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Background: Pleurodesis performed either by pleurectomy or pleural abrasion is recommended in the approach to primary spontaneous pneumothorax to avoid recurrence. However, the efficacy of parietal pleural abrasion in producing pleurodesis is questioned. This study aims to determine the efficacy of apical abrasion alone, abrasion plus fibrin sealant application, and pleurectomy in producing pleurodesis in rabbits.Methods: Rabbits were subjected to video-assisted thoracic surgery alone (control) or to video-assisted thoracic surgery with apical gauze abrasion, abrasion plus fibrin sealant instillation, or apical pleurectomy. Blood samples were collected preoperatively and 48 h and 28 days postoperatively to measure total leukocytes (white blood cell count), neutrophil counts, and serum interleukin (IL)-8 levels. After 28 days the animals were sacrificed for macroscopic evaluation of the degree of apical pleurodesis and microscopic evaluation of local pleural fibrosis and collagen deposition.Results: White blood cell and neutrophil counts were similar in all groups, whereas the serum IL-8 level peaked at 48 h in all groups and decreased after 28 days, except in the pleurectomy group. After 28 days the abrasion plus fibrin sealant and pleurectomy groups had significantly more pleural adhesions, pleural fibrosis, and collagen deposition than the abrasion alone group, mainly due to thick mature fibers.Conclusions: Abrasion with local fibrin sealant instillation is as effective as pleurectomy in producing pleurodesis in rabbits. Apical pleurectomy elicits a more persistent elevation of serum IL-8 levels than apical abrasion alone or abrasion plus fibrin adhesive instillation. [ABSTRACT FROM AUTHOR]

The article discusses a study which aimed to identify clinical, laboratory, and radiologic predictors associated with the prescription of definitive therapy for malignant pleural effusions (MPE) patients. Topics covered include the measures used in the association analyses, the variables useful for predicting definitive therapy, and patients that are more likely to be treated with pleurodesis and/or indwelling pleural catheter (IPC).

The authors reflect on the availability of multiple options for the management of malignant pleural effusion (MPE), wherein the options include large-bore and small-bore tube pleurodesis, multiple sclerosants, indwelling pleural catheters, and thoracoscopy. Topics covered include how MPE is treated since 1935, the British Thoracic Society (BTS) guidelines on MPE management published in 2010, and the highlights of various case studies conducted based on the BTS guidelines.

The authors reflect on the criticism of Dr. Colin T. Gillespie and Dr. Malcolm M. DeCamp on the topic of small-bore versus large-bore catheters for management of malignant pleural effusions (MPEs). Topics covered include the authors' comparison of small-bore and large-bore catheters, the highlights of various prospective studies on using small-bore catheters and 12F catheters for chemical and talc pleurodesis, and the British Thoracic Society recommendations on using small-bore tubes.

The authors reflect on the use of small-bore pleural catheter placement as the preferred initial management for malignant pleural effusions (MPEs). Topics covered include the management and therapeutic options for MPE, the process of performing pleurodesis to manage and treat MPE, and the benefits of using tunneled pleural catheter (TPC) and small-bore catheters for the palliation of MPE.

Focuses on interoperative photodynamic therapy after pleuropneumonectomy for the treatment of patients with pleural mesothelioma. Postoperative mortality rate; Prevention of intracavity recurrence; Dosimetry equipment for pleural cavities.

An abstract of the study "Hepatic Hydrothorax, Clinical Characteristics, and Surgical Treatment Results" by Juan Jacinto and colleagues is presented.

We report the case of a 25-year-old African-American man presenting to the Henry Ford Hospital emergency department with acute dyspnea secondary to a pneumothorax resulting from a migratory acupuncture needle. The patient received acupuncture treatment approximately 5 years prior to this presentation for treatment of posttraumatic chronic right shoulder pain. Chest radiography revealed retained needles in his right shoulder girdle and a needle overlying the thoracic cage with an attendant pneumothorax. Catheter aspiration for simple pneumothorax provided immediate symptomatic relief. Video-assisted thoracoscopy was then used to remove the migratory acupuncture needle from the chest wall. The patient recovered without complication and was discharged to home.

Study Objective: Pulmonary lymphangioleiomyomatosis (LAM) is a rare, serious disorder characterized by proliferation of abnormal smooth-muscle cells and affects almost exclusively women of childbearing age. Optimal management of chylothorax, a well-recognized complication of LAM, in these patients has not been defined. This study was performed to characterize the clinical course and identify appropriate management options for chylothorax occurring in patients with LAM., Design: Identification and retrospective review of available medical records on patients with LAM and chylothorax., Setting: Tertiary-referral medical center., Patients: All patients with LAM seen at Mayo Clinic, Rochester, MN, from January 1, 1976, to December 31, 2000., Intervention: None., Measurement and Results: Eight of 79 patients (10.1%) with LAM had chylothorax. All were women aged 33 to 51 years, and four patients had underlying tuberous sclerosis complex. These eight women represented 3.5% of the 229 patients with chylothorax seen over this 25-year period at Mayo Clinic Rochester. Six patients had unilateral pleural effusion and two patients had bilateral effusions at initial presentation. The size of the chylothorax varied and was not necessarily progressive. Management of chylothorax ranged from thoracentesis only to thoracotomy with thoracic duct ligation and parietal pleurectomy. When needed, pleurodesis by instillation of sclerosing agents or parietal pleurectomy appeared to be effective in controlling chylothorax., Conclusions: Chylothorax occurring in patients with LAM has a variable clinical course. Although pleurodesis with or without thoracic duct ligation appears to be effective in controlling intractable chylothorax, less invasive treatments such as thoracentesis or observation may suffice in some cases. Management of chylothorax in patients with LAM should be individualized depending on the size and clinical effects of the chylous pleural effusion, as well as comorbid factors and local expertise.

Malignant diffuse mesothelioma is the most common type of mesothelioma, with a median survival ranging from 8.5 to 18 months after diagnosis. Good performance status, absence of chest pain, age < 50 years, and epithelial histology are all associated with improved survival. Several investigators have described staging systems for this tumor and have emphasized the importance of thoracoscopy in the diagnosis and staging of the disease. Pleurectomy is the most common surgery employed to manage patients with diffuse mesothelioma, and this procedure is associated with minimal postoperative morbidity and mortality. Because mesothelioma usually recurs locally after surgery, efforts at optimizing local control have included both intraoperative phototherapy and chemotherapy. However, neither of these techniques has demonstrated any significant benefit to date and thus should not be considered as standards of care. No studies have compared pleurectomy to extrapleural pneumonectomy (EPP) in randomized trials. However, nonrandomized series suggest a significant improvement in disease-free survival for those undergoing EPP versus pleurectomy. Other data suggest that EPP may improve local control but may predispose the patient to distant metastases. A randomized comparison of these techniques may be beneficial in identifying the most effective procedure for patients with malignant diffuse mesothelioma.

Study Objectives: Malignant pleural mesothelioma (MPM) is predominantly a local/regional disease that results in a survival time that ranges from 4 to 12 months without treatment. Single-modality therapy using surgery, chemotherapy, or radiotherapy alone is largely ineffective. The objective of the study was presentation of the use of pleuropneumonectomy in a multimodality treatment setting and the results., Design: Didactic presentation., Setting: Academic tertiary-care hospital., Patients: One hundred eighty-three patients who underwent multimodality therapy., Interventions: Of all the single-modality treatment approaches, pleuropneumonectomy has been associated most consistently with long-term disease-free survival and has provided the greatest amount of tumor cytoreduction. The technique of pleuropneumonectomy traditionally has been linked with high perioperative mortality and morbidity when compared with that of other cytoreductive techniques such as pleurectomy/decortication. Recently, improvements in operative mortality (< 5%) have been reported, largely due to improvements in patient selection and perioperative management. Multimodality therapy, including chemotherapy, radiotherapy, and extrapleural pneumonectomy, was used to treat patients., Results: Outcomes were presented for 183 patients with MPM who underwent multimodality therapy., Conclusions: With the development of multimodality therapy, pleuropneumonectomy followed by sequential chemotherapy and radiotherapy has demonstrated a significant survival benefit, especially for patients who have epithelial tumor histology, tumor-free resection margins, and tumor-free extrapleural node status.

Thoracoscopy has provided chest physicians and surgeons with an opportunity to rethink their approach to patients with pleural and pulmonary disease. In this brief review, several methods pertaining to videothoracoscopic procedures are described, followed by a summary of the major indications for this procedure. The question of whether a thoracoscopic approach to diagnosis or treatment could replace more conventional approaches is addressed for several disease processes. Finally, a few thoughts about future directions of this emerging technology are shared.

Study Objective: To evaluate the role of intrapleural fibrinolytic treatment (IPFT) in traumatic clotted hemothorax., Design and Patients: Between August 1995 and February 1997, 24 patients with traumatic clotted hemothorax were included. Streptokinase (SK), 250,000 IU, or urokinase (UK), 100,000 IU, diluted in 100 mL of saline solution was given daily. We administered 5.0+/-1.8 (range, 2 to 9) doses of SK or 6.25+/-5.97 (range, 2 to 15) doses of UK., Setting: Dicle University School of Medicine, Thoracic and Cardiovascular Surgery Department., Results: Complete response, which was defined as resolution of symptoms with complete drainage of fluid and no residual space radiographically, occurred in 15 (62.5%) patients. Partial response, which was defined as resolution of symptoms with a small pleural cavity, occurred in seven (29.2%) patients. Two patients (8.3%) required decortication; they were defined as nonresponders. The mean period of time between the diagnosis and fibrinolytic treatment (FT) was 11.65+/-6.38 (range, 4 to 25) days. There were no complications related to IPFT. There was no mortality during the course of IPFT., Conclusion: The use of intrapleural fibrinolytic agents has resulted in resolution of clotted hemothorax with an overall success rate of 91.7%. We recommend that IPFT should be added to the algorithm for management of clotted hemothorax before proceeding with minithoracotomy or pleural decortication.

Study Objective: The preoperative cardiopulmonary risk index (CPRI) is a multifactorial index intended to predict postoperative outcome after thoracic surgery. It combines cardiac and pulmonary information into one parameter that ranges from 1 to 10, with 10 being the worst. A CPRI > or = 4 has been advocated as an effective predictor of postoperative pulmonary and cardiac complications. This study prospectively evaluates the predictive value of CPRI in a large population of patients undergoing thoracic surgery., Design: We performed prospective calculation of CPRI in patients about to undergo thoracic surgery. Postthoracic surgery occurrence of pneumonia, atelectasis, arrhythmias, congestive heart failure, respiratory failure requiring therapy, or death occurring within 30 days of surgery was compared with preoperative CPRI and its components., Patients and Participants: One hundred eighty consecutive patients, aged 15 to 87 years, were studied., Interventions: Operations performed included 114 lobectomies, 35 wedge resections, 19 pneumonectomies, 5 pleurectomies, 5 lymph node dissections, 1 thoracic wall resection, and 1 paravertebral tumor resection., Measurements and Results: Twenty-seven percent of patients experienced complications. CPRI and its components did not predict complications, deaths, or the number of in-hospital days. We found a CPRI > or = 4 to be a moderate predictor of outcome for patients undergoing pneumonectomy (n = 19). It correctly identified four of nine postpneumonectomy complications., Conclusion: The preoperative CPRI and its components are inadequate predictors of medical complications after thoracic surgery in a general population. In the subgroup of patients undergoing pneumonectomy, the index may be of some value in forecasting outcome.

Malignant mesothelioma of the pleura occurs primarily in individuals who were exposed to asbestos either in the workplace or home. The incidence of malignant mesothelioma is rising and, reflective of the malignancy's long latency period, is expected to continue to increase into the next century. Current treatment measures, including surgery, radiation therapy, chemotherapy, intrapleural therapy, and combined-modality therapies, have had varying impacts on survival. This paper explores current trends in the treatment of malignant pleural mesothelioma.

Study Objective: To evaluate the outcome of pleurectomy using video-assisted thoracic surgery (VATS) for pleurodesis in patients with malignant pleural effusion., Design: Cohort prospective study. Follow-up of patients from referral for thoracoscopy to death., Setting: Regional Cardiothoracic Surgical Centre., Patients: Nineteen patients (median age 63 years, range 51 to 84 years) with malignant pleural effusion, secondary to mesothelioma in 13 and metastatic adenocarcinoma in 6., Intervention: Video-assisted parietal pleurectomy., Measurements and Results: Median operating time was 35 min (range 15 to 60 min). The median fall in hemoglobin concentration in the first 24 h postsurgery was 1.1 g/dL (0.3-2.5 g/dL). The median postoperative morphine requirement was 1.25 mg/h (0-6.2 mg/h) in the first 12 h postoperatively. All patients were successfully extubated in the operating room, without the need for reventilation, and all patients were successfully discharged from the hospital with a median postoperative stay of 5 days (range 2 to 20 days). At current median follow-up of 12 months (range 4 to 17 mon) 6 patients died of their underlying disease. In the remaining 13 patients, two have developed recurrent effusions., Conclusions: Using VATS to perform parietal pleurectomy is a safe, effective method of obtaining palliative pleurodesis in patients with malignant effusions.

In 1985 the Lung Cancer Study Group (LCSG) initiated clinical trials in malignant pleural mesothelioma because LCSG member institutions had access to large numbers of patients and had significant experience treating this uncommon cancer. The first trial, LCSG 851, defined the patient population seen by the LCSG, and the feasibility of performing surgical resection by extrapleural pneumonectomy in a multi-institutional setting. Of 83 patients entered on this study from September 1985 to June 1988, only 20 could undergo an extrapleural pneumonectomy, and 3 of 20 patients died postoperatively. This experience prompted the LCSG to explore combining a potentially less morbid operation, pleurectomy/decortication, with adjuvant therapy. The results of another LCSG trial (LCSG 861) and of a small single institutional pilot study demonstrated the feasibility of intrapleural cisplatin-based chemotherapy, and led to the development of LCSG 882, which combined pleurectomy/decortication with postoperative intrapleural, and subsequent systemic, cisplatin-based chemotherapy. This study was not completed because of discontinuation of funding for the LCSG. However, a single-institution phase 2 trial of very similar design has subsequently shown the feasibility of this combined modality approach.

We report a case of pleural dissemination of invasive thymoma, which was successfully treated with intrathoracic chemothermotherapy following panpleuropneumonectomy. Intrathoracic chemothermotherapy in combination with surgery may be a hopeful adjuvant treatment to control pleural disseminated lesions of invasive thymoma.

We have analyzed our experience with 90 consecutive patients who were operated on for parapneumonic empyema between 1981 and 1992. Patients whose empyema did not resolve with chest tube drainage were taken to the operating room. Nineteen patients had limited thoracotomy and drainage. Seventy-one patients had formal thoracotomy, debridement, pleurectomy, and decortication. We found that an age greater than 60 years, cardiac disease, end-stage renal disease, end-stage bronchitis, prolonged tube drainage, and immunosuppression are associated with increased morbidity and mortality. In those patients who do not respond well to a short course of chest tube drainage, we recommend early aggressive surgical approach, including formal thoracotomy and definitive treatment. This allowed for early discharge from the hospital without chest tubes or open draining wounds. In extremely ill patients, limited thoracotomy may be all that is safe or possible and usually suffices.

Malignant mesothelioma is an uncommon and usually fatal cancer, for which there is no standard treatment. However, surgical resection remains the mainstay of treatment because of the inability to treat the entire hemithorax effectively with radiation and the lack of effective chemotherapy drugs. Extrapleural pneumonectomy is the only technically feasible operation for patients who have bulky local tumor and chronic entrapment of the lung, but pleurectomy/decortication is associated with a lower operative morbidity and mortality, and seems to lead to an equally good survival in patients who have early-stage disease. Because of the high risk of local recurrence after surgical resection by either extrapleural pneumonectomy or pleurectomy/decortication, efforts have been directed at developing effective adjuvant treatment. Radiation given postoperatively after pleurectomy/decortication has led to a minimal improvement in survival and to significant side effects. Adjuvant chemotherapy is considered investigational but is currently being evaluated in a clinical trial using high-dose intrapleural and systemic chemotherapy after pleurectomy/decortication. Additional well-designed prospective trials are needed to alter the dismal outcome of this disease.

Several options are available for treatment of malignant pleural effusions in patients with non-small-cell lung cancer. Repeat thoracentesis may be appropriate for the patient with limited survival and a slowly recurrent effusion. Pleurodesis with a sclerosing agent administered via a chest tube is the most widely used therapy, though controversy exists as to which drug produces the best results. Pleuroperitoneal shunting remains an option for those patients whose lung is trapped by tumor. Video-assisted thoracoscopy is likely to change the treatment patterns of malignant pleural effusion. Thoracoscopic pleurectomy can be performed with minimal morbidity. Alternatively, sclerosing agents such as talc can be easily and uniformly introduced into the thoracic cavity under thoracoscopic control. Future therapy is likely to entail a diagnostic thoracentesis followed by a definitive thoracoscopic procedure.

Twenty-one of 146 cases of spontaneous pneumothorax that were treated by thoracentesis or continuous low negative pressure suction drainage (-12 cm H2O) of the pleural space developed REPE. The rate of REPE was higher in patients 20 to 39 years of age than in those over the age of 40, and the rate progressively increased in proportion to the extent of pneumothorax, as assessed by roentgenographic criteria. It is postulated that age-related changes in the lung may afford some degree of protection against developing REPE. It is also suggested that the treatment of pneumothorax with thoracentesis and/or suction drainage in young patients, or in the face of a large pneumothorax, requires careful consideration in view of a relatively high incidence of REPE in such individuals.

A case of unilateral bronchospasm during pleurodesis in a patient with a history of recurrent pneumothorax and asthma is presented. The etiology of this event is not clear; however, it likely includes reflex parasympathetic bronchoconstriction due to physical stimulation of the pleural surface during pleurodesis. Treatment involved independent lung ventilation, corticosteroids, and aminophylline.

Pleural effusion secondary to lymphedema may be chronic, symptomatic and refractory to treatment, occasionally requiring invasive and painful procedures such as chemical pleurodesis, open pleural abrasion or pleurectomy to achieve control of the effusion and gain symptomatic relief. We report a patient with yellow nail syndrome and chronic pleural effusion successfully treated with pleuroperitoneal shunting.

Between January 1977 and December 1978, 24 patients with recurrent or chronic spontaneous pneumothorax were treated in the Hong Kong University Cardiothoracic Centre at Grantham Hospital by talc pleurodesis. Talc poudrage had been carried out under local infiltration anesthesia by a technique that utilizes the Venturi principle and the help of an oxygen injector, used normally for ventilating a patient during bronchoscopy with a rigid bronchoscope. By using this method of poudrage, a uniform application of the powder over the whole pleural surface can be achieved and successful pleurodesis can be obtained in all patients under local anesthesia.

Chemical sclerosis of the pleural space is used to prevent recurrence of spontaneous pneumothorax. To test whether sclerosis restricts diaphragmatic excursion, we measured diaphragmatic excursion by ultrasonography in subjects with unilateral pleural sclerosis and compared it with diaphragmatic excursions in normal subjects, in subjects with cystic fibrosis (a diffuse bilateral lung disease), and in those who underwent surgical procedures that obliterate the pleural space. In five subjects with unilateral chemical sclerosis, diaphragmatic excursion was significantly less on the sclerosed side than on the contralateral side (10.7 +/- 1.3 vs 17.3 +/- 1.7 mm, mean +/- SEM; p less than .01). Compared with those of normal subjects, the side-to-side differences in excursion were increased by pulmonary disease (p less than .03) and additionally by unilateral sclerosis (p less than .015). There was no significant difference between diaphragmatic excursions on left and right sides of subjects without history of pleural disease. These data suggest that chemical pleural sclerosis causes a measurable reduction in diaphragmatic excursion on the affected side. The physiologic significance of this effect is not known.

Two hundred consecutive patients with malignant pleural effusion were reviewed. The pathologic etiology of malignant pleurisy was: primary lung cancer in 123 cases; five, mesothelioma; and 72 cases secondary to metastatic tumors. Adenocarcinoma of the lung and mammary cancer were the most frequent tumors causing malignant pleural effusion. The modalities employed in local treatment consisted of thoracocentesis in 62 patients, tube thoracotomy in 111 cases with local instillation of adriamycin, MMC, CQ, 5FU, OK432 or talc. Surgical procedures including pleuropneumonectomy or reduction surgery of the tumor with decortication were performed in ten patients. Tube drainage with local instillation of drugs was more effective than thoracocentesis with or without local therapy. Excellent initial results were obtained in patients who received reduction surgery with decortication and pleurodesis. Results of cytologic investigation were positive in 157 cases (78.5 percent). The tumor cells disappeared in 79.4 percent of primary cancer pleurisy cases and 81.1 percent of patients with metastases while disappearance or significant decrease in pleural effusion following treatment was obtained in 75.2 and 77.8 percent respectively. The median survival was 11.3 months in primary cases, and 11.7 months in patients with metastases.

Swallowing-induced atrial tachycardia is a rare phenomenon generally assumed to be caused by abnormal parasympathetic reflexes arising in the esophagus or pharynx. We describe a patient with intractable swallow tachycardia. Since certain features of the case suggested a mechanical rather than a reflex mechanism, he was treated by intrapleural repositioning of the esophagus to effect physical separation of esophagus and left atrium. Ten months after an uncomplicated procedure, the patient remains asymptomatic and free of arrhythmia.