Chylothorax
Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg in Operative Pediatric Surgery, 2020
Although pleurodesis can be performed as a stand-alone operation to treat a refractory chylothorax, the procedure is more commonly employed in combination with thoracic duct ligation, particularly if no focal leak is identified. Once access to the parietal pleura is obtained either by thoracotomy or thoracoscopy, the entire parietal pleura of the lower thorax adjacent to the thoracic duct is mechanically abraded with a surgical sponge, peanut, or cautery scratch pad. An alternative approach to pleurodesis is to instill a chemical agent such as bleomycin, doxycycline, or talc, all of which are known to facilitate significant pleural inflammation. Chemical pleurodesis is generally reserved for treatment in older children and in patients with congenital lymphangiomatosis. A chest tube should be left in place after pleurodesis.
Complications of Pulmonary and Chest Wall Resection
Stephen M. Cohn, Matthew O. Dolich in Complications in Surgery and Trauma, 2014
Studies have demonstrated that alveolar pleural fistula closure is promoted in the postoperative period by removing thoracostomy tubes from suction and placing them to “water seal” only [25]. If alveolar pleural fistula persists despite this maneuver, chest tubes can be placed to a Heimlich valve and if appropriate, the patient can be discharged. Alternatively, chemical pleurodesis can be performed at the bedside. For patients who are unable to be compliant with home chest tube management or for whom extensive subcutaneous emphysema is causing discomfort and/or morbidity, a return to the operating room may be indicated either via thoracotomy or thoracoscopy for lysis of adhesions, assurance of complete lung expansion, and creation of a parietal pleural tent to promote air leak closure; aerostatic tissue sealants may also be employed to this end.
Answers
Andrew Schofield, Paul Schofield in The Complete SAQ Study Guide, 2019
Fluid in the pleural space is known as a pleural effusion. The fluid may be a transudate or an exudate. Transudates are commonly caused by cardiac failure, cirrhosis or renal failure. Exudates have high protein content and are commonly due to infection, inflammation or malignancy. Examination of the chest classically reveals reduced chest expansion on that side, a ‘stony dull’ percussion note and reduced breath sounds. Small effusions may be seen on a chest X-ray as blunting of the costophrenic angle. Larger effusions are seen more clearly as a fluid level/meniscus in the lung fields. A diagnostic aspiration is performed to determine the nature of the effusion. Drainage may be required if the effusion is causing symptoms. If pleural effusions are recurrent, pleurodesis may be necessary. This involves the installation of an irritant, such as talc, into the pleural space to cause local inflammation and fusion of the pleura to the chest wall. Persistent collections may require surgical intervention.
Making cold malignant pleural effusions hot: driving novel immunotherapies
Published in OncoImmunology, 2019
Pranav Murthy, Chigozirim N. Ekeke, Kira L. Russell, Samuel C. Butler, Yue Wang, James D. Luketich, Adam C. Soloff, Rajeev Dhupar, Michael T. Lotze
Management choice is guided by the patient’s prognosis, preference, functional status, rate of pleural effusion accumulation and resolution, failed therapeutic options, and the surgical team’s experience. To date, there are no established criteria for selecting from the available therapeutic options. The decision to undergo pleurodesis is often based upon an anticipated survival of longer than three to four months.16 Talc pleurodesis was previously the mainstay of treatment. The mechanism of action involves promoting local inflammation following installation of a sclerosing pleurodesis agent to promote pleural symphysis and prevent recurrent fluid collection.16 Despite the potential therapeutic benefits, pleurodesis failure remains a major drawback. A meta-analysis of 62 randomized trials involving over 3,000 patients compared and ranked agents based on pleurodesis efficacy.16 Talc poudrage was identified as the superior method when compared to bleomycin, mepacrine, or iodine installation. There was no evidence of survival benefit associated with any of the individual types of pleurodesis. Failure of lung expansion remains a contraindication for chemical pleurodesis and the introduction of the intrapleural catheter has served as an initial suitable remedy for lung entrapment.43
Therapeutical effect of intrapleural perfusion with hyperthermic chemotherapy on malignant pleural effusion under video-assisted thoracoscopic surgery
Published in International Journal of Hyperthermia, 2018
Xing Feng, Lucheng Zhu, Xiaoling Xiong, Hong Jiang, Zhibing Wu, Wen Meng, Yasi Xu, Shirong Zhang, Shenglin MA
Current treatments for MPE are complicated and usually take multiple procedures for diagnostic and therapeutic purposes, such as diagnostic thoracentesis (often more than once), pleural biopsies (closed or thoracoscopic) followed by therapeutic thoracentesis, surgical or bedside pleurodesis (when MPE recurs) and indweling pleural catheter (IPC) insertion or further thoracenteses if pleurodesis failed [1]. Although many non-surgical diagnostic methods exist, there is still 15–25% of pleural effusions remained undiagnosed [9]. Boutin and coauthors reported that figure was 21.5% [10]. Repeated thoracentesis increase the diagnostic rate but cause both physically and psychologically traumatic to the patient and a burden to the healthcare system. Palliative pleurodesis is commonly used for the treatment of MPE. But the fluid control rate is only 75% at 1 month and 50% by 6 months [11]. Besides, pleurodesis is associated with many complications such as pain, fever and acute respiratory distress syndrome [12,13]. IPC allows ambulatory fluid drainage, and minimised the need for hospitalisation and costs [14]. It has been increasingly employed for patients with symptomatic MPE [15,16], particularly for those who failed after pleurodesis or were unsuitable for pleurodesis. But IPC also has severe complications including infection, blockage symptomatic loculations, catheter track metastases [17–19]. Moreover, none of these approaches provide a significant survival benefit except symptoms relief. In Isık’s study, the median survival was only 6 months in talc pleurodesis group and 8 months in pleurectomy group. One-year survival in two groups was 0.6% and 0.8%, respectively [6]. Therefore, it is of great importance to remove the pleura fluids and simultaneously destroy metastatic pleural lesions to prevent recurrence and prolong survival.
Minimally invasive palliative interventions in advanced lung cancer
Published in Expert Review of Respiratory Medicine, 2018
Christopher Mallow, Margaret Hayes, Roy Semaan, Thomas Smith, Russell Hales, Roy Brower, Lonny Yarmus
The mechanism by which the pleural space is eradicated is known as pleurodesis. Pleurodesis is performed via thoracoscopy, or through a small-bore chest tube. The two main types are chemical pleurodesis, which consists of placing a sclerosing agent into the pleural space, and mechanical pleurodesis, which consists of physically disrupting the pleura. Talc is the most effective and most well studied sclerosing agent [68]. The effect of talc on pleurodesis is more successful than bleomycin, tetracycline, mustine, and doxycline [68].
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