Diseases of the pleura
Louis-Philippe Boulet in 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.
Uniportal video-assisted thoracoscopic surgery (VATS)
Larry R. Kaiser, Sarah K. Thompson, Glyn G. Jamieson in Operative Thoracic Surgery, 2017
One of the most appropriate indications for uniportal VATS seems to be represented by the management of pneumothorax.3,16 The presence of a chest drain, often placed in an emergency setting, and of a usually visible target lesion (i.e., a bleb or bulla) make the single-port approach immediately feasible both under general or loco-regional anesthesia.13 Wedge resection of the apex and apical pleurectomy or talc pleurodesis are easily accomplished through uniportal VATS using articulating instruments.3 In particular, a scratch pad appropriately folded and cut to size can be mounted on the articulating arm of an endograsper.16 The scratch pad can be applied to the entire circumference of the inner chest wall by rotating the endograsper arm.3,16 The initial tear induced in the parietal pleura can be used as starting point for an apical pleurectomy using endo Kitners to elevate the parietal pleura from the endothoracic fascia.16 Alternatively, a thorough abrasion can be easily obtained by extending the procedure, under visual control, onto the remaining chest wall and diaphragm. Likewise, any blebs or bullae can be resected concomitantly in any peripheral area of the lung by changing the orientation of the videothoracoscope and operative instrument ensemble. Talc pleurodesis is also a viable choice in selected patients with bilateral symptomatic recurrent pneumothoraces.
Asbestos exposure and mesothelioma
Dorsett D. Smith in The Health Effects of Asbestos, 2015
Patients with advanced disease who are not surgical candidates can be treated with a talc pleurodesis. A British group undertook an open-label, parallel-group, randomized controlled trial with any subtype of confirmed or suspected mesothelioma with pleural effusion recruited from 12 hospitals in the United Kingdon. Eligible patients were randomly assigned (1:1) to either video-assisted thoracoscopic partial pleurectomy (VAT-PP) or talc pleurodesis. Overall survival at 1 year was 52% (95% CI: 41–62) in the VAT-PP group and 57% (95% CI: 46–66) in the talc pleurodesis group. The authors concluded that VAT-PP is not recommended for improving overall survival in patients with pleural effusion due to malignant pleural mesothelioma, and talc pleurodesis might be preferable considering the fewer complications and shorter hospital stay associated with this treatment. (Rintoul RC, Ritchie AJ, Edwards JG et al. Efficacy and cost of videoassisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): An open-label, randomised, controlled trial. Lancet 2014;384:1118–27.)
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.
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