thoracoscopy with talc poudrage from August 1983 to May 1999. Of these, 457 patients had malignant pleural effusions, 108 patients had benign pleural effusions, and 49 patients had spontaneous pneumothorax. Sixty-four patients were excluded from evaluation for efficacy: 30 patients (4.9%) because the lung did not expand at the time of the procedure and 34 patients (5.5%) because they died within 30 days of the thoracoscopy. All exclusions were in the malignant group. The overall success rate of the 393 patients with malignant pleural effusions was 93.4%, while the overall success for the 108 patients with benign effusions was 97%, although 7 patients (7%) with benign effusions required a second thoracoscopy. The success rate with pneumothorax was 100%. Major morbidity included empyema in 4%, reexpansion pulmonary edema in 2.2%, and respiratory failure 1.3%. Thoracoscopy with talc poudrage is effective in producing a pleurodesis in malignant and benign pleural effusion and in spontaneous pneumothorax. However, it should be noted that the insufflation of talc has a systemic distribution associated with a low rate of morbidity and perhaps does induce ARDS, which is sometimes fatal in a small percentage of patients. Because of these side effects, the search for a better agent should be continued.
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            Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion.

            Talc has been generally accepted to be the most effective sclerosant for chemical pleurodesis, although the optimal route of administration remains unclear. We designed a prospective, randomized study to compare video-assisted thoracoscopic talc insufflation with bedside talc slurry in the treatment of malignant pleural effusion. From September 1993 to November 1995, 57 patients were recruited and randomized to either video-assisted thoracoscopic talc insufflation under general anesthesia (n = 28) or talc slurry by the bedside (n = 29). Patients with poor general condition (Karnofsky score less than 30%), poor pulmonary function (forced expiratory volume in 1 second less than 0.5 L), or trapped lungs were excluded from this study. Five grams of purified talc was used for either video-assisted thoracoscopic talc insufflation or talc slurry. There was no statistically significant difference between the two groups of patients with respect to age, sex ratio, chest drainage duration, postprocedural hospital stay, parenteral narcotics requirement, complications, or procedure failure (ie, recurrence). Video-assisted thoracoscopic talc insufflation has not been shown to be a superior approach compared with talc slurry in our study. Because the former demands more resources, we advocate that talc slurry should be considered as the procedure of choice in the treatment of symptomatic malignant pleural effusion in patients who do not have trapped lungs.
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              Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions.

              To evaluate the efficacy of small-bore (12 French vanSonnenberg) catheters compared with standard large-bore chest tubes in the drainage and sclerotherapy of malignant pleural effusions. Retrospective review. An academic tertiary care hospital. Adult patients with documented neoplasms and malignant pleural effusions, treated between 1986 and 1995. All patients included in the study underwent drainage of malignant pleural effusions either by large-bore chest tube or by ultrasound-guided small-bore catheter. After drainage, pleurodesis was performed. Outcome as defined by recurrence of effusion was determined by blinded examination of all postpleurodesis chest radiographs. We identified 58 cases of malignant pleural effusion in which small-bore catheters were used and 44 in which large-bore chest tubes were used. The majority of patients had breast (n = 56, 55%) or lung cancer (n = 29, 28%). The median age was 65 years. Fifty-nine patients were actively being treated with chemotherapy at the time of pleurodesis. The following sclerosing agents were used: talc, 27 (26%); tetracycline, 72 (70%); bleomycin, 2 (2%); and interferon, 1 (1%). Actuarial probabilities of recurrence at 6 weeks and 4 months were 45% and 53% for the small tubes vs 45% and 51% for the large tubes. Univariate and multivariate analyses failed to demonstrate that tube size had any influence on the rate of recurrence. We were unable to detect any major differences in outcomes with the use of either size of chest tube. Our study suggests that small-bore catheters may be effective in the treatment of malignant pleural effusions and deserve further evaluation in prospectively designed trials.
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                Author and article information

                Journal
                J Cardiothorac Surg
                Journal of Cardiothoracic Surgery
                BioMed Central
                1749-8090
                2010
                19 April 2010
                : 5
                : 27
                Affiliations
                [1 ]Thoracic Surgery Department, Theagenio Cancer Hospital, A. Simeonidi 2, Thessaloniki, 54007, Greece
                [2 ]Thoracic Anesthesia Department, Theagenio Cancer Hospital, A. Simeonidi 2, Thessaloniki, 54007, Greece
                Article
                1749-8090-5-27
                10.1186/1749-8090-5-27
                2873359
                20403196
                11e09d99-e958-4517-9c8c-bb03cb017e17
                Copyright ©2010 Barbetakis et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 19 December 2009
                : 19 April 2010
                Categories
                Research article

                Surgery
                Surgery

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