Asian Cardiovasc Thorac Ann 2008;16:120-123
© 2008 Asia Publishing EXchange Ltd
Management of Malignant Pleural Effusion Associated with Trapped Lung Syndrome
Rizwan A Qureshi, FRCS,
Sandra L Collinson, MD,
Roy J Powell, MD1,
Peter O Froeschle, FETCS,
Richard G Berrisford, FRCS
Department of Thoracic Surgery
1 Exeter NHS Research and Development Support Unit Royal Devon & Exeter NHS Foundation Trust Exeter, United Kingdom
For reprint information contact: Rizwan A Qureshi, FRCS, Tel: 44 7710 756 103, Fax: 44 121 709 0101, Email: rizwanqureshi2{at}aol.com, 4 Appletree Close, Catherine De Barne, Solihull B91 2TQ, United Kingdom.
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ABSTRACT
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Management of recurrent malignant pleural effusion associated with trapped lung syndrome remains problematic. An alternative treatment using a pleural catheter has been advocated. Between August 1999 and August 2002, 127 patients underwent thoracoscopy for malignant pleural effusion. Of these, 52 (41%) with trapped lung were managed by insertion of a pleural catheter. Mean age was 66 years (range, 42–89 years). The most frequent diagnosis was breast cancer. Spontaneous pleurodesis (drainage < 10 mL) occurred in 25 (48%) patients whose catheter was removed after 30 to 255 days (mean, 93.8 days). Symptomatic relief was achieved in 49 (94%) patients. Mean dyspnea score improved significantly from 3.0 to 1.9. Complications comprised catheter blockage, surgical emphysema, cellulitis, and loculated effusion in 2 patients each. Mean length of hospital stay was 3 days (range, 1–16 days). Median survival was 126 days (range, 10–175 days). We conclude that long-term placement of a pleural catheter provides effective palliation for malignant pleural effusion associated with trapped lung syndrome.
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INTRODUCTION
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Management of the patient with recurrent malignant pleural effusion (MPE) remains problematic. Dyspnea and reduced physical capability severely affect the quality of life. For patients with limited life expectancy, effective palliation requires treatment with a high rate of symptomatic improvement, low procedure-related mortality and morbidity, and a short hospital stay. Local measures include thoracentesis (repeated as necessary) and tube thoracostomy, although neither affords a high probability of long-term control of the effusion.1
The high rate of re-accumulation of fluid after simple drainage is the rationale behind the use of sclerosing agents to attempt to obliterate the pleural space and reduce the likelihood of recurrence. However, the ability of the lung to completely re-expand after fluid evacuation is necessary if the pleural surfaces are to come into contact, an essential prerequisite to pleurodesis. Among sclerosing agents, asbestos-free talc has proved to be superior, with a success rate ranging from 81%–100%, compared to 70%–75% with tetracycline.2,3
Trapped lung syndrome is defined as a recurrent MPE associated with a thickened restrictive cortex that encases the lung and prevents adequate expansion. In these cases, lung reexpansion after fluid drainage is insufficient to achieve pleurodesis, thus an alternative treatment using a pleural catheter has been advocated.4,5 This offers the patient a painless method of draining the effusion whilst remaining at home. We report our early experience with a Pleurx pleural catheter (Denver Biomaterials, Inc., Golden, CO, USA) in the management of recurrent MPE.
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PATIENTS AND METHODS
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From August 1999 to August 2002, 127 patients underwent video-assisted thoracoscopic surgery (VATS) for suspected MPE at the Royal Devon & Exeter Hospital. Inclusion criteria were determined at the time of surgery. Patients with MPE associated with trapped lung were considered eligible for pleural catheter treatment. Patients in whom lung expansion was adequate to fill the hemithorax and allow apposition of visceral and parietal surfaces were considered eligible for talc insufflation pleurodesis. Exclusion criteria were loculated effusion associated with pleural space infection, coagulopathy and chylous effusion. Tube thoracostomy was considered an appropriate option for pleural effusion associated with infection, and talc pleurodesis was considered appropriate for pleural effusion associated with coagulopathy and chylous effusion. Talc pleurodesis was carried out in 75 patients, and 52 had pleural catheter treatment. Of these 52 patients, 22 were male. Their mean age was 66 years (range, 42–89 years). There was left-sided effusion in 27, and right-sided effusion in 25. In the pleural catheter group, 45 (87%) patients had been treated by one or more modality before referral (Table 1
). All such cases were treated in conjunction with oncological colleagues who supervised other therapy, where appropriate. Diagnoses are given in Table 2. The most frequent neoplasms were breast cancer and malignant mesothelioma. We used the UK Medical Research Council (MRC) dyspnea score on admission, early postoperatively, and at serial follow-up examinations to assess the outcome of this procedure.6
The Pleurx pleural catheter consists of a 15.5F silicone catheter, 66 cm in length, with fenestrations along its proximal 25.5 cm. More distally, there is a polyester cuff, and at the end of the catheter there is a latex rubber valve mechanism. This valve is designed to prevent the passage of air or fluid in either direction, unless accessed by the matched drainage line provided in the kit. The access tip of the line is inserted into the valve when pleural fluid drainage is required. After induction of general anaesthesia, rigid bronchoscopy was performed in selected patients to exclude endobronchial obstruction. The pleural space was examined by VATS. The pleural effusion was drained, and adhesions were divided using blunt dissection. The degree of lung expansion was assessed with sustained positive-pressure ventilation at 25–40 cm H2O. The fenestrated end of the catheter was placed in the pleural cavity through a VATS 10-mm camera port. A further 5-mm skin incision was made approximately 5-cm anterior to the VATS port, and a subcutaneous tunnel was created between the 2 incisions. The catheter was drawn through the tunnel until the polyester cuff was approximately 1 cm beyond the anterior incision. The tunneler was removed from the catheter which was secured with 2/0 Prolene sutures, and the skin incisions were closed with interrupted 4/0 nylon sutures, leaving the catheter and valve projecting from the skin. Initial drainage was performed with –10 kPa suction to prevent trapping of air in the pleural cavity. The cap was applied to the safety valve, and the catheter was secured on a foam catheter pad and 8 gauze pads.
Postoperative chest radiographs were assessed in the recovery room. Routine oncology review was undertaken to determine the need for VATS port-site radiotherapy to prevent translocation of malignant cells into the pleural catheter. Drainage was performed by a nurse at home, initially 3 times a week for the first 3 weeks. The subsequent drainage regime depended on drainage volume. The patients were routinely seen in the thoracic surgical clinic in the first 2 weeks postoperatively, where the MRC dyspnea score was assessed, with follow-up thereafter as necessary. As the amount of drainage reduced and pleurodesis (in selected cases) was achieved, the catheter was removed in the outpatient clinic under local anesthesia.
The data were analyzed using SPSS version 9.0 for windows 95 (SPSS, Inc., Chicago, IL, USA). Where data are normally distributed, means and 95% confidence intervals are applied, otherwise medians are given. Survival was estimated using Kaplan-Meier survival analysis. Log-rank tests were used for comparing survival distributions. Symptomatic relief, which was measured using paired before-and-after MRC dyspnea scores, was evaluated using the Wilcoxon matched pairs signed ranks test.
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RESULTS
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Follow-up data were available for all patients. There was compliance with treatment in 50 of the 52 cases (96.2%). Symptomatic relief was achieved in 49 (94.2%) patients. Spontaneous pleurodesis was obtained in 22 (42.3%) patients whose catheters were removed after 30 to 255 days (mean, 93.8 days). There was a significant reduction in mean MRC dyspnea score from 3.0 to 1.9 ( p < 0.001); 46 (88.5%) patients had lower scores after treatment, 5 had the same score, and only one had an increased score. Complications occurred in 8 (15.4%) patients (Table 3). Six patients experienced chest pain on initial drainage, which subsided on subsequent drainage. Pain was generally well controlled with analgesic medication, which should be given before the first few drainage procedures. There was no tumor seedling of the catheter tract.
The mean hospital stay was 3 days (range, 1–16 days). One patient stayed for 16 days because she was awaiting a palliative mastectomy for fungating breast cancer, another stayed for 15 days because of social circumstances. There was no intraoperative death. There were 4 early deaths (within 30 days): 3 due to disease progression, and one from pulmonary embolism (hospital mortality rate, 7.5%). The median survival of evaluated patients was 126 days (range, 77–175 days). Survival varied according to diagnosis; those with breast cancer and mesothelioma survived longer, having median survival times of 202 days (range, 117–287 days) and 144 days (range, 58–230), respectively.
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DISCUSSION
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When a patient is seen with a symptomatic recurrent pleural effusion, treatment options include serial thoracentesis, tube thoracostomy with chemical pleurodesis, thoracoscopy with chemical pleurodesis, decortication, thoracotomy decortication/pleurectomy, pleuroperitoneal shunt, or long-term indwelling tunneled pleural catheter.4,5,7–11 Factors that should be considered when choosing the most appropriate treatment include patient acceptance, convenience, symptom relief, hospitalization time, complications, success rate, cost and performance status. We believe initial assessment with VATS is important to identify those with trapped lung. It offers complete evacuation of the pleural cavity and visualizes the appropriate pleural surface for diagnostic biopsies. Furthermore, adhesions may be broken up to assist complete lung expansion. In patients with complete lung expansion, thoracoscopic pleurodesis allows optimal preparation of the pleural surface and homogeneous distribution of talc under vision, maximizing the chance of complete pleurodesis.7 If the lung is trapped, there is increased negative intrapleural pressure, with filling of the pleural cavity until the balance of hydrostatic pressure is restored, resulting in recurrent pleural effusion. An alternative treatment is intermittent or continuous drainage with a chronic indwelling catheter, as in this study.
It might be argued that some patients might not be fit to undergo initial thoracoscopy. Our policy in this cohort is to carry out pleural catheter insertion by the Seldinger technique under local infiltration. We managed 15 patients with this technique, of whom 10 had previously been treated with a chest drain. Primary histology was malignant mesothelioma in 7, breast cancer in 3, lymphoma in 3 and lung cancer in 2. There was compliance in 13 patients, and subsequent symptomatic relief in 12 of them. Morbidity occurred in 2 patients, and spontaneous pleurodesis was evident in 8. The initial report of pleural catheter insertion under radiologic guidance was encouraging, but experience is limited.4 Video-assisted thoracoscopic surgery decortication with its associated high morbidity is not considered appropriate in these patients with poor performance status.12,13 Pleuroperitoneal shunting was suggested for trapped lung, but high morbidity, shunt failure, translocation of tumor cells into the peritoneal cavity, and less patient compliance limited its widespread use.11,13,14 We previously used a Denver shunt for MPE associated with trapped lung and found that patients had difficulties in using the shunts. We agree with Bernard and colleagues9 that thoracotomy for decortication/pleurectomy for trapped lung should be avoided in patients with limited life expectancy as it has been associated with prolonged air leak, longer hospital stay, 23% morbidity and 10% hospital mortality.9,10
The patients’ subjective opinions of the pleural catheter have not been described previously. The interview showed nearly 97% compliance and 95% symptomatic relief in this series. We agree with Clementsen and colleagues15 that small-bore percutaneous catheters are well tolerated, more comfortable, safe and effective. It is noteworthy that spontaneous pleurodesis occurred in nearly 50% of patients treated with the indwelling pleural catheter, by unknown mechanisms. When patients are treated with tube thoracostomy for several days, pleurodesis will develop in a significant proportion.16,17 In contrast, it is very uncommon for patients who are treated with serial therapeutic thoracenteses to develop spontaneous pleurodesis.1 We believe that 2 conditions are necessary to induce spontaneous pleurodesis: the pleural space must be completely drained, and there must be inflammation in the pleural space. Placement of a chest tube results in pleural inflammation. The pleural catheter has a polyester cuff to promote fibrosis along a subcutaneous tunnel. This enhances stability and may retard internal migration of infective organisms. It also has the safety feature of a one-way valve, limiting the risk of pneumothorax or accidental leakage of pleural fluid. The use of vacuum drainage should promote more thorough and rapid aspiration of fluid than gravity drainage, although it is necessarily an intermittent type of drainage.
In this series, 15.4% of patients experienced a complication after discharge from hospital, which is comparable with other studies.12 These additional complications seem minor compared to the extended hospital stay or repeated admissions with other modalities. Tumor seedling through the catheter tract is a potentially serious complication.13 However, we believe it can be prevented by routine radiotherapy to the catheter tract, irrespective of histology. One potential concern over long-term drainage is the possibility of nutritional depletion caused by protein and lipid loss. The often debilitating nature of these patients’ diseases makes this difficult to assess. A dietitian’s assessment with appropriate nutritional supplements should be considered in selected cases.
On the basis of this experience, we conclude that a long-term pleural catheter is an appropriate option in MPE associated with trapped lung syndrome. Patient acceptance is good, symptoms are relieved, the success rate is high and the associated complications are mostly minor. Thus the quality of their limited life is improved.
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REFERENCES
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ABSTRACT
INTRODUCTION
