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The Lung and the Pleura
Published in E. George Elias, CRC Handbook of Surgical Oncology, 2020
On the other hand, the management of patients with malignant mesothelioma is usually palliative, as there is no cure. Surgical management in the form of pleurectomy or even pneumonectomy carries a high morbidity and mortality, except in specific cases. The surgical approach, radiation therapy, and/or chemotherapy have produced poor results. The overall survival rates are 1 to 2 years, with an occasional patient surviving 5 years or more. A new approach that is being investigated is a multitherapeutic one which includes resection of all gross tumors, followed by repeated intracavitary instillation of adriamycin, combined with systemic chemotherapy by a platinum compound. This may be followed by total chest irradiation for any residual disease.
How should aggressive chyloreflux (e.g., chyluria, chyloascites, chylothorax, chyle leakage) be handled?
Published in Byung-Boong Lee, Peter Gloviczki, Francine Blei, Jovan N. Markovic, Vascular Malformations, 2019
Cristobal M. Papendieck, Miguel Amore
The drainage of accumulated chylous fluid is an adjunctive management to surgical treatment. Thoracentesis and paracentesis can relieve symptoms of respiratory failure, but tube thoracostomy is often indicated to obtain continuous drainage. Video-assisted thoracic surgery (VATS) is a technique to allow necessary intervention to manage chylous leakage based on the amount and location of output of the chylous leak. Pleural abrasion and pleurodesis with talc or other agents are effective when output measured through a chest tube is less than 500 mL/day. Fibrin glue can be used when no focal drainage point can be determined with diffuse drainage. Partial pleurectomy is another option to resolve symptoms. However, the ligation of the thoracic duct is often indicated for high-output chylous drainage exceeding 1 L/day, either by VATS or thoracotomy. Alternatively, coil embolization of the thoracic duct may be performed through the cannulation of the cisterna chyli. The Denver pleuroperitoneal shunt has also been used for extreme cases of chylothorax.1, 3
Diseases of the pleura
Published in Louis-Philippe Boulet, Applied Respiratory Pathophysiology, 2017
In individuals presenting with spontaneous primary pneumothoraces, air evacuation from the pleural space by simple aspiration or through conventional tube thoracostomy is indicated for patients with >20% pneumothoraces and for those with significant symptoms [15]. Definitive surgery may be indicated at the time of the first episode in patients with tension pneumothoraces, persistent air leakage (>4–5 days), pneumohemothoraces (occurs in approximately 5% of cases), and failure of the lung to reexpand. Recurrence is, however, the most common indication for surgery, which is usually recommended at the time of the second episode. The operative procedure which involves bleb resection and some form of mechanical pleurodesis (parietal pleurectomy or pleural abrasion) can be done through an axillary incision or more commonly through a thoracoscopic approach.
The role of pleurodesis in respiratory diseases
Published in Expert Review of Respiratory Medicine, 2018
Rachel M. Mercer, Maged Hassan, Najib M. Rahman
Pleurectomy and decortication are often used in combination but can be performed separately. A pleurectomy involves stripping the parietal and sometimes part of the visceral pleura; this is most commonly performed as part of a pleurectomy decortication for mesothelioma [64] or for a non-resolving pneumothorax. A visceral peel encasing the lung prevents lung expansion and therefore pleural apposition; this can be surgically removed in a procedure called decortication. In patients who are fit enough for surgical intervention, decortication can be undertaken to allow the lung to fully re-expand, to promote successful pleurodesis. This operation confers significant morbidity and is not commonly performed for pleurodesis alone as the patients are often palliative and the dyspnea can frequently be controlled after placement of an IPC.
Surgical and non-surgical management of malignant pleural effusions
Published in Expert Review of Respiratory Medicine, 2018
Deirdre B. Fitzgerald, Coenraad F. N. Koegelenberg, Kazuhiro Yasufuku, Y. C. Gary Lee
The global trend toward less invasive measures will progress: There will be continual move away from invasive surgical approaches such as thoracotomy and aggressive pleurectomy in favor of VATS and less invasive modifications of it. The benefits of surgical approaches to MPE will be scrutinized, and may help to define the subset of patients that best suits this approach.Various ways of combining IPC with pleurodesis will emerge, including talc poudrage with IPC placement at the same operation and talc instillation via IPC. A novel drug-eluting IPC has been developed and a recently published pilot study has shown promising results with successful pleurodesis in eight of nine patients with expandable lung at a median of 4 days [112]. A multicentered RCT is underway to compare this with non-eluting IPCs.Continual effort will focus on simplifying existing therapies while maximizing their benefits. For example, the IPC-Plus trial [92] is the first RCT to explore outpatient instillation of talc via an IPC, its feasibility and safety data will open up new opportunities for future practice.
Current opinion and comparison of surgical procedures for the treatment of primary spontaneous pneumothorax
Published in Expert Review of Respiratory Medicine, 2022
Kenji Tsuboshima, Masatoshi Kurihara, Kuniaki Seyama
Abrasion is performed on the parietal pleura using a gauze, cautery scratchpad, electric cautery, etc [14]. As a result, adhesion between the visceral and parietal pleura is expected. The concept is similar to pleurectomy; however, adverse events such as pain and hemothorax are less likely to occur.