Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome

OBJECTIVE: This study aimed to assess prospectively the accuracy, safety and outcome of flex-rigid pleuroscopy in the diagnosis of patients with indeterminate pleural effusions. METHODS: Included in the study were all patients with unilateral exudative pleural effusions of unknown aetiology who underwent diagnostic flex-rigid pleuroscopy from July 2003 to June 2005, and were followed until December 2005. The procedure was conducted in the endoscopy suite under local anaesthesia and, where indicated, talc poudrage was carried out at the same time. Clinical data, length of hospitalization, chest tube drainage, outcome, diagnostic accuracy of pleuroscopy and procedure-related adverse events were recorded prospectively. RESULTS: Fifty-one patients were recruited (20 male and 31 female). Median age was 53 years (range 45-67). Flex-rigid pleuroscopy was 96% accurate and yielded a diagnosis in 49 out of 51 patients. It was safely carried out without need for surgical intervention, blood transfusion or endotracheal intubation. Culture-negative fever was observed in eight patients (16%), and five patients (10%) required additional analgesia for postoperative pain. Duration of chest tube drainage and length of stay for patients who underwent diagnostic pleuroscopy were 1 and 2 days, respectively, while they were both 3 days when talc poudrage was carried out. Success rates with pleuroscopic talc pleurodesis for malignant pleural effusions were 94%, 92% and 89.5% at 3, 6 and 12 months, respectively, and the 30-day mortality was 0%. CONCLUSION: Flex-rigid pleuroscopy is a safe procedure with a high diagnostic accuracy and should be considered for the evaluation of indeterminate pleural effusion.     

Rigid and semirigid pleuroscopy: the future is bright

Abstract:   Pleuroscopy provides the pulmonologist with a unique opportunity to visualize the contents of the pleural space, perform biopsy of the parietal pleura under direct visual guidance, allow optimal chest tube placement and perform pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. We discuss the techniques, indications, contraindications and complications of pleuroscopy using rigid and semirigid instruments. In addition, the potential value and expanding role of pleuroscopy with semirigid instrumentation is debated.     

胸腔镜下胸膜固定术治疗恶性胸腔积液的疗效分析

目的探讨内科胸腔镜下滑石粉胸膜固定术治疗恶性胸腔积液的疗效。方法我科收治的48例中-大量恶性胸腔积液患者随机分为两组,实验组25例行内科胸腔镜下滑石粉胸膜固定术,对照组23例经常规胸腔闭式引流后于胸腔内灌注滑石粉。经胸膜固定后,对于PS 0-2分的患者均予全身化疗2周期。随访复查胸CT及B超,观察12周的胸水控制情况,并对两组的疗效及不良反应进行统计学分析。结果实验组有效率92.0%（23/25）、完全缓解率84.0%（21/25）,对照组有效率60.9%（14/23）、完全缓解率43.5%（10/23）,二者具有显著性差异。不良反应中,胸痛实验组高于对照组,差异有统计学意义;发热两组无统计学差异。结论内科胸腔镜下滑石粉胸膜固定术治疗恶性胸腔积液疗效好,且具有安全、微创特点,值得临床推广。     

Medical thoracoscopy in an Australian regional hospital

Medical thoracoscopy is not widely available in Australia. A medical thoracoscopy service has been set up in a regional hospital using no specialized equipment and at minimal cost. Of the first 100 procedures carried out, 89 were for investigation of pleural effusion, 6 for pneumothorax and 6 for empyema. Of the 89 pleural effusions, 73 were diagnosed as malignant (43 carcinoma, 24 mesothelioma, 3 lymphoma, 2 melanoma and 1 sarcoma). The sensitivity for a malignant diagnosis was 94.5%, with 100% specificity. Four patients had unsuspected tuberculous effusions. Pleurodesis was carried out with instillation of dry sterile talc in 67 cases. In 92.5% of these, no further drainage procedure was needed. There was one fatality caused by pre-existing sepsis in a debilitated patient with disseminated carcinoma. Medical thoracoscopy is a simple, safe and cost-effective technique for diagnosing and treating pleural effusions and provides a useful service in the setting of a regional hospital.     

可弯曲式内科胸腔镜在恶性胸膜间皮瘤中的诊断价值

目的探讨可弯曲式胸腔镜对恶性胸膜间皮瘤的诊断价值。方法对30例不明原因胸腔积液患者进行胸腔镜检查。全麻下于腋部胸壁第6～7肋间置入胸腔镜套管,吸去大部分胸腔积液后按照内、前、上、后、侧、下的顺序观察胸膜腔并进行胸膜活检。结果 30例患者中有6例经直视下取活检病理证实为恶性胸膜间皮瘤。结论胸膜间皮瘤,单纯依靠影像学诊断较为困难,通过内科胸腔镜可在直视下取到理想的胸膜组织,提高了诊断阳性率。     

可弯曲内科胸腔镜术对恶性胸腔积液的诊治价值

目的探讨可弯曲内科电子胸腔镜在诊治恶性胸腔积液中的价值。方法经可弯曲内科电子胸腔镜检查确诊的118例恶性胸腔积液的临床资料进行了分析,118例中55例经内科胸腔镜行滑石粉喷洒胸膜固定术。结果 118例均经胸膜活检病理确诊,包括肺癌胸膜转移106例(腺癌74例、鳞癌22例、小细胞癌7例、大细胞癌1例、病理未能分型2例),其他部位胸膜转移6例,胸膜间皮瘤4例,胸膜淋巴瘤2例。胸膜病变主要表现为大小不等的结节、肿块、扁平隆起、白斑、胸膜充血等。胸腔镜下滑石粉胸膜固定术组的胸水控制率为96.4%(53/55),通过胸腔闭式引流管注药的对照组胸水控制率为67.3%(37/55),两组疗效相差显著(P0.01)。胸膜固定术患者术后出现胸痛52例、发热45例,均对症治疗后好转,118例均未发现严重并发症。结论可弯曲内科电子胸腔镜术诊治恶性胸腔积液是一种安全、微创、高效而实用的方法,值得临床广泛推广。     

Clinical implications of pleural effusions in ovarian cancer

The pleural cavity constitutes the most frequent extra‐abdominal metastatic site in ovarian carcinoma (OC). In patients with OC and pleural effusions, a positive fluid cytology is required for a stage IV diagnosis. Unfortunately, about 30% of malignant pleural effusions exhibit false‐negative cytological pleural fluid results. In those circumstances, exploratory video‐assisted thoracoscopic surgery (VATS) serves as a diagnostic, staging and even therapeutic modality. Maximal (no visible disease) or, at least, optimal (no residual implant greater than 1 cm) cytoreduction should be the primary surgical goal in stage IV OC patients. This is due to residual tumour after cytoreductive surgery being one of the most important factors impacting on survival. Although malignant pleural effusions do not preclude abdominal surgical debulking, excision of gross pleural nodules may be necessary to achieve optimal cytoreduction. VATS quantifies pleural tumour burden and allows for intrathoracic cytoreduction or, if the latter is not feasible, ensures that abdominal surgery is not unnecessarily performed on women in whom gross tumour would still remain in the pleural space afterwards. Taxane‐platinum neoadjuvant chemotherapy should be offered to this group. Patients with tumour extension into the pleural space have a median overall survival of 2 years.     

Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single‐centre experience

Background and objective

Malignant pleurisy is associated with advanced oncological disease and dyspnoea is the most common presenting symptom. Pleurodesis is the preferred palliative and supportive treatment option, targeting symptom relief. The identification of clinical and endoscopic features that determine the success of talc pleurodesis in malignant pleurisy could guide clinical decision‐making.

Methods

All symptomatic patients with malignant pleurisy subjected to talc pleurodesis through medical thoracoscopy between January 2012 and December 2015 were included. Univariate and multivariate analyses were performed to identify factors associated with successful pleurodesis.

Results

Of the 155 patients, 122 (78%) were classified as having a successful pleurodesis based on clinical and radiological criteria. Factors associated with unsuccessful pleurodesis (univariate analysis) were the presence of pleural adhesions (odds ratio (OR): 0.43 (95% CI: 0.19–0.96); P = 0.04), extensive spread of pleural lesions (OR: 0.17 (95% CI: 0.05–0.59); P = 0.001), the use of systemic corticosteroids (OR: 0.28 (95% CI: 0.10–0.83); P = 0.02) and a prolonged time period between the clinical diagnosis of the pleural effusion and the moment of pleurodesis (OR: 0.14 (95% CI: 0.06–0.32); P < 0.0001). The latter being associated with failure of pleurodesis in a multivariate analysis (OR: 0.08 (95% CI: 0.01–0.25); P < 0.0001). Chest ultrasound prior to pleurodesis showed a sensitivity of 91% and a specificity of 88% in predicting the success of pleurodesis.

Conclusion

The success rate of pleurodesis in malignant pleurisy could potentially be enhanced by correct patient selection and early referral for pleurodesis. Ultrasonic assessment of pleural adhesions and potential lung expansion prior to pleurodesis is useful in clinical decision‐making.

     

红霉素胸膜固定术对难治性胸膜疾病的治疗价值

目的探讨红霉素胸膜固定术对难治性胸膜疾病（恶性胸腔积液、复发性气胸）的治疗价值。方法经胸腔闭式引流管将红霉素0．75～1．0g溶于5％葡萄糖40ml溶液注入到胸膜腔治疗复发性气胸18例,恶性胸腔积液12例为治疗组,以同期14例复发性气胸,10例恶性胸腔积液用胸腔穿刺抽气、抽液和（或）胸腔闭式引流的治疗方法为对照组。结果以红霉素为硬化剂的胸膜固定术治疗30例难治性胸膜疾病均痊愈或好转出院,30例患者均随访,治疗组18例气胸中2例复发,复发率11．1％,较对照组43．3％差异有显著性（P〈0．05）。治疗组12例恶性胸腔积液0．5及1年生存率分别为100％、75％分别高于对照组的60％、20％,两者均有显著性差异（P〈0．05）。结论红霉素可作为一种有效的胸膜硬化剂治疗复发性气胸、恶性胸腔积液。     

Interventional therapies for malignant pleural effusions: The present and the future

The approach to management of malignant pleural effusions (MPE) has changed over the past few decades. The key goals of MPE management are to relieve patient symptoms using the least invasive means and in the most cost‐effective manner. There is now a realization that patient‐reported outcome measures should be the primary goal of MPE treatment, and this now is the focus in most clinical trials. Efforts to minimize patient morbidity are complemented by development of less invasive treatments that have mostly replaced the more aggressive surgical approaches of the past. Therapeutic thoracentesis is simple, effective and generally safe, although its benefits may only be temporary. Pleurodesis is the conventional and for a long time the only definitive therapy available. However, the efficacy and safety of talc pleurodesis has been challenged. Indwelling pleural catheter (IPC) drainage is increasingly accepted worldwide and represents a new concept to improve symptoms without necessarily generating pleural symphysis. Recent studies support the effectiveness of IPC treatment and provide reassurance regarding its safety. An unprecedented number of clinical trials are now underway to improve various aspects of MPE care. However, choosing an optimal intervention for MPE in an individual patient remains a challenge due to our limited understanding of the underlying pathophysiology of breathlessness in MPE and a lack of predictors of survival and pleurodesis outcome. This review provides an overview of common pleural interventional procedures used for MPE management, controversies and limitations of current practice, and areas of research most needed to improve practice in future.     

Diagnosis and management of malignant pleural effusions

Abstract:   Malignant pleural effusions (MPEs) complicate the clinical course of patients with a broad array of malignancies, which are most often due to lymphomas or carcinomas of the breast, lung, gastrointestinal tract or ovaries. Patients may present with a MPE as the initial manifestation of a cancer or develop an effusion during the advanced phases of a known malignancy. In either circumstance, the median survival after presentation with a MPE is 4 months. Effusions may result from direct pleural invasion (MPE) or indirect effects (paraneoplastic effusions), such as impairment of fluid efflux from the pleural space by lymphatic obstruction or pleural effects of cancer radiation or drug therapy. Because only 50% of patients with cancer who develop a pleural effusion during their clinical course have a MPE, careful evaluation of the effusion to establish its aetiology is required to direct therapy. Management is palliative with interventions directed towards decreasing the volume of intrapleural fluid and the severity of associated symptoms.     

Pleural procedures and pleuroscopy

Pleural procedures are commonly performed by physicians from a range of specialities. These procedures vary in complexity, from relatively straightforward pleural aspiration to more challenging procedures such as pleuroscopy. After appropriate training, even complex pleural procedures have a low risk of complications. Nevertheless, an appreciation of procedural risks is essential for physician training and forms the crux of a valid patient consent process. This review presents a systematic evaluation of the potential complications of common pleural procedures.     

Pleural controversy: pleurodesis versus indwelling pleural catheters for malignant effusions

Malignant pleural effusions (MPE) are a common complication of advanced malignancy. The treatment of MPE should be focused on palliation of associated symptoms. The traditional approach to MPE has been to attempt pleurodesis by introducing a sclerosant into the pleural space. A more recent development in the treatment of MPE has been the use of indwelling pleural catheters (IPC) for ongoing drainage of the pleural space. Controversy exists as to which approach is superior. Pleurodesis approaches will have the advantage of a time-limited course of treatment and high pleurodesis rate at the cost of a more invasive procedure requiring a general anaesthetic or conscious sedation (for thoracoscopic approaches) and an inpatient hospital stay. Use of IPC will allow the patient to be treated on an outpatient basis with a minimally invasive procedure, at the cost of long-term need for catheter drainage and care. Symptom control appears similar between techniques. Complication rates between the two approaches cannot be easily compared, but studies suggest more frequent severe complications such as respiratory failure, arrhythmias and even mortality following pleurodesis, with infection rates similar between the two approaches. IPC will likely see increasing utilization in the future but patient preference and local resources and expertise will continue to play a significant part in treatment decisions. Randomized trials directly comparing the two approaches are needed and some are underway. Novel combination approaches utilizing both IPC and pleurodesis agents have the potential to further improve the care of these patients.     

内科胸腔镜对恶性胸腔积液诊治的临床研究

目的探讨内科胸腔镜在恶性胸腔积液诊治中的临床应用效果。方法对我科以恶性胸腔积液住院的患者,分为胸腔镜组及对照组,对诊治结果进行诊断分析,评价内科胸腔镜对恶性胸腔积液的诊断阳性率和治疗恶性胸腔积液的临床疗效。结果胸腔镜组确诊率为92.9%,对照组确诊率为69.05%。两组患者的治疗效果比较,其完全缓解率具有统计学意义(P<0.05)。结论内科胸腔镜对恶性胸腔积液进行胸膜活检,诊断率阳性率高,在治疗方面,胸腔镜下胸膜固定术能够有效地控制恶性胸腔积液的产生,效果明显优于传统胸腔引流术,值得临床广泛推广应用。     

Pleural effusions and pneumothorax: Beyond simple plumbing

Pleural diseases affect millions of people worldwide. Pleural infection, malignant pleural diseases and pneumothorax are common clinical challenges. A large number of recent clinical trials have provided an evidence‐based platform to evaluate conventional and novel methods to drain pleural effusions/air which reduce morbidity and unnecessary interventions. These successes have generated significant enthusiasm and raised the profile of pleural medicine as a new subspecialty. The ultimate goal of pleural research is to prevent/stop development of pleural effusions/pneumothorax. Current research studies mainly focus on the technical aspects of pleural drainage. Significant knowledge gaps exist in many aspects such as understanding of the pathobiology of the underlying pleural diseases, pharmacokinetics of pleural drug delivery, etc. Answers to these important questions are needed to move the field forward. This article collates opinions of leading experts in the field in highlighting major knowledge gaps in common pleural diseases to provoke thinking beyond pleural drainage. Recognizing the key barriers will help prioritize future research in the quest to ultimately cure (rather than just drain) these pleural conditions.     

What is the significance of non‐specific pleuritis? A trick question

Non‐specific pleuritis (NSP) is defined as fibrinous or inflammatory pleuritis which cannot be attributed to a specific benign or malignant etiology. It can be diagnosed in biopsies in up to 30% of cases of exudative pleuritis after thoracoscopy, with a mean of 19.2%. In 66 out of 469 (14.2%) patients in combined series, a malignant pleural disease (mostly mesothelioma) was found during a follow‐up of at least 21 months. Most likely, a follow‐up time of 12 months is sufficient, although the current routine is a follow‐up of 2 years. Because of a benign course in 85% of patients with NSP, a repeated invasive procedure after thoracoscopy is only indicated in a limited group of patients. The most important indications for a repeated pleural biopsy are persistent chest pain, recurrent pleural effusion, radiologic findings suggestive for malignant pleural disease.     

电视胸腔镜胸膜固定术治疗恶性胸腔积液的疗效观察

目的 探讨电视胸腔镜胸膜固定术治疗恶性胸腔积液的疗效.方法 选取我院因各种原因导致并经病理诊断确诊为恶性胸腔积液的患者50例,随机分为两组,观察组采用电视胸腔镜胸膜固定术治疗,对照组采用胸腔闭式引流手术治疗.观察两组患者有效率、缓解率情况,以及胸腔积液中白细胞、总蛋白定量及乳酸脱氢酶（LDH）的改善情况.结果 观察组患者总有效率为96.0%,完全缓解率为92.0%,明显高于对照组的64.0%和32.0%,差异具有统计学意义,P〈0.05.且治疗后两组患者积液检查的白细胞、蛋白含量以及乳酸脱氢酶的量都显著降低,但观察组降低幅度明显高于对照组,差异具有统计学意义.P〈0.05.结论 电视胸腔镜胸膜固定术治疗恶性胸腔积液效果显著,且安全性高,值得推荐.