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OBJECTIVES The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading, Recommendation, Assessment, Development and Evaluation). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made. Shareable Abstract This update of an ERS Task Force statement from 2015 provides a concise comprehensive update of the literature base. 24 evidence-based recommendations were made for management of pneumothorax, balancing clinical priorities and patient views. https://bit.ly/3TKGp9e [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The optimal surgical strategy for primary spontaneous pneumothorax remains a matter of debate and variation in surgical practice is expected. This variation may influence clinical outcomes, such as postoperative complications and length of stay. This national population-based registry study provides an overview and extent of variability of current surgical practice and outcomes in the Netherlands. METHODS To identify national patterns of care and between-hospital variability in the treatment of primary spontaneous pneumothorax, patients who underwent surgical pleurodesis and/or bullectomy between 2014 and 2021, were identified from the Dutch Lung Cancer Audit—Surgery database. The type of surgical intervention, postoperative complications, length of stay and ipsilateral recurrences were recorded. RESULTS AND CONCLUSIONS Out of 4338 patients, 1851 patients were identified to have primary spontaneous pneumothorax. The median age was 25 years (interquartile range 20–31) and 82% was male. The most performed surgical procedure was bullectomy with pleurodesis (83%). The overall complication rate was 12% (Clavien–Dindo grade ≥III 6%), with the highest recorded incidence for persistent air leak >5 days (5%). Median postoperative length of stay was 4 days (interquartile range 3–6) and 0.7% underwent a repeat pleurodesis for ipsilateral recurrence. Complication rate and length of stay differed considerably between hospitals. There were no differences between the surgical procedures. In the Netherlands, surgical patients with primary spontaneous pneumothorax are preferably treated with bullectomy plus pleurodesis. Postoperative complications and length of stay vary widely and are considerable in this young patient group. This may be reduced by optimization of surgical care. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Surgical management of spontaneous pneumothorax typically involves wedge resection and mechanical pleurodesis. It is unclear whether combining mechanical and chemical pleurodesis can further reduce the recurrence rate. We have performed a meta-analysis of studies comparing the combined approach with mechanical pleurodesis alone. METHODS A comprehensive search of the existing literature was performed using PubMed, EMBASE and Web of Science for all types of studies that compared combined pleurodesis to a single approach. We used the Cochrane Risk of Bias Tool and Strengthening The Reporting of OBservational Studies in Epidemiology (STROBE) to assess the quality of the studies. Relative risk of pneumothorax recurrence was calculated, and the differences between the studies were examined. The primary outcome was the recurrence of pneumothorax. RESULTS Of 2301 eligible studies, 5 studies were included. Five hundred sixty-one patients who received combined pleurodesis were compared to 286 patients who received mechanical pleurodesis only. Patients treated with combined intervention had a 63% lower risk of developing a recurrent pneumothorax compared to single intervention [relative risk 0.37, 95% confidence interval (CI) 0.18–0.76; P  = 0.006]. There were no statistically significant differences in the length of stay (standardized mean difference −0.17, 95% CI −0.39 to 0.05, P  = 0.138), the duration of postoperative air leak (standardized mean difference 0.17, 95% CI −1.14 to 1.47, P  = 0.804) or the duration of postoperative chest tube drainage (standardized mean difference −0.07, 95% CI −0.27 to 0.12, P  = 0.471). CONCLUSIONS This meta-analysis demonstrated that combined intervention with mechanical and chemical pleurodesis for spontaneous pneumothorax may be more effective in preventing recurrence than mechanical pleurodesis alone. These findings will provide some guidance to surgeons in the decision-making process. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Treatment of refractory hepatic hydrothorax, a complication of liver cirrhosis, is complex. We aimed to investigate the usefulness of the '4-step approach', which is a minimally invasive surgical strategy combining 4 therapeutic modalities: (i) pneumoperitoneum to localize diaphragmatic defects; (ii) thoracoscopic pleurodesis; (iii) postoperative positive-pressure ventilation; and (iv) peritoneal drainage for abdominal decompression. METHODS We retrospectively analysed the medical records of 12 patients with hepatic hydrothorax who underwent surgical treatment using the 4-step approach from January 2013 to December 2017. Nine of them (75.0%) were Child C cases; the median model for end-stage liver disease score was 20.5. The diaphragmatic defects localized after forming a pneumoperitoneum were treated with primary closure followed by thoracoscopic pleurodesis, postoperative positive-pressure ventilation and peritoneal drainage. RESULTS Diaphragmatic defects were localized in all patients except one. The median postoperative positive-pressure ventilation duration was 20.1 h. Peritoneal drainage was performed for a median duration of 5 days; the peritoneal drains were removed at a median of 8 postoperative days. The median duration of postoperative hospital stay until discharge/transfer was 9.5 days. No operative mortalities occurred. The median duration of follow-up was 10.9 months. Eight deaths (66.7%) occurred during the follow-up period; however, no deaths were surgery-associated. Ipsilateral pleural effusion recurred in 3 patients (25%), among whom reoperation was performed in 1 without recurrence at the 13-month follow-up. CONCLUSIONS The 4-step approach seems to be a safe and effective minimally invasive surgical strategy for treating refractory hepatic hydrothorax. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Non-small-cell lung cancer (NSCLC) patients with ipsilateral pleural dissemination (M1a) are generally contraindicated for surgery. However, several small-sample studies have demonstrated that they might benefit from surgery. We investigated the effects of primary tumour resection on survival in these patients. METHODS Stage IV NSCLC patients with ipsilateral pleural dissemination were identified from the US National Cancer Institute Surveillance, Epidemiology and End Results database entries from 2010 to 2015. Survival analysis was performed before and after matching. Multivariable regression models were built to identify prognostic factors. RESULTS Of the 5513 patients with ipsilateral pleural dissemination, 309 underwent primary tumour resection. In the entire cohort, surgery was associated with improved overall survival (OS) in both the unmatched and matched cohorts (both log rank, P  < 0.001). In the surgery-recommended cohort, patients treated with surgery also had significantly longer OS before and after matching. Multivariable regression models showed that surgery was an independent favourable prognostic factor for OS [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.48–0.65; P  < 0.001] and lung cancer-specific mortality (subhazard ratio 0.60, 95% CI 0.51–0.70; P  < 0.001). Surgery was independently associated with improved survival in all subgroups except for those with pericardial effusion (P  = 0.065) or N3 disease (P  = 0.17). In the surgical cohort, patients who underwent lobe/bilobectomy had significantly better OS than those who underwent sublobar resection (log rank, P  < 0.001). CONCLUSIONS Inclusion of primary tumour resection in multimodal therapy of NSCLC was associated with improved survival in selected patients with ipsilateral pleural dissemination, except for those with pericardial effusion or N3 disease. [ABSTRACT FROM AUTHOR]

Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning. Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study aimed to identify the causes of recurrent pneumothorax and to evaluate the results of repeated video-assisted thoracic surgery (VATS) for recurrent pneumothorax after VATS wedge resection for primary spontaneous pneumothorax (PSP). METHODS: A retrospective review was conducted on 188 patients with recurrent PSP, of a population of 1414 patients who underwent VATS wedge resection for PSP. Reoperations were performed when an air leak persisted longer than 3 days after closed thoracostomy, when a visible bulla of greater than 1 cm on high-resolution computed tomography (HRCT) was observed and when rerecurrence took place after other treatments. The HRCT findings before and after recurrence were compared to evaluate the type of the new bulla. Patients were divided into 2 groups according to the additional procedure performed during the first operation; in Group I, a coverage procedure was performed, and in Group II, mechanical pleurodesis was performed after VATS wedge resection. RESULTS: During a median follow-up period of 27.7 months, 76 patients underwent repeated VATS for ipsilateral recurrent PSP after VATS. The indications for repeated VATS were the presence of a bulla on HRCT in 41 patients and a persistent air leak in 35 patients. Group I comprised 36 patients and Group II comprised 40 patients. The HRCT findings showed no bulla in 3 (4%) patients, were suspicious for a bulla in 11 (15%) patients, showed a bulla at the staple line in 26 (34%) patients and showed a new bulla in a location other than on the staple line in 36 (47%) patients. The frequency of new bullae was not different between the 2 groups, but Group I showed a lesser tendency for bullae to occur at the staple line than Group II. Dense fibrosis around the staple line was also found intraoperatively. CONCLUSIONS: Repeated VATS was a feasible method to treat recurrent PSP after VATS for PSP. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The human fibrinogen/thrombin surgical patch is proposed for videothoracoscopic pleurodesis after recurrent observation in routine clinical practice of site-specific pleuro-pulmonary adhesions. METHODS: A total of 36 experimental videothoracoscopies were performed on 18 pigs, all of which underwent a bilateral sequential procedure. The right or left side was casually approached and two 4.8 ⨰ 4.8 cm Tachosil® patches were placed over the dorsal lung surface in the highest antigravitary position through a double-port thoracoscopy. The contralateral side was subsequently entered by a single-port thoracoscopy to perform talc poudrage in accordance with current recommendations (1 g/18 kg). Thoracoscopy and autopsy were performed after 60 days to evaluate the outcome. Pleurodesis was graded on a predefined three-tier scale (none-moderate-firm); specimens were then submitted to the pathologist. The statistical analyses performed were: frequencies distribution, variables association test and hypothesis testing using binomial distribution. RESULTS: Pleurodesis was firm in 15/18 cases (P = 0.004), moderate in 2/18, and none in 1/18 cases with the sealant matrix. Talc pleurodesis was firm in 7/18 cases and moderate in 11/18. No surgical, medical, behavioural or growth disorders were recorded. There was complete correspondence between lung surface covered by the sealant patch and pleural adhesion topography (P < 0.001) and no other sites of adhesion were found at autopsy, whereas talc effect was commonly found to produce random pleural cavity obliteration, most frequently in declivous places, with inhomogeneous pleural adhesion for tissue density and rough/smooth outline (P < 0.001). The pathologist disclosed that talc creates a variable and unpredictable inflammatory background, sometimes severe, with the development of many granulomas. Fibrin sealant patch pleurodesis is caused by connective tissue irrespective of the pleural and pulmonary anatomy. CONCLUSIONS: The fibrin sealant patch is effective in producing localized pleurodesis in swine. The morphology and topography of the adhesions, 2 months after the patch placement, are consistent and more predictable than after talc poudrage. The latter causes a diffuse pleurodesis which is not predictable, with a predominantly gravitational location and produces a much more serious inflammatory response. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To compare the recurrence rate of primary spontaneous pneumothorax (PSP) after uniportal video assisted thoracic surgery (VATS) bullectomy and mechanical pleurodesis in patients managed with a regulating pressure drainage system compared and those managed with a traditional one. METHODS: Retrospective propensity score case-matched analysis of 174 consecutive patients submitted to uniportal VATS bullectomy and mechanical pleural abrasion (2007-13) in two centres. Definition of recurrence: Recurrent PSP requiring new treatment (i.e. aspiration, chest tube reinsertion, reoperation) within 12 months from the operation. All patients were managed with a single 24-Fr chest tube. Group 1 (106 patients): Tube connected to a traditional device (T) maintained on wall suction (-20 cmH2O) for 48 h. Group 2 (68 patients): Tube connected to a regulating pressure device (R) set at -20 cmH2O for 48 h. Chest tube removal criteria: No air leak (no bubbling or air flow <20 ml/min for at least 8 h) and pleural effusion <200 ml/day. Propensity score case-matching analysis was performed using the following variables: Age, gender, height, weight, side of operation, dystrophic score, length of stapled parenchyma. RESULTS: The two groups of 68 pairs were well matched for baseline and surgical characteristics. Patients of Group 2 (R) showed a significantly lower incidence of recurrence rate compared with matched counterparts (T) (3, 4.4 vs 10, 14%, P = 0.041). There were no differences in persistent air leak incidence, chest tube duration or hospital stay between the groups. Group 2 had a higher 48-h output of pleural effusion compared with Group 1 (P < 0.0001). CONCLUSIONS: By stabilizing the pleural pressure at the preset values, novel regulating pressure devices may enhance pleurodesis, leading to a reduced incidence of PSP recurrences after uniportal VATS bullectomy and pleural abrasion. [ABSTRACT FROM AUTHOR]

OBJECTIVES: There are no guidelines regarding the surgical approach for spontaneous pneumothorax. It has been reported, however, that the risk of recurrence following video-assisted thoracic surgery is higher than that following open thoracotomy (OT). The objective of this study was to determine whether this higher risk of recurrence following video-assisted thoracic surgery could be attributable to differences in intraoperative parenchymal resection and the pleurodesis technique. METHODS: Data for 7647 patients operated on for primary or secondary spontaneous pneumothorax between 1 January 2005 and 31 December 2012 were extracted from Epithor®, the French national database. The type of pleurodesis and parenchymal resection was collected. Outcomes were (i) bleeding, defined as postoperative pleural bleeding; (ii) pulmonary and pleural complications, defined as atelectasis, pneumonia, empyema, prolonged ventilation, acute respiratory distress syndrome and prolonged air leaks; (iii) in-hospital length of stay and (iv) recurrence, defined as chest drainage or surgery for a second pneumothorax. RESULTS: Of note, 6643 patients underwent videothoracoscopy and 1004 patients underwent OT. When compared with the thoracotomy group, the videothoracoscopy group was associated with more parenchymal resections (62.4 vs 80%, P = 0.01), fewer mechanical pleurodesis procedures (93 vs 77.5%, P < 10-3), fewer postoperative respiratory complications (12 vs 8.2%, P = 0.01), fewer cases of postoperative pleural bleeding (2.3 vs 1.4%, P = 0.04) and shorter hospital lengths of stay (16 vs 9 days, P = 0.01). The recurrence rate was 1.8% (n = 18) in the thoracotomy group versus 3.8% (n = 254) in the videothoracoscopy group (P = 0.01). The median time between surgery and recurrence was 3 months (range: 1-76 months). CONCLUSIONS: In the surgical management of spontaneous pneumothorax, videothoracoscopy is associated with a higher rate of recurrence than OT. This difference might be attributable to differences in the pleurodesis technique rather than differences in the parenchymal resection. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To compare the efficacy, safety, and outcome of thoracoscopic talc poudrage (TTP) versus povidone–iodine pleurodesis (PIP) through a thoracostomy tube as a palliative treatment of pleural effusion due to metastatic breast carcinoma (MBC). Methods: A total of 42 MBC patients were prospectively enrolled in a randomized controlled trial. Twenty-two patients received TTP (group A), whereas 20 patients (group B) underwent pleurodesis by instilling povidone–iodine through a thoracostomy tube, as a bedside procedure. Results: The mean age was 48.2±9.9 (range: 29–64) years and 50.2±7 (range: 32–62) years for groups A and B, respectively (p =ns). At presentation, all patients had moderate to severe dyspnea, New York Heart Association (NYHA)>II and Medical Research Council (MRC) dyspnea scale 3–5. Morbidity in both groups was low. Post-procedure analgesic requirements due to severe pleuritic chest pain were higher in group A (18% vs 0%, p =0.2). Four patients in group A (18%) and one in group B (5%) were febrile (>38°C) within 48h of the procedure. Both groups achieved good symptom control, with improvement in MRC dyspnea scale (1–3). There were no in-hospital deaths. Post-procedure hospital stay was lower in group B (p =0.009). The mean progression-free interval was 6.6 (range 3–15) months. At follow-up (mean: 22.6 (range: 8–48) months), recurrence of significant pleural effusion requiring intervention was noted in two and three patients in group A and group B, respectively (p =ns). Conclusion: Povidone–iodine can be considered as a good alternative to TTP to ensure effective pleurodesis for patients with malignant pleural effusion due to MBC. The drug is available, cost effective and safe, can be given through a thoracostomy tube and can be repeated if necessary. [Copyright &y& Elsevier]

Abstract: Objective: Although widely adopted, there is lack of immediate and long-term follow-up data for patients undergoing video-assisted thoracoscopic surgery (VATS) management of pneumothorax. Therefore, we have reviewed our experience with both primary (PSP) and secondary (SSP) spontaneous pneumothorax to assess the perioperative outcomes and long-term efficacy associated with different VATS operative strategies. Methods: A retrospective case series review was undertaken on all patients undergoing VATS procedures for PSP or SSP over a 17-year period. Results: A total of 644 VATS pneumothorax procedures were performed between 1992 and 2008 on 569 patients, of which 550 procedures were performed for PSP and 94 for SSP. Mean age for PSP and SSP groups were 28.4±10.4 and 58.2±14.2 years, respectively. Surgical technique used bullectomy in combination with abrasion (273), poudrage (246) and pleurectomy (46). Isolated poudrage was used in 72 cases. Median postoperative stay was 3 and 4 days, respectively. Major complications occurred in 25 (4.6%) PSP and 18 (19.2%) SSP patients. Two patients in the SSP group died (2.1%). Median follow-up was 73 months. Freedom from further surgery for the two populations was PSP: 98.1% at 5 years (confidence interval (C.I.): 96.9–99.4) and 97.8% at 10 years (C.I.: 96.5–99.2); SSP: 96.1% at 5 years (C.I.: 91.5–1.006) and 96.1% at 10 years (C.I.: 91.5–1.006). Freedom from further operation at 10 years was independent of the pleurodesis technique employed: abrasion 96.4%, poudrage 98.9% and pleurectomy 97.5% (p =0.22). Conclusions: VATS management of both PSP and SSP offers good short-term results and excellent long-term freedom from repeat surgery. In combination with bullectomy, results of abrasion and poudrage do not significantly differ from pleurectomy. We recommend abrasion for pleurodesis in young patients reserving poudrage for the elderly. Pleurectomy may not be necessary. [Copyright &y& Elsevier]

Abstract: Background: The optimal surgical management of primary spontaneous pneumothorax (PSP) is still controversial, especially in terms of the technique to be used. The aim of this paper was to report our experience of videothoracoscopic silver nitrate pleurodesis (VATSNP). Methods: Between 1995 and 2004, all the medical records of the patients who had undergone silver nitrate videothoracoscopic pleurodesis (SNVTP) were reviewed. All the patients had systematic prospective clinical and radiological follow-up at 1 month. The last 250 patients were retrospectively recontacted for long-term follow-up. Results: Six hundred and three patients underwent SNVP. No intra-operative death or major complication occurred during or after the procedures. Mean operating time was 40.2±10.7min. The conversion to thoracotomy rate was 2.5%. Main postoperative complications were prolonged air leak (15.6%), partial residual pneumothorax (5.1%), pleural effusion (2.5%) and postoperative bleeding (2.0%). The follow-up was 100% complete 1 month after discharge; at 1 month, the recurrence rate was 0.5%. The last 250 patients were retrospectively recontacted with a mean follow-up of 2.9±2.3 years (184 patients). The long-term recurrence rate was 1.1%. Conclusions: It is one of the first reports on the use of video-assisted thoracoscopic silver nitrate pleurodesis for PSP. We demonstrate safety and effectiveness of the procedure with long-term results comparable with standard open pleural abrasion or pleurectomy. [Copyright &y& Elsevier]

Summary: The aim of this study was to review systematically the available evidence on pleurodesis for malignant effusion, focusing on the choice of the agents, route of delivery and other strategies to improve outcomes. Four electronic databases (MEDLINE, EMBASE, Web of Science and Cochrane Controlled Trials Register) were searched, reference lists checked and letters requesting details of unpublished trials and data sent to authors of previous trials. Studies of malignant pleural effusion in humans were selected with no language restrictions applied. Criteria for randomised clinical trial (RCT) eligibility were random allocation of patients and non-concurrent use of another experimental medication or device. Methodological quality evaluation of the trials was based on randomisation, blinding, allocation concealment and intention to treat analysis. A random effect model was used to combine the relative risk estimates of the treatment effects whenever pooling for an overall effect was considered appropriate. Forty-six RCTs with a total of 2053 patients with malignant pleural effusions were reviewed for effectiveness of pleurodesis. Talc tended to be associated with fewer recurrences when compared to bleomycin (RR, 0.64; 95% CI, 0.34–1.20) and, with more uncertainty, to tetracycline (RR, 0.50; 95% CI, 0.06–4.42). Tetracycline (or doxycycline) was not superior to bleomycin (RR, 0.92; 95% CI, 0.61–1.38). When compared with bedside talc slurry, thoracoscopic talc insufflation was associated with a reduction in recurrence (RR, 0.21; 95% CI, 0.05–0.93). Strategies such as rolling the patient after instillation of the sclerosing agent, protracted drainage of the effusion and use of larger chest tubes were not found to have any substantial advantages. Talc appears to be effective and should be the agent of choice for pleurodesis. Thoracoscopic talc insufflation is associated with fewer recurrences of effusions compared with bedside talc slurry, but this is based on two small studies. Where thoracoscopy is unavailable bedside talc pleurodesis has a high success rate and is the next best option. [Copyright &y& Elsevier]

Abstract: Objective: Pleurodesis is of a potential benefit in pleural carcinomatosis and symptomatic malignant effusions, but the best way of achieving this is still uncertain. The aim of this prospective study was to analyse the results of pleurodesis after intra-pleural thoracoscopic administration of collagen powder. Methods: 45 patients (19 men and 26 women; median age of 64 years, range from 36 to 73 years) with malignant pleural effusions underwent thoracoscopic collagen pleurodesis. The procedure involved thoracoscopic drainage of pleural effusion and intra-pleural insufflation of 1g of bovine dermal collagen powder under general anaesthesia. Assessment of the immediate side effects and pH estimation of drained pleural fluid took place whilst inpatient. The patients were subsequently followed up for 1 year at 3-monthly intervals including outpatient clinical review and chest radiography. Prognostic value of pleural fluid pH in relation to the outcome of pleurodesis and patients'' survival was statistically analysed. Results: The procedure was well tolerated and there were no serious complications or deaths. Thoracoscopic collagen pleurodesis resulted in immediate resolution of malignant pleural effusion and all patients remained free of re-accumulated fluid for at least 1month. Only 5 (11%) patients later developed recurrent effusion and required its repeat drainage at some point during the follow-up period. In the vast majority (89%) patients, thoracoscopic collagen pleurodesis proved successful in complete and permanent resolution of pleural fluid collection. Acid medium (pH<7.3) of plural fluid was associated with poor survival (P<0.05), but did not influence the clinical and radiological outcome of collagen pleurodesis (P>0.05). Conclusions: Thoracoscopic collagen pleurodesis is a simple and effective method of treatment of malignant pleural effusions. [Copyright &y& Elsevier]

Abstract: Objective: The objective of the study was to see whether a rapid method of pleurodesis was superior to the standard protocol in patients with symptomatic malignant pleural effusion. Methods: Between January 2000 and February 2003, a prospective randomised trial was carried out in a sequential sample of 27 patients with malignant pleural effusions documented cytopathologically. Twelve patients were allocated to group 1 (standard protocol) and 15 to group 2 (new protocol). A small-bore catheter (12Fr) and oxytetracycline (35mg/kg of body weight) were used in both groups. In group 1, patients had drainage until radiological evidence of lung re-expansion was obtained and the amount of fluid drained was less than 150ml/day, before oxytetracycline was instilled. The catheter was removed when the amount of fluid drained after instillation was less than 150ml/day. In group 2, patients had the oxytetracycline instilled in a fractionated-dose manner following frequent aspirations at 6h intervals. The catheter was removed when the total amount of fluid drained after instillation of the oxytetracycline [OT] was less than 150ml/last three aspirations. Response was evaluated at 1, 3 and 6 months after pleurodesis. Results: There was no statistically significant difference in the demographic features, site of the primary tumour, disease characteristics, and response rates in any evaluation period in both groups (P>0.05). However, the number of days of drainage and hospitalisation, and the cost were significantly lower in the second group (P<0.001). Conclusions: This new pleurodesis method provided shorter hospital stay resulting in superior cost-effectiveness and palliation without sacrificing the efficacy of pleurodesis. [Copyright &y& Elsevier]

Objective: To evaluate the efficacy and risks of autologous ‘blood patch’ pleurodesis in patients with persistent air leak after pulmonary resection. Methods: All patients operated on by a single surgeon between January 2002 and January 2004 and presenting with a persistent air leak after pulmonary resection have been treated by the autologous blood patch pleurodesis technique. Fifty millilitres of autologous blood were injected through the chest tube that was then rinsed, clamped for 30min and then unclamped and placed back to water seal. Results: We have obtained a 100% success rate in 11 patients with persistent air leak who have been treated with this technique over a 2-year period. Most air leaks (72.7%) ceased within 12h of blood injection. No patient developed empyema, but two patients developed fever and pleural fluid grew Staphylococcus after blood pleurodesis. At 3-month follow-up, all patients were well and their lungs were expanded fully. Conclusions: In our experience a single injection of 50ml of blood is sufficient to seal persistent air leaks in less than 48h. Although highly effective, the autologous blood patch pleurodesis technique should not be used in patients with incomplete lung re-expansion or positive pleural fluid culture to minimize the risk of empyema. [Copyright &y& Elsevier]

Objective: Non-steroidal anti-inflammatory drugs (NSAIDs) are often applied for pain management after thoracic surgery. Since these drugs diminish collagen deposition through inhibition of the prostaglandin synthesis, we investigated their effects on adhesion formation after endoscopic mechanical pleural abrasion, which is often applied in the therapy of pneumothorax. Methods: Mechanical pleural abrasion was performed unilaterally by the use of video-assisted thoracoscopic surgery technique in an established pig model. Ten animals (41.3±3.4 kg) were divided into a treatment group and a control group. In the treatment group, animals received 100 mg diclofenac (2 mg/kg body weight) orally daily for 3 weeks after surgery. At 3 weeks, all animals were sacrificed and efficacy of pleurodesis was macroscopically assessed by three independent reviewers blinded to the treatment of animals using a five-point severity pleurodesis score (from 0, no adhesions to 4, complete symphisis) and obliteration grade rating the distribution of adhesions (from 0, no adhesions to 4, adhesions in the whole chest). Microscopic evaluation was performed by two pathologists blinded to the study groups as well. A four-point score assessed the amount of collagen deposition (from 1, a few collagen fibers to 4, scar). Results: Gross observation showed more dense adhesions in control animals with a median pleurodesis score of 3.67±1.0 in comparison to 2±2.2 in the treatment group (P=0.01*, Mann–Whitney non-parametric test). Distribution of adhesions was comparable in both groups with a median obliteration score of 3.67±1.3. Histopathologic examination showed a higher amount of collagen deposition in the control group, suggesting more dense adhesions, whereas in the treatment group there was loose granulation tissue (score of 4.0±0.8 vs. 2.3±1.0 in the treatment group, P=0.06). The degree of inflammatory reaction was comparable in the two groups. Conclusions: Our results demonstrate that perioperative use of NSAIDs highly affects the quality of pleural adhesions obtained after mechanical abrasion in this pig model, which further suggests that these drugs should be avoided for pain management when a pleurodesis is performed. [Copyright &y& Elsevier]

Objective: Recurrent pleural effusion is a common condition and often presents a challenge for treatment. The aim of this report is to evaluate the long-term follow-up of thoracoscopic management of malignant recurrent pleural effusions. Methods: From July 1st, 1992 to February 28th, 2001, out of 2311 VATS procedures performed at our Institution, 690 patients (29.85%) underwent videothoracoscopy (VATS) for recurrent pleural effusion. Of these 611 (88.55%) were treated for a malignant pleural effusion. There were 374 male and 237 female, with a mean age of 61.2 years. In all patients VATS was performed under general anaesthesia. The pleural affusion was carefully aspirated; fibrinous adhesions were taken down while dense fibrous adhesions were selectively divided; some limited decortications were also performed. Multiple pleural biopsies were always performed. Pleurodesis was performed with 5 g of sterile purified talc insufflated through a talc atomizer. One chest tube was left in situ for 3–5 days. Results: Operative mortality was 0.81% (five cases). Postoperative complications occurred in 19 cases (3.1%). Specific histologic diagnosis was obtained in all patients. Follow-up was available for 602 patients (98.5%). After a median follow-up of 64 months (range 5–105 months), talc pleurodesis was successful in controlling recurrence of effusion in 92.7% (558 out of 602) of patients. The success rate did not show any statistically significant difference between patients who underwent postoperative adjuvant therapy and patients who did not. In two patients with failure of talc pleurodesis a redo-VATS was performed. Conclusions: VATS represents the method of choice for both diagnosis and treatment of malignant recurrent pleural effusions. Talc poudrage is safe and effective in obtaining pleurodesis. [Copyright &y& Elsevier]

Catamenial pneumothorax (CPX) is an aetiologically very complex disease for which the treatments for pneumothorax and endometriosis are generally adapted. However, emphasizing secondary prevention, we developed a new method. This powerful new technique for prevention of pneumothorax during menstruation by surgical pleurodesis using absorbable mesh is presented. CPX is a relatively rare disease characterized by recurrent pneumothorax during menstruation. Although pathological diagnosis is desirable, CPX is clinically defined as recurrent pneumothorax synchronized with the menstrual cycle. Unfortunately, conventional therapy, including hormonal treatment and surgical procedures, seems to be associated with a high rate of recurrence; there is no well-established treatment for CPX. Recently, we developed a useful and effective operative method for spontaneous pneumothorax, with which one can remove the lesion site and sew a polyglactin mesh on the lung concurrently by endoscopic linear cutter under video-assisted thoracoscopic surgery, dressing the lung with polyglactin mesh to reinforce the stump and facilitating pleural adhesion for secondary prevention. We have used this method to resect pathological lung lesions and promote pleurodesis to prevent recurrence. In addition, polyglycolate felt was placed to cover the lesion site in the diaphragm in four cases of repetitive and treatment-resistant CPX as surgical pleurodesis, and successful results were obtained. [ABSTRACT FROM AUTHOR]

Apical pleurodesis procedures, in addition to the resection of bullae or blebs, proved to lower the recurrence rate in spontaneous pneumothoraces. Here, we describe our thoracoscopic technique of making a 360° apical pleurodesis. After resecting responsible bullae or blebs thoracoscopically, we dissect the parietal pleura off the chest wall up, turn it over on the mediastinal side, clip it on the mediastinal pleura and place the lung apex against the rough surface to promote extensive apical pleurodesis. The technique has been performed for 18 patients so far and no late recurrence of pneumothorax has been noted. [ABSTRACT FROM AUTHOR]

A response from the author of the article "An effective method of pleurodesis involving absorbable mesh for repetitive catamenial pneumothorax" in the 2012 issue is presented.

Abstract: Lymphangioleiomyomatosis (LAM) is a rare, idiopathic disease affecting young women often complicated by refractory and difficult to manage chylothorax. We report one case of a patient who received a bilateral lung transplantation for LAM presenting a refractory chylothorax. The instillation of povidone iodine in the pleural space was effective in inducing pleurodesis. [Copyright &y& Elsevier]

The article presents a case study of a 55 year old female patient, who underwent tube throacostomy for pneumothorax that had recurred five times and talc pleurodesis in 2006, and was diagnosed with granulomatous inflammation.

A letter to the editor and a reply are presented in response to the article "An effective method of pleurodesis involving absorbable mesh for repetitive catamenial pneumothorax," by T. Ikeda and colleagues.