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Malignant pleural effusion (MPE) is a common cancer complication. Clinical and economic implications of different recurrent MPE treatment pathways have not been evaluated fully. What clinical outcomes, complications, health care resource use, and costs are associated with various rapidly recurrent MPE treatment pathways? This retrospective cohort study using Surveillance, Epidemiology and End Results Medicare data (2011-2015) included patients 66 to 90 years of age with rapidly recurrent MPE. Rapid recurrence was defined as receipt of a second pleural procedure within 14 days of the first thoracentesis, including nondefinitive repeated thoracentesis or a definitive treatment option including chest tube, indwelling pleural catheter (IPC), or thoracoscopy. Among 8,378 patients with MPE, 3,090 patients (36.9%) had rapidly recurrent MPE (mean ± SD age, 75.9 ± 6.6 years; 45.6% male; primary cancer, 62.9% lung and 37.1% other). Second pleural procedures were nondefinitive thoracentesis (62.3%), chest tube (17.1%), IPC (13.2%), or thoracoscopy (7.4%). A third pleural procedure was required more frequently if the second pleural procedure was nondefinitive thoracentesis vs chest tube placement, IPC placement, or thoracoscopy (70.3% vs 44.1% vs 17.9% vs 14.4%, respectively). The mean number of subsequent pleural procedures over the patient's lifetime varied significantly among the procedures (1.74, 0.82, 0.31, and 0.22 procedures for patients receiving thoracentesis, chest tube, IPC, and thoracoscopy, respectively; P <. 05). Average total costs after the second pleural procedure to death adjusted for age at primary cancer diagnosis, race, year of second pleural procedure, Charlson comorbidity index, cancer stage at primary diagnosis, and time from primary cancer diagnosis to diagnostic thoracentesis were lower with IPC ($37,443; P <.0001) or chest tube placement ($40,627; P =.004) vs thoracentesis ($47,711). Patients receiving thoracoscopy ($45,386; P =.5) incurred similar costs as patients receiving thoracentesis. Early definitive treatment was associated with fewer subsequent procedures and lower costs in patients with rapidly recurrent MPE. [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction: Persistent air leak (PAL) is associated with prolonged hospitalization, high morbidity and increased treatment costs. Conservative treatment consists of observation, chest tube drainage, and pleurodesis. Guidelines recommend surgical evaluation if air leak does not respond after 3–5 days. One-way endobronchial valves (EBV) have been proposed as a treatment option for patients with PAL in which surgical treatment is not feasible, high risk or has failed. We aimed to provide a comprehensive overview of reported EBV use for PAL and issue best practice recommendations based on multicenter experience. Methods: We conducted a retrospective observational case-series study at four different European academic hospitals and provided best practice recommendations based on our experience. A systematic literature review was performed to summarize the current knowledge on EBV in PAL. Results: We enrolled 66 patients, male (66.7%), median age 59.5 years. The most common underlying lung disease was chronic obstructive pulmonary disease (39.4%) and lung cancer (33.3%). The median time between pneumothorax and valve placement was 24.5 days (interquartile range: 14.0–54.3). Air leak resolved in 40/66 patients (60.6%) within 30 days after EBV treatment. Concerning safety outcome, no procedure-related mortality was reported and complication rate was low (6.1%). Five patients (7.6%) died in the first 30 days after intervention. Conclusion: EBV placement is a treatment option in patients with PAL. In this multicenter case-series of high-risk patients not eligible for lung surgery, we show that EBV placement resulted in air leak resolution in 6 out of 10 patients with a low complication rate. Considering the minimally invasive nature of EBV to treat PAL as opposed to surgery, further research should investigate if EBV treatment should be expanded in low to intermediate risk PAL patients. [ABSTRACT FROM AUTHOR]

Le pneumothorax de l'enfant est rare avec une prise en charge hétérogène liée à l'absence de recommandations pédiatriques spécifiques. Chez le nouveau-né, le pneumothorax survient sur un terrain favorisant et/ou malformatif et son traitement est fonction de la tolérance et du contexte. Chez l'adolescent, la physiopathologie reste méconnue, notamment le rôle des lésions emphysémateuses apicales (bulles, blebs) dans la survenue du pneumothorax spontané et sa potentielle récidive. Une pathologie sous-jacente doit systématiquement être recherchée. Le pneumothorax est confirmé par un cliché de radiographie de thorax de face en inspiration. La réalisation d'un scanner thoracique (examen le plus sensible) ne semble pas indispensable en cas de premier épisode paucisymptomatique avec un pneumothorax < 2 cm (traitement conservateur) et en l'absence d'argument pour une étiologie secondaire. Elle reste discutée lorsqu'un drain thoracique a dû être posé, dans le but de rechercher des bulles ou une pathologie sous-jacente. L'échographie pleurale peut présenter un intérêt diagnostique en situation d'urgence extrême ou dans le suivi de patients de soins intensifs. La supériorité du drainage versus exsufflation à l'aiguille lors d'un premier épisode reste débattue. Le taux de récidive après un premier épisode de pneumothorax est de 50–60 % chez l'enfant. Le traitement chirurgical du pneumothorax est réalisé en cas de récidive ou en cas de bullage persistant après 48 heures de drainage. Une résection de l'apex avec pleurodèse mécanique (pleuro-abrasion, pleurectomie) est à privilégier chez l'enfant, malgré son taux de récidive rapporté supérieur à la pleurodèse chimique (5 % contre 1 %). L'information de l'enfant et de sa famille sur les activités éventuellement contre-indiquées est nécessaire. The rare occurrence and the absence of dedicated recommendations in pediatric pneumothorax lead to very heterogenous management courses. In neonatal pneumothorax, specific risk factors or congenital malformations are usually found. The treatment of neonatal pneumothorax depends on tolerance and context. Pathophysiology of pneumothorax in adolescents remains uncertain, including the exact role of emphysematous lesions of the lungs (bullae, blebs) in spontaneous pneumothorax or in possible recurrence. An underlying condition should always be sought. Diagnostic of pneumothorax is made using chest X-ray. A first episode of well-tolerated primitive spontaneous pneumothorax with pneumothorax < 2 cm should be managed conservatively and CT-scan (highest sensitivity) should not be systematic, unless a secondary cause is suspect. CT-scan should be discussed in cases requiring chest tube drainage, in order to look for bullae or an underlying cause. Pleural ultrasound may be used for diagnosis in life-threatening cases or as a follow-up tool in intensive care patients. The superiority of chest tube drainage versus needle exsufflation in the management of a first episode remains debated. In children, recurrence following a first episode of spontaneous pneumothorax occurs in 50 to 60% of cases. Surgical management should be performed in recurrent pneumothoraces or persistent bubbling after 48 hours of efficient drainage. Bullectomy with mechanical pleurodesis (pleurectomy, pleuroabrasion) should be preferred to chemical pleurodesis in children, despite its higher recurrence rate (5% versus 1%). The child and their parents must be informed on contraindicated activities. [ABSTRACT FROM AUTHOR]

Background/Purpose: Biomaterial implants are emerging as a treatment choice for pleurodesis; however, the optimal biomaterial and form for managing spontaneous pneumothorax, particularly post-video-assisted thoracic surgery, remain under investigation. This study evaluated the mechanical and biological properties of the poly-ε-caprolactone (PCL) membrane as a sclerosing agent for pleurodesis in Landrace pigs. Methods: Twenty-four Landrace pigs were split into two groups for mechanical abrasion and PCL membrane pleurodesis, with the latter group's PCL meshes inserted using video-assisted thoracic surgery. The mechanical and biological properties of the PCL membrane were assessed in pigs at three, six, and 12 months after the procedure. This assessment involved a range of techniques, such as the T-Peel test, macroscopic evaluation with a scoring scale, microscopic examination, and biomechanical and molecular weight analysis. Results: The PCL membrane group outperformed the traditional abrasion group, with stronger adhesions seen over longer implantation durations. This group also showed superior and more consistent results in both macroscopic and microscopic evaluations compared to the control group. The membrane-based method was easier and faster to perform than the control group's method, and importantly, no mortality occurred following membrane implantation. Conclusion: This study is the pioneering effort to present long-term findings regarding the mechanical and biological properties of the PCL membrane in an in vivo animal model. The membrane demonstrated better adhesion ability than that of traditional abrasion and showed reassuring biocompatibility in both the pig model, suggesting its potential as treatment for patients with primary spontaneous pneumothorax. Further clinical studies are needed to support these observations.

Background Methods Results Conclusion Primary spontaneous pneumothorax occurs in patients with no underlying lung disease and guidelines recommend chest tube drainage for the first episode, with surgical intervention reserved for recurrent episodes, persistent air leak or failure of lung re‐expansion. Modern surgical management is associated with reduced length of hospital stay and superior freedom from recurrence compared with chest tube drainage alone. The objective of this study was to identify risk factors for failed chest tube drainage in patients who present with first episode primary spontaneous pneumothorax.A retrospective analysis of patients who presented to Royal Prince Alfred Hospital, Australia with first episode PSP and underwent chest tube insertion was performed. Patient demographics and size of pneumothorax were examined in relation to the primary outcome, a composite of failed chest tube drainage and recurrent ipsilateral pneumothorax.Fifty‐five patients underwent chest tube drainage for first episode primary spontaneous pneumothorax between 1st January 2017 and 31st December 2020. Complete lung collapse on admission chest x‐ray was associated with an increased risk of the primary outcome (63% versus 19%, OR 7.3 [96% CI 2.0–27.4), P = 0.004).This small retrospective study found that patients that undergo chest drain insertion for first episode primary spontaneous pneumothorax who present with complete lung collapse on admission are at high risk of requiring pleurodesis and therefore may benefit from early surgical referral. [ABSTRACT FROM AUTHOR]

Background: Malignant pleural effusions (MPEs) are common, and a third of them have underlying trapped lung (TL). Management of MPE and TL is suspected to be heterogeneous. Understanding current practices in Australasia is important in guiding policies and future research. Aims: Electronic survey of Australia‐New Zealand respiratory physicians, thoracic surgeons and their respective trainees to determine practice of MPE and TL management. Results: Of the 132 respondents, 56% were respiratory physicians, 23% were surgeons and 20% were trainees. Many respondents defined TL as >25% or any level of incomplete lung expansion; 75% would use large‐volume thoracentesis to determine whether TL was present. For patients with TL, indwelling pleural catheters (IPCs) were the preferred treatment irrespective of prognosis. In those without TL, surgical pleurodesis was the most common choice if prognosis was >6 months, whereas IPC was the preferred option if survival was <3 months. Only 5% of respondents considered decortication having a definite role in TL, but 55% would consider it in select cases. Forty‐nine per cent of surgeons would not perform decortication when the lung does not fully expand intra‐operatively. Perceived advantages of IPCs were minimisation of hospital time, effusion re‐intervention and usefulness irrespective of TL status. Perceived disadvantages of IPCs were lack of suitable drainage care, potentially indefinite duration of catheter‐in‐situ and catheter complications. Conclusion: This survey highlights the lack of definition of TL and heterogeneity of MPE management in Australasia, especially for patients with expandable lungs. This survey also identified the main hurdles of IPC use that should be targeted. [ABSTRACT FROM AUTHOR]

Background: Pleural effusions often cause disabling breathlessness, however the mechanism is unknown. Patients with pleural effusions are subjected to pleural fluid drainage on a 'trial and error' basis, as symptom relief varies. This population commonly complain of bendopnoea (breathlessness on bending forward) which has not been investigated. Our pilot data found bendopnoea was significantly associated with presence of pleural effusion. The PLEASE‐3 study will evaluate bendopnoea as a screening test for effusion‐related breathlessness, its predictive value of symptomatic benefits from fluid drainage and explore its underlying physiological mechanism. Methods: PLEASE‐3 is a multi‐centre prospective study. Eligible patients are assessed at baseline (pre‐drainage) and for patients undergoing drainage, up to 72 h post‐procedure. Outcome measures include the prevalence of bendopnoea, its correlation with size of effusion and its predictive value of breathlessness relief after drainage. The relationship of bendopnoea with breathlessness, physiological parameters, functional capacity and diaphragmatic characteristics will be assessed. The study will recruit 200 participants. Discussion: This is the first study to investigate bendopnoea in patients with pleural effusion. It has minimal exclusion criteria to ensure that the results are generalisable. The presence and clinical significance of bendopnoea in the context of pleural effusion requires thorough investigation. The post assessment of patients undergoing pleural fluid drainage will provide insight into whether the presence of bendopnoea is able to predict clinical outcomes. Trial Registration: Name of the registry: Australia New Zealand Clinical Trial Registry Trial registration number: ACTRN12622000465752. URL of the trial registry record for this trial:https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383639&isReview=true Date of registration: Registered on 24 March 2022. Funding of the trial: This study has received funding from the Sir Charles Gairdner Research Advisory Council research project grant. The study is sponsored by the Institute for Respiratory Health, a not‐for‐profit organisation. Name and contact information for the trial sponsor: Mr Bi Lam; Finance manager. Level 2, 6 Verdun Street, Nedlands WA 6009. t‖ + 61 8 6151 0877 e‖ bi.lam@resphealth.uwa.edu.au Role of sponsor: The funder is not involved in the planning of the study, gathering, analysing, and interpreting the data, or in preparing the manuscript. [ABSTRACT FROM AUTHOR]

Rationale: Malignant pleural effusions (MPEs) are associated with significant health service use and healthcare costs, but the current evidence is limited. Objectives: To compare 12-month post-procedure: 1) health service utilization; and 2) healthcare costs after indwelling pleural catheter (IPC) insertion with at-home drainage performed by home care nursing services, versus in-hospital chemical pleurodesis. Methods: We performed a retrospective population-based study on a cohort of adults with MPEs who underwent IPC insertion or chemical pleurodesis between January 1, 2015 and December 31, 2019 using provincial health administrative data (Ontario, Canada). Patients were followed from the procedure date until death or until 12 months after the procedure. Inverse probability of treatment weighting was performed to adjust for imbalances in baseline characteristics. Differences in length of stay, readmissions, emergency department visits, home care visits, and healthcare costs were estimated using weighted regression analysis. Results: Of 5,752 included individuals, 4,432 (77%) underwent IPC insertion and 1,320 (23%) had pleurodesis. In the weighted sample, individuals who received an IPC had fewer inpatient days (12.4 d vs. 16 d; standardized mean difference, 0.229) but a higher proportion of subsequent admissions for empyema (2.7% vs. 1.1%; P = 0.0002) than those undergoing pleurodesis. Individuals with IPCs received more hours of nursing home care (41 h vs. 21.1 h; standardized mean difference, 0.671) but overall had lower average healthcare costs ($40,179 vs. $46,640 per patient; standardized mean difference, 0.177) than those receiving pleurodesis. Conclusions: IPCs with home nursing drainage are associated with reduced health resource use compared with pleurodesis in adults with MPEs, even after controlling for important baseline and clinical characteristics. Given that both procedures have similar health outcomes, our findings support the ongoing promotion of IPCs to increase outpatient management of patients with MPEs. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy and safety of intrapleural perfusion with hyperthermic chemotherapy (IPHC) in treating malignant pleural effusion (MPE). Methods: PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), VIP Chinese Science and Technology Journal Full-text Database (VP-CSJFD), and Wanfang database were searched by computer from database establishment to January 17, 2024. Relevant randomized controlled articles with IPHC as the observational group and intrapleural perfusion chemotherapy (IPC) as the control group for MPE were included. Then, the methodological quality of the included articles was evaluated and statistically analyzed using Stata 16.0. Results: Sixteen trials with 647 patients receiving IPHC and 661 patients receiving IPC were included. The meta-analysis found that MPE patients in the IPHC group had a more significant objective response rate [RR = 1.31, 95%CI (1.23, 1.38), P < 0.05] and life quality improvement rate [RR = 2.88, 95%CI (1.95, 4.24), P < 0.05] than those in the IPC group. IPHC and IPC for MPE patients had similar incidence rates of asthenia, thrombocytopenia, hepatic impairment, and leukopenia. Conclusion: Compared with IPC, IPHC has a higher objective response rate without significantly increasing adverse reactions. Therefore, IPHC is effective and safe. However, this study is limited by the quality of the literature. Therefore, more high-quality, multi-center, large-sample, rigorously designed randomized controlled clinical studies are still needed for verification and evaluation. [ABSTRACT FROM AUTHOR]

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]

Introduction: Pulmonary infections, such as tuberculosis, can result in numerous pleural complications including empyemas, pneumothoraces with broncho-pleural fistulas, and persistent air leak (PAL). While definitive surgical interventions are often initially considered, management of these complications can be particularly challenging if a patient has an active infection and is not a surgical candidate. Case Presentation: Autologous blood patch pleurodesis and endobronchial valve placement have both been described in remedying PALs effectively and safely. PALs due to broncho-pleural fistulas in active pulmonary disease are rare, and we present two such cases that were managed with autologous blood patch pleurodesis and endobronchial valves. Conclusion: The two cases presented illustrate the complexities of PAL management and discuss the treatment options that can be applied to individual patients. Established Facts: Persistent air leak (PAL) due to broncho-pleural fistulas (BPFs) can be difficult to treat in patients who are not surgical candidates or have failed prior interventions. Autologous blood patch pleurodesis is a safe and effective treatment for PAL most commonly in the postoperative setting. The use of endobronchial valves has been described to ameliorate PAL due to BPFs, though experience remains limited in pleuropulmonary tuberculosis. [ABSTRACT FROM AUTHOR]

Biomaterial implants are emerging as a treatment choice for pleurodesis; however, the optimal biomaterial and form for managing spontaneous pneumothorax, particularly post-video-assisted thoracic surgery, remain under investigation. This study evaluated the mechanical and biological properties of the poly-ε-caprolactone (PCL) membrane as a sclerosing agent for pleurodesis in Landrace pigs. Twenty-four Landrace pigs were split into two groups for mechanical abrasion and PCL membrane pleurodesis, with the latter group's PCL meshes inserted using video-assisted thoracic surgery. The mechanical and biological properties of the PCL membrane were assessed in pigs at three, six, and 12 months after the procedure. This assessment involved a range of techniques, such as the T-Peel test, macroscopic evaluation with a scoring scale, microscopic examination, and biomechanical and molecular weight analysis. The PCL membrane group outperformed the traditional abrasion group, with stronger adhesions seen over longer implantation durations. This group also showed superior and more consistent results in both macroscopic and microscopic evaluations compared to the control group. The membrane-based method was easier and faster to perform than the control group's method, and importantly, no mortality occurred following membrane implantation. This study is the pioneering effort to present long-term findings regarding the mechanical and biological properties of the PCL membrane in an in vivo animal model. The membrane demonstrated better adhesion ability than that of traditional abrasion and showed reassuring biocompatibility in both the pig model, suggesting its potential as treatment for patients with primary spontaneous pneumothorax. Further clinical studies are needed to support these observations. [ABSTRACT FROM AUTHOR]

Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient's needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice. [ABSTRACT FROM AUTHOR]

Malignant pleural effusion (MPE) has become an increasingly prevalent complication in oncological patients, negatively impacting their quality of life and casting a shadow over their prognosis. Owing to the pathophysiological mechanisms involved and the heterogeneous nature of the underlying disease, this entity is both a diagnostic and therapeutic challenge. Advances in the understanding of MPE have led to a shift in the treatment paradigm towards a more personalized approach. This article provides a comprehensive review and update on the pathophysiology of MPE and describes the diagnostic tools and the latest advances in the treatment of this complex clinical entity. Resumen: El derrame pleural maligno (DPM) se ha convertido en una complicación cada vez más prevalente en los pacientes oncológicos, empeorando la calidad de vida y ensombreciendo el pronóstico de los mismos. Debido a los mecanismos fisiopatológicos involucrados y a la naturaleza heterogénea de la enfermedad subyacente, esta entidad representa un desafío diagnóstico y terapéutico. Los avances en la comprensión del DPM han originado un cambio en el paradigma del tratamiento hacia un enfoque más personalizado. Este artículo proporciona una revisión exhaustiva y una actualización sobre la fisiopatología del DPM, y describe las herramientas diagnósticas y los últimos avances en el tratamiento de esta compleja entidad clínica.

Background: Several studies have indicated that intrapleural infusion of bevacizumab is an effective treatment for non-small cell lung cancer (NSCLC) with malignant pleural effusion (MPE). However, the impact of bevacizumab administered through an indwelling pleural catheter (IPC) on the prognosis of these patients is unknown. Methods: Consecutive advanced NSCLC patients with symptomatic MPE receiving an IPC alone or bevacizumab through an IPC were identified in a tertiary hospital. The patient characteristics and clinical outcomes were collected. Results: A total of 149 patients were included, and the median age was 60.3 years. Males and nonsmokers accounted for 48.3% and 65.8%, respectively. A total of 69.8% (104/149) of patients harbored actionable mutations, including 92 EGFR-activating mutations, 11 ALK fusions, and 1 ROS1 fusion. A total of 81.9% (122/149) of patients received IPC alone, and 18.1% (27/149) received bevacizumab through an IPC. The incidence of spontaneous pleurodesis during the first 6 months was greater in the bevacizumab-treated group than in the IPC-treated group in the subgroup with actionable mutations (64.3% vs. 46.9%, P = 0.28). The median overall survival (OS) in patients with actionable mutations treated with bevacizumab through an IPC was 42.2 months, which was significantly longer than the 26.7 months in patients who received an IPC alone (P = 0.045). However, the median OS did not differ between the two arms in the subgroup without actionable mutations (10.8 vs. 41.0 months, P = 0.24). No significant difference between the bevacizumab through an IPC group and the IPC group was detected in the number of participants who had adverse events, either in patients with actionable mutations (14.3% vs. 8.4%; P = 0.42) or in patients without actionable mutations (16.7% vs. 12.8%; P = 1.00). [ABSTRACT FROM AUTHOR]

The use of non-steroidal anti-inflammatory drugs (NSAID) in patients undergoing pleurodesis remains controversial. Although many surgeons are comfortable prescribing NSAIDs post-operatively, some oppose this practice due to concerns of suppressing the inflammatory response and quality of pleurodesis. Only a small body of inconsistent publications exists with respect to guiding therapy in this common clinical scenario. A retrospective cohort study was undertaken assessing effect of NSAID exposure on pleurodesis outcomes. An institutional thoracic surgery database was reviewed yielding 147 patients who underwent pleurodesis for pneumothorax between 2010 and 2018. Medical records and imaging were reviewed for patient characteristics, NSAID exposure, recurrent pneumothorax and other adverse events. There was no overall difference between rates of recurrence and procedural failure of pleurodesis (Relative Risk [RR] 1.67 [95% CI 0.74-3.77]). However, NSAID exposure of >48 hours was associated with increased risk of recurrent pneumothorax (RR 2.16 [95% CI 1.05-4.45]). There was no increased rate of other adverse events related to NSAID usage. NSAID exposure does not increase failure rates or other adverse events following pleurodesis for pneumothorax. However, prolonged NSAID exposure post-pleurodesis may increase procedural failure rates. Further large volume randomised control trials are required. [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]

Objectives: Non‐immune hydrops fetalis (NIHF) is the pathological accumulation of fluids in fetal compartments, without maternal isoimmunization. Fetal interventions (e.g. shunting, fetal paracentesis, fetal thoracocentesis, fetal pleurodesis) are used to alleviate fluid accumulations, but the outcome is uncertain because the underlying causes of NIHF vary. We aimed to explore the etiology and long‐term outcome of NIHF after fetal intervention. Methods: This was a retrospective review of fetuses with NIHF, defined by the presence of fetal ascites, pleural or pericardial effusion, skin edema or cystic hygroma, or a combination of these features, who underwent intervention at our institution during the period 2012–2021. Clinical surveillance, genetic analysis and viral infection screening were used to define the etiology. Chart reviews and telephone interviews were conducted to assess the long‐term outcomes. Results: In total, 55 fetuses were enrolled and 46 cases had final follow‐up data after delivery. Etiology was identified in 33 cases, including four for which the underlying causes were not identified initially using small‐gene‐panel tests but which were later diagnosed with monogenic disorders by whole‐exome sequencing (WES). Twenty‐three cases with follow‐up survived, having a follow‐up period of 2–11 years at the time of writing, of which 17 were healthy. All 11 cases initially presenting as congenital chylothorax survived with favorable outcome. Conclusions: The etiologies of NIHF are heterogeneous, and the long‐term (spanning 2–11 years) outcome of fetal intervention varies, according to the underlying etiology, with cases caused by congenital chylothorax having the best prognosis. Genome‐wide tests, such as WES, may be helpful in determining the underlying condition in cases caused by a genetic disorder, and this may affect fetal therapy approaches in the future. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. Linked article: There is a comment on this article by Zhao and Li. Click here to view the Correspondence. [ABSTRACT FROM AUTHOR]

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Key Clinical Message: Chylothorax is a rare entity associated with morbidity. Surgical thoracic duct ligation (TDL) by thoracoscopic approach is the recommended choice for persistent chylothorax. However, thoracoscopy is not feasible in case of previous pleurodesis. We describe a successful laparoscopic transhiatal en‐mass TDL in a 61‐year‐old lady for persistent spontaneous chylothorax after failed optimal conservative management and three sessions of pleurodesis. The study shows that laparoscopic transhiatal thoracic duct ligation is an effective alternative in a case where thoracoscopy is not feasible due to various reasons. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy of pleurodesis using OK-432 after cardiac surgery in the neonatal period or early infancy. Methods: We retrospectively reviewed the data of 11 consecutive patients who underwent cardiac surgery in the neonatal period or early infancy and pleurodesis using OK-432 for persistent postoperative pleural effusion in two institutions. Results: The median age at surgery was 8 days (interquartile range [IR], 2–18) with a body weight of 2.84 kg (IR, 2.30–3.07). The maximum amount of pleural drainage before pleurodesis was 94.7 (IR, 60.2–107.7) ml/kg/day. Pleurodesis was initiated at postoperative day 20 (IR, 17–22) and performed in bilateral pleural spaces in seven patients and unilateral in four. The median numbers of injection were 4 (IR, 3–6) times per patient and 3 (IR, 2–3) times per pleural space. In 10 patients, pleural effusion was decreased effectively, and drainage tubes were removed without reaccumulation within 15 (IR, 12–28) days after initial pleurodesis. However, in one patient, with severe lymphedema, pleural effusion was uncontrollable, resulting in death due to sepsis. Adverse events were observed in nine patients; temporal deterioration of lung compliance and arterial blood gas occurred in two, insufficient drainage requiring new chest tube(s) in five, temporal atrial tachyarrhythmia in one, and lymphedema in four. Conclusions: Pleurodesis using OK-432 is effective and reliable for persistent postoperative pleural effusion in neonates and early infants. Most of the complications, which derived from inflammatory reactions, were temporary and controllable. However, severe lymphedema is difficult to control. [ABSTRACT FROM AUTHOR]

Objectives: The choice of therapeutic intervention for postoperative air leak varies between institutions. We aimed to identify the optimal timing and patient criteria for therapeutic intervention in cases of postoperative air leaks after lung resection. Methods: This study utilized data from a prospective multicenter observational study conducted in 2019. Among the 2187 cases in the database, 420 cases with air leaks on postoperative day 1 were identified. The intervention group underwent therapeutic interventions, such as pleurodesis or surgery, while the observation group was monitored without intervention. A comparison between the intervention group and the observation group were analyzed using the cumulative distribution and hazard functions. Results: Forty-six patients (11.0%) were included in the intervention group. The multivariate analysis revealed that low body mass index (p = 0.019), partial resection (p = 0.010), intraoperative use of fibrin glue (p = 0.008), severe air leak on postoperative day 1 (p < 0.001), and high forced expiratory volume in 1 s (p = 0.021) were significant predictors of the requirement for intervention. The proportion of patients with persistent air leak in the observation group was 20% on postoperative day 5 and 94% on postoperative day 7. The hazard of air leak cessation peaked from postoperative day 3 to postoperative day 7. Conclusions: This research contributes valuable insights into predicting therapeutic interventions for postoperative air leaks and identifies scenarios where spontaneous cessation is probable. A validation through prospective studies is warranted to affirm these findings. [ABSTRACT FROM AUTHOR]

Purpose: To elucidate clinical outcomes using a digital drainage system (DDS) for massive air leakage (MAL) after pulmonary resection. Methods: A total of 135 consecutive patients with pulmonary resection air leakage of > 100 ml/min on the DDS were evaluated retrospectively. In this study, MAL was defined as ≥ 1000 ml/min on the DDS. We analyzed the clinical characteristics and surgical outcomes of patients with MAL compared with non-MAL (101–999 ml/min). Using the DDS data, the duration of the air leak was plotted with the Kaplan‒Meier method and compared using the log-rank test. Results: MAL was detected in 19 (14%) patients. The proportions of heavy smokers (P = 0.04) and patients with emphysematous lung (P = 0.03) and interstitial lung disease (P < 0.01) were higher in the MAL group than in the non-MAL group. The MAL group had a higher persistence rate of air leakage at 120 h after surgery than the non-MAL group (P < 0.01) and required significantly more frequent pleurodesis (P < 0.01). Drainage failure occurred in 2 (11%) and 5 (4%) patients from the MAL and non-MAL groups, respectively. Neither reoperation nor 30-day surgical mortality was observed in patients with MAL. Conclusions: MAL was able to be treated conservatively without surgery using the DDS. [ABSTRACT FROM AUTHOR]

Needle biopsy (NB) is used for the diagnosis of lung cancer, but there is still controversy about its effect on the prognosis after surgery. We conducted this meta-analysis to compare the prognosis of lung cancer patients who underwent preoperative NB with that of those who did not. We systematically searched seven databases and Google Scholar for eligible studies. Recurrence-free survival (RFS) and overall survival (OS) were analyzed as primary outcome measures. Nine articles with a collective total of 13,541 patients (NB group, n = 4550; non-NB group, n = 8991) were included in our meta-analysis. OS [hazard ratio (HR) = 1.43 (0.96, 2.12), p = 0.08] and RFS (HR = 1.59 [1.25, 2.01], p = 0.0001) tended to be better in the non-NB group than in the NB group. Pleural recurrence (risk ratio (RR) = 2.40 [1.42, 4.07], p = 0.001) was significantly lower in the non-NB group than in the NB group. The recurrence analysis data did not reach significance, but the overall trend was better for the non-NB group. These findings demonstrate that NB is detrimental to the survival prognosis of lung cancer patients and increases the chance of pleural recurrence. [ABSTRACT FROM AUTHOR]

Introduction: Malignant pleural mesothelioma is difficult to prognosticate. F18‐Fluorodeoxyglucose positron emission tomography (FDG PET) shows promise for response assessment but is confounded by talc pleurodesis. F18‐Fluorothymidine (FLT) PET is an alternative tracer specific for proliferation. We compared the prognostic value of FDG and FLT PET and determined the influence of talc pleurodesis on these parameters. Methods: Overall, 29 prospectively recruited patients had FLT PET, FDG PET and CT‐scans performed prior to and post one chemotherapy cycle; 10 had prior talc pleurodesis. Patients were followed for overall survival. CT response was assessed using mRECIST. Radiomic features were extracted using the MiM software platform. Changes in maximum SUV (SUVmax), mean SUV (SUVmean), FDG total lesion glycolysis (TLG), FLT total lesion proliferation (TLP) and metabolic tumour volume (MTV) after one chemotherapy cycle. Results: Cox univariate analysis demonstrated FDG PET radiomics were confounded by talc pleurodesis, and that percentage change in FLT MTV was predictive of overall survival. Cox multivariate analysis showed a 10% increase in FLT tumour volume corresponded with 9.5% worsened odds for overall survival (P = 0.028, HR = 1.095, 95% CI [1.010, 1.187]). No other variables were significant on multivariate analysis. Conclusion: This is the first prospective study showing the statistical significance of FLT PET tumour volumes for measuring mesothelioma treatment response. FLT may be better than FDG for monitoring mesothelioma treatment response, which could help optimise mesothelioma treatment regimes. [ABSTRACT FROM AUTHOR]

Background: Malnutrition and liver impairment after duodenal switch (DS) are possible and undesired complications, often conservatively treated. However, in specific cases, surgical revision may be necessary. This study aims to describe outcomes achieved by two bariatric surgery centers and address effectiveness and safety of revisional surgical procedures to resolve these complications. Methods: A retrospective chart review was performed in two bariatric surgery centers from 2008 to 2022. Patients who required revisional surgery to treat malnutrition and/or liver impairment refractory to nutritional and total parenteral nutrition intervention (TPN) after duodenal switch were included. No comparisons were performed due to the descriptive nature of this study. Results: Thirteen patients underwent revisional surgery, the mean age was 44.7, the 53.8% were females, and the mean preoperative BMI was 54.7 kg/m2; the mean time between DS and revisional procedure was 26.5 months, and 69.1% of patients were placed on TPN. One patient developed hepatic encephalopathy; one patient presented with ascites, pleural effusion, and renal insufficiency, undergoing reoperation after revisional procedure due to a perforated ileal loop. Mortality rate was 0%; all patients regained weight after the revisional procedure, and the mean total protein and albumin blood levels 12 months after surgery were 6.3 and 3.6 g/dl, respectively. Conclusions: While refractory malnutrition and/or liver failure are rare among patients post-DS, if underdiagnosed and untreated, this can lead to irreversible outcomes and death. All revisional procedures included in this study resulted in improvement of the nutritional status and reversal of liver impairment, with low complication rates. [ABSTRACT FROM AUTHOR]

Background: Congenital Chylothorax (CC) is a rare condition, which is defined as an accumulation of the chyle in the pleural cavity;moreover, it is associated with significant morbidities, including respiratory distress, malnutrition, immunodeficiency, and infections. Case Report: The diagnosis of chylothorax was made upon count cell analysis of the pleural fluid with ≥80% lymphocytesdetected before birth or within 28 days after birth. In this study, we presented five cases of CC infants. They were dischargedfrom our tertiary center at Hedi Chaker Hospital, Sfax, Tunisia, from January 2010 to December 2018. There were three malesand two females. Prenatal diagnosis was made in four cases. There were four full-term newborns and one near-term of 36weeks. Pleural effusion was on the right side in three cases, on the left side in one case, and bilateral in one case. Four casesrequired mechanical ventilation. Somatostatin was indicated in one case. The treatment was successful in four cases. One casepresented a dysmorphic syndrome and died of pneumothorax.Conclusion: The treatment of CC is based on conservative management. Somatostatin or its analog octreotide is considered anadjunctive treatment of CC. However, the refractory cases are treated with chemical pleurodesis or surgical treatment. Wepropose an algorithm for the treatment of CC.

Abstract Background The prolonged air leak is probably the most common complication following lung resections. Around 10–20% of the patients who undergo a lung resection will eventually develop a prolonged air leak. The definition of a prolonged air leak varies between an air leak, which is evident after the fifth, seventh or even tenth postoperative day to every air leak that prolongs the hospital stay. However, the postoperative hospital stay following a thoracoscopic lobectomy can be as short as 2 days, making the above definitions sound outdated. The treatment of these air leaks is also very versatile. One of the broadly accepted treatment options is the autologous blood pleurodesis or “blood patch”. The purpose of this trial is to investigate the impact of a prophylactic autologous blood pleurodesis on reducing the duration of the postoperative air leak and therefore prevent the air leak from becoming prolonged. Methods Patients undergoing an elective thoracoscopic anatomic lung resection for primary lung cancer or metastatic disease will be eligible for recruitment. Patients with an air leak of > 100 ml/min within 6 h prior to the morning round on the second postoperative day will be eligible for inclusion in the study and randomization. Patients will be randomized to either blood pleurodesis or watchful waiting. The primary endpoint is the time to drain removal measured in full days. The trial ends on the seventh postoperative day. Discussion The early autologous blood pleurodesis could lead to a faster cessation of the air leak and therefore to a faster removal of the drain. A faster removal of the drain would relieve the patient from all the well-known drain-associated complications (longer hospital stay, stronger postoperative pain, risk of drain-associated infection, etc.). From the economical point of view, faster drain removal would reduce the hospital costs as well as the costs associated with the care of a patient with a chest drain in an outpatient setting. Trial registration German Clinical Trials Register (DRKS) DRKS00030810. 27 December 2022

Abstract Background Pleurodesis is often performed for air leaks; however, the ideal materials and timing of the procedure remain controversial. We investigated the efficacy of pleurodesis using different materials and timing. Methods We retrospectively reviewed 913 consecutive patients who underwent segmentectomy or lobectomy for non-small cell lung cancer between 2014 and 2021. Pleurodesis efficacy was assessed on the day of chest tube removal. Results Eighty-six patients (9%) underwent pleurodesis for postoperative air leaks. Pleurodesis was performed on a median of postoperative day (POD) 5. Talc was the most frequently used material (n = 52, 60%), followed by autologous blood patches (n = 20, 23%), OK-432 (n = 12, 14%), and others (n = 2, 2%). No difference existed in the number of days from initial pleurodesis to chest tube removal among the three groups (talc, 3 days; autologous blood patch, 3 days; OK-432, 2 days; P = 0.55). No difference in patient background, except for sex, was observed between patients who underwent pleurodesis within 4 PODs and those who underwent pleurodesis on POD 5 or later. Drainage time was significantly shorter in patients who underwent pleurodesis within 4 PODs (median, 7 vs. 9 days; P = 0.004). Conclusions The efficacies of autologous blood patch, talc, and OK-432 would be considered comparable and early postoperative pleurodesis could shorten drainage time. Prospective studies are required.

Abstract Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to healthcare systems. Over the last decades the understanding of pathophysiology mechanisms, diagnostic techniques and optimal treatment intervention in MPE have been greatly advanced by recent high-quality research, leading to an ever less invasive diagnostic approach and more personalized management. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. In the next future, because of a better understanding of underlying tumor biology together with more sensitive molecular diagnostic techniques, it is likely that combined diagnostic and therapeutic procedures allowing near total outpatient management of MPE will become popular. This article provides a review of the current advances, new discoveries and future directions in the pathophysiology, diagnosis and management of MPE.

Abstract Objectives The management for pneumothorax patients involves surgical intervention, nevertheless postoperative recurrences are often encountered. To reduce the rates of recurrence, thoracic surgeons have experimented with various novel techniques, such as pleural abrasion, chemical pleurodesis, and staple line coverage with absorbable sheets, in addition to bullectomy. And in recent years, there have been reports of the effectiveness of the use of intraoperative glucose intrapleural spray (GIS) containing 50 ml of 50% glucose solution in addition to bullectomy. However, information on the effects and adverse events of GIS is limited. Current study was aimed to assess the efficacy and safety of GIS in preventing recurrence of pneumothorax. Patients and methods We conducted a retrospective study with 74 cases of bullectomy with or without GIS between 2018 and 2021 at Okazaki City Hospital. Of these cases, 50 received GIS (GIS group) while 24 were treated conservatively (C group). Result The GIS group consisted of 46 males and 4 females, whereas the C group consisted of 23 males and 1 female, with mean ages of 38.5 ± 5.7 years and 30.5 ± 6.7 years, respectively. The GIS group exhibited a mean increase in blood glucose of 23.8 mg/dL postoperatively, and postoperative infections were observed in 2 cases in the GIS group (4.0%) and 2 cases in the C group (8.3%). The NRS scores of the patients in the GIS group and the C group three hours postoperatively were 4.0 and 3.1, respectively (p = 0.28). No prolongation of postoperative drainage period by GIS was observed (1.2 days and 1.4 days in the GIS and C groups, respectively). Postoperative recurrence occurred in two patients from the C group. The postoperative total drainage volumes were 341.8 ± 25.2 ml and 74.2 ± 25.5 ml in the GIS and C groups, respectively, showing a significant increase in drainage volume (p

Objectives: The management for pneumothorax patients involves surgical intervention, nevertheless postoperative recurrences are often encountered. To reduce the rates of recurrence, thoracic surgeons have experimented with various novel techniques, such as pleural abrasion, chemical pleurodesis, and staple line coverage with absorbable sheets, in addition to bullectomy. And in recent years, there have been reports of the effectiveness of the use of intraoperative glucose intrapleural spray (GIS) containing 50 ml of 50% glucose solution in addition to bullectomy. However, information on the effects and adverse events of GIS is limited. Current study was aimed to assess the efficacy and safety of GIS in preventing recurrence of pneumothorax. Patients and methods: We conducted a retrospective study with 74 cases of bullectomy with or without GIS between 2018 and 2021 at Okazaki City Hospital. Of these cases, 50 received GIS (GIS group) while 24 were treated conservatively (C group). Result: The GIS group consisted of 46 males and 4 females, whereas the C group consisted of 23 males and 1 female, with mean ages of 38.5 ± 5.7 years and 30.5 ± 6.7 years, respectively. The GIS group exhibited a mean increase in blood glucose of 23.8 mg/dL postoperatively, and postoperative infections were observed in 2 cases in the GIS group (4.0%) and 2 cases in the C group (8.3%). The NRS scores of the patients in the GIS group and the C group three hours postoperatively were 4.0 and 3.1, respectively (p = 0.28). No prolongation of postoperative drainage period by GIS was observed (1.2 days and 1.4 days in the GIS and C groups, respectively). Postoperative recurrence occurred in two patients from the C group. The postoperative total drainage volumes were 341.8 ± 25.2 ml and 74.2 ± 25.5 ml in the GIS and C groups, respectively, showing a significant increase in drainage volume (p < 0.01). None of them presented dehydration-related symptoms. Conclusions: The use of intraoperative glucose intrapleural spray is effective and safe in terms of preventing recurrences and postoperative complications. [ABSTRACT FROM AUTHOR]

Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to healthcare systems. Over the last decades the understanding of pathophysiology mechanisms, diagnostic techniques and optimal treatment intervention in MPE have been greatly advanced by recent high-quality research, leading to an ever less invasive diagnostic approach and more personalized management. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. In the next future, because of a better understanding of underlying tumor biology together with more sensitive molecular diagnostic techniques, it is likely that combined diagnostic and therapeutic procedures allowing near total outpatient management of MPE will become popular. This article provides a review of the current advances, new discoveries and future directions in the pathophysiology, diagnosis and management of MPE. [ABSTRACT FROM AUTHOR]

Background: The prolonged air leak is probably the most common complication following lung resections. Around 10–20% of the patients who undergo a lung resection will eventually develop a prolonged air leak. The definition of a prolonged air leak varies between an air leak, which is evident after the fifth, seventh or even tenth postoperative day to every air leak that prolongs the hospital stay. However, the postoperative hospital stay following a thoracoscopic lobectomy can be as short as 2 days, making the above definitions sound outdated. The treatment of these air leaks is also very versatile. One of the broadly accepted treatment options is the autologous blood pleurodesis or "blood patch". The purpose of this trial is to investigate the impact of a prophylactic autologous blood pleurodesis on reducing the duration of the postoperative air leak and therefore prevent the air leak from becoming prolonged. Methods: Patients undergoing an elective thoracoscopic anatomic lung resection for primary lung cancer or metastatic disease will be eligible for recruitment. Patients with an air leak of > 100 ml/min within 6 h prior to the morning round on the second postoperative day will be eligible for inclusion in the study and randomization. Patients will be randomized to either blood pleurodesis or watchful waiting. The primary endpoint is the time to drain removal measured in full days. The trial ends on the seventh postoperative day. Discussion: The early autologous blood pleurodesis could lead to a faster cessation of the air leak and therefore to a faster removal of the drain. A faster removal of the drain would relieve the patient from all the well-known drain-associated complications (longer hospital stay, stronger postoperative pain, risk of drain-associated infection, etc.). From the economical point of view, faster drain removal would reduce the hospital costs as well as the costs associated with the care of a patient with a chest drain in an outpatient setting. Trial registration: German Clinical Trials Register (DRKS) DRKS00030810. 27 December 2022 [ABSTRACT FROM AUTHOR]

Background: Pleurodesis is often performed for air leaks; however, the ideal materials and timing of the procedure remain controversial. We investigated the efficacy of pleurodesis using different materials and timing. Methods: We retrospectively reviewed 913 consecutive patients who underwent segmentectomy or lobectomy for non-small cell lung cancer between 2014 and 2021. Pleurodesis efficacy was assessed on the day of chest tube removal. Results: Eighty-six patients (9%) underwent pleurodesis for postoperative air leaks. Pleurodesis was performed on a median of postoperative day (POD) 5. Talc was the most frequently used material (n = 52, 60%), followed by autologous blood patches (n = 20, 23%), OK-432 (n = 12, 14%), and others (n = 2, 2%). No difference existed in the number of days from initial pleurodesis to chest tube removal among the three groups (talc, 3 days; autologous blood patch, 3 days; OK-432, 2 days; P = 0.55). No difference in patient background, except for sex, was observed between patients who underwent pleurodesis within 4 PODs and those who underwent pleurodesis on POD 5 or later. Drainage time was significantly shorter in patients who underwent pleurodesis within 4 PODs (median, 7 vs. 9 days; P = 0.004). Conclusions: The efficacies of autologous blood patch, talc, and OK-432 would be considered comparable and early postoperative pleurodesis could shorten drainage time. Prospective studies are required. [ABSTRACT FROM AUTHOR]

Background A prevalent clinical issue that can affect people of any age is pneumothorax. Depending on the degree of cardiorespiratory impairment, the severity of the symptoms, and the size of the pneumothorax, the course of treatment might range from conservative to surgical. In this study, we examined the risks of pneumothorax recurrence in individuals with spontaneous pneumothorax using the pleural abrasion and pleurectomy procedures. Patients and methods We did a randomized controlled trial involving 80 patients with spontaneous pneumothorax. Patients were randomly allocated to undergo video-assisted thoracoscopic surgery bullectomy with mechanical pleurodesis; pleural abrasion, or pleurectomy. We compared the incidence of recurrence of spontaneous pneumothorax as a primary outcome, postoperative drainage amount, hospital stay, and mortality as our secondary outcome in both groups. This trial is listed on ClinicalTrials.gov as NCT05407974. Results There were two cases of recurrence of pneumothorax in the pleurectomy group and no recurrence in the pleural abrasion group with P value of 0.152. The drainage amount was higher in the pleurectomy group with mean 230.00±75.79 ml than the abrasion group with mean 192.50±65.58 ml (P=0.020). There was no statistically significant difference between the two groups as regards hospital stay (P=0.556), there were no cases with hospital mortality in both groups. Conclusion Mechanical pleurodesis performed with bullectomy as a technique to reduce the recurrence of spontaneous pneumothorax has proven its efficiency in our study. Despite pleurectomy group showed increase in the drainage amount postoperatively compared with pleural abrasion. There was no difference in the recurrence rates, hospital stay, and in hospital mortality in both groups. Our conclusion does support the adoption of mechanical pleurodesis in patients undergoing bullectomy for spontaneous pneumothorax whether by pleurectomy or pleural abrasion. [ABSTRACT FROM AUTHOR]

Congenital chylothorax is a serious neonatal condition with high mortality and difficult management. Chemical pleurodesis can limit the need for surgical treatment, but there is no consensus on the optimal chemical agent for the lack of solid evidence. We report our experience with povidone-iodine (PVI) chemical pleurodesis in two neonates with congenital chylothorax. Pleurodesis consisted in the injection of 2 ml/kg of a 4% povidone iodine solution inside the pleural space, leaving the pleural tube clamped for the subsequent 4 hours. In both cases, repeated doses of povidone-iodine were required to completely stop chyle formation. Based on our experience, chemical pleurodesis with povidone-iodine promptly and definitely stopped pleural effusion, with no side effect observed. Since its first use in 2003, we provide analysis of all published neonatal case reports concerning PVI chemical pleurodesis in congenital chylothorax (n = 20), with both success and survival rate at 80 %. [ABSTRACT FROM AUTHOR]

Background: Congenital Chylothorax (CC) is a rare condition, which is defined as an accumulation of the chyle in the pleural cavity; moreover, it is associated with significant morbidities, including respiratory distress, malnutrition, immunodeficiency, and infections. Case Report: The diagnosis of chylothorax was made upon count cell analysis of the pleural fluid with ≥80% lymphocytes detected before birth or within 28 days after birth. In this study, we presented five cases of CC infants. They were discharged from our tertiary center at Hedi Chaker Hospital, Sfax, Tunisia, from January 2010 to December 2018. There were three males and two females. Prenatal diagnosis was made in four cases. There were four full-term newborns and one near-term of 36 weeks. Pleural effusion was on the right side in three cases, on the left side in one case, and bilateral in one case. Four cases required mechanical ventilation. Somatostatin was indicated in one case. The treatment was successful in four cases. One case presented a dysmorphic syndrome and died of pneumothorax. Conclusion: The treatment of CC is based on conservative management. Somatostatin or its analog octreotide is considered an adjunctive treatment of CC. However, the refractory cases are treated with chemical pleurodesis or surgical treatment. We propose an algorithm for the treatment of CC. [ABSTRACT FROM AUTHOR]

Objective: This study presents DraiNet, a deep learning model developed to detect pneumothorax and pleural effusion in pediatric patients and aid in assessing the necessity for tube thoracostomy. The primary goal is to utilize DraiNet as a decision support tool to enhance clinical decision-making in the management of these conditions. Methods: DraiNet was trained on a diverse dataset of pediatric CT scans, carefully annotated by experienced surgeons. The model incorporated advanced object detection techniques and underwent evaluation using standard metrics, such as mean Average Precision (mAP), to assess its performance. Results: DraiNet achieved an impressive mAP score of 0.964, demonstrating high accuracy in detecting and precisely localizing abnormalities associated with pneumothorax and pleural effusion. The model's precision and recall further confirmed its ability to effectively predict positive cases. Conclusion: The integration of DraiNet as an AI-driven decision support system marks a significant advancement in pediatric healthcare. By combining deep learning algorithms with clinical expertise, DraiNet provides a valuable tool for non-surgical teams and emergency room doctors, aiding them in making informed decisions about surgical interventions. With its remarkable mAP score of 0.964, DraiNet has the potential to enhance patient outcomes and optimize the management of critical conditions, including pneumothorax and pleural effusion. [ABSTRACT FROM AUTHOR]

Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis. A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model. 23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12–0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = −0.74 days, 95% CI −0.28 to −1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14–1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71–2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant. The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials. • Use of mesh material significantly decreased the incidence of post-operative air leak. • Use of mesh reduces the recurrence rate in the long term. • Polyglycolic acid and vicryl as mesh materials are better than ORC. [ABSTRACT FROM AUTHOR]

Objective: To compare talc poudrage and tetracycline pleurodesis within patients suffering from malignant pleural effusion. Study Design: Controlled Clinical Trial. Setting: Department of Pulmonology, Jinnah Hospital Lahore. Period: September, 2022 up until May, 2023. Material & Methods: 100 individuals, both male and female, ranging in age from 20 to 80 years, diagnosed with malignant pleural effusion confirmed on biopsy were included by nonprobability consecutive sampling. Patients with active pleural infection, hemodynamic instability, systemic infection, serum hematocrit < 25%, hemothorax, chylothorax, multiple etiologies of pleural effusion, prior chemical pleurodesis, sensitivity to study drugs, life expectancy < 1 month, pregnancy and chest X-ray displaying trapped lung post chest tube drainage on the affected side were excluded. The patients were allocated into two groups at random using a lottery system. In group 1, patients received pleurodesis with talc poudrage and in group 2, patients received pleurodesis alongside tetracycline. Success was assessed after 4 weeks of pleurodesis. Results: In this study, mean age in talc group was 58.94±13.6 years and in tetracycline group it was 59.26±13.7 years.65% patients were male and 35% were females. Success was 94% in talc group and 76% in tetracycline group with p-value = 0.012. In terms of adverse effects, there is no statistically significant difference between the two groups. Conclusion: Talc pleurodesis has a higher success rate than the tetracycline pleurodesis. Talc pleurodesis also has less adverse effects than tetracycline pleurodesis. [ABSTRACT FROM AUTHOR]

Objective: Pleuroperitoneal communication (PPC) is an uncommon but serious complication of continuous ambulatory peritoneal dialysis (CAPD). At present, there are many kinds of treatment options, with different effects. We describe our single-institutional experiences in the minimally invasive surgery of pleuroperitoneal communication complicating continuous ambulatory peritoneal dialysis in detail. Methods: Our study consecutively enrolled 12 pleuroperitoneal communication patients complicating CAPD. All patients underwent direct closure of the defective diaphragm and mechanical rub pleurodesis under video-assisted thoracoscopy. What is more, pseudomonas aeruginosa injection was infused into the thoracic cavity postoperatively to further promote pleural adhesion, which was the innovation of our study. Results: After 1.0–8.3 months of CAPD, all 12 patients presented hydrothorax in the right side. All these patients received surgery 7–179 days (18.0 ± 49.5 days) after onset. Bleb-like lesions situated on the diaphragm were discovered in all patients and three patients also had obvious hole on the surface of diaphragm. Pseudomonas aeruginosa injection was infused into the thoracic cavity postoperatively, and three cases showed fever with remission after 2–3 days of symptomatic treatment. The time from surgery to restarting CAPD ranged from 14 to 47 days, with a median of 20 days. There was no recurrence of hydrothorax and transformation to hemodialysis during the follow-up period (median: 7.5 months). Conclusions: Video-assisted thoracoscopic direct closure of the defective diaphragm and mechanical rub pleurodesis plus chemical pleurodesis using pseudomonas aeruginosa injection postoperatively is a safe and effective option for the treatment of pleuroperitoneal communication complicating continuous ambulatory peritoneal dialysis with 100% success rate. [ABSTRACT FROM AUTHOR]

Background: The confirmation of malignant pleural effusions (MPE) requires an invasive procedure. Diagnosis can be difficult and may require repeated thoracentesis or biopsies. F18Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET) can characterize the extent of malignant involvement in areas of increased uptake. Patterns of uptake in the pleura may be sufficient to obviate the need for further invasive procedures. Methods: This is a retrospective review of patients with confirmed malignancy and suspected MPE. Patients who underwent diagnostic thoracentesis with cytology and contemporaneous FDG-PET were identified for analysis. Some underwent confirmatory pleural biopsy. The uptake pattern on FDG-PET underwent blinded review and was categorized based on the pattern of uptake. Results: One hundred consecutive patients with confirmed malignancy, suspected MPE and corresponding FDG-PET scans were reviewed. MPE was confirmed in 70 patients with positive pleural fluid cytology or tissue pathology. Of the remaining patients, 15 had negative cytopathology, 14 had atypical cells and 1 had reactive cells. Positive uptake on FDG-PET was noted in 76 patients. The concordance of malignant histology and positive FDG-PET occurred in 58 of 76 patients (76%). Combining histologically confirmed MPE with atypical cytology, positive pleural FDG-PET uptake had a positive predictive value of 91% for MPE. An encasement pattern had a 100% PPV for malignancy. Conclusion: Positive FDG-PET pleural uptake represents an excellent method to identify MPE, especially in patients with an encasement pattern. This may eliminate the need for additional invasive procedures in some patients, even when initial pleural cytology is negative. [ABSTRACT FROM AUTHOR]

Background: The presence of pleural effusions and ascites in patients is often considered a marker of illness severity and a poor prognostic indicator. This study aims to compare inpatient and outpatient costs of alternative invasive treatments for ascites and pleural effusions. Methods: The retrospective single-institution study included inpatient cases treated for pleural effusion (J90 and J91) or ascites (R18) at the University Hospital Cologne (UHC) in Germany between January 01, 2020, and December 31, 2021. Costs for punctures and indwelling catheter systems (ICSs) as well as pleurodesis were analyzed in different comparator treatment pathways. Real-world data from the UHC tertiary care center were based on diagnosis-related group fees from 2020 to 2021. A simulation of outpatient expenses was carried out to compare inpatient and outpatient costs for each pathway from a payer perspective. Results: A total of 4323 cases (3396 pleural effusions and 1302 ascites) were analyzed. For ascites, inpatient implantation with home care drainage was found to be the most expensive option, with total costs of €1,918.58 per procedure, whereas outpatient puncture was the least expensive option at €60.02. For pleural effusions, the most expensive treatment pathway was pleurodesis at €8,867.84 compared with the least costly option of outpatient puncture resulting in total costs per procedure of €70.03. A break-even analysis showed that outpatient puncture remains the most inexpensive treatment option, and the ICS comprises a cost-saving potential. Longevity of several months with the use of ICSs results in both enhanced quality of life for patients and increased cost savings. [ABSTRACT FROM AUTHOR]

Pleuroperitoneal leak as a cause of pleural effusions in peritoneal dialysis is a rare but important complication to consider in continuous ambulatory peritoneal dialysis (CAPD) patients presenting with recurrent progressive dyspnoea. Generally, these effusions are unilateral and right-sided, resulting in shortness of breath and reduced ultrafiltration volume, which are initially managed by peritoneal rest. We describe a case of bilateral pleural effusions in a 57-year-old female on chronic CAPD who developed recurrent progressive dyspnoea but maintained adequate dialysis output. A chest radiograph revealed bilateral pleural effusions with high glucose content, and scintigraphy confirmed the existence of a definite pleuroperitoneal communication. She was managed by temporary substitution to haemodialysis, followed by suturing of the shunt and successful video-assisted thoracoscopic surgery (VATS) pleurodesis with an aldehyde-based surgical glue. Unexplained recurring dyspnoea in chronic CAPD should raise the suspicion of a possible pleuroperitoneal leak, even in patients without an apparent loss of ultrafiltration. Pleurodesis using an aldehyde-based adhesive was effective and tolerated well by our patient and may be considered in managing cases of recurrent pleural effusion.