Suction is maintained on the chest tubes for a period of 24 to 48 hours. The drains are removed after radiologic evidence of lung expansion has been obtained and the fluid drainage level diminishes to less than 100 mL per day.5,12,15,16 For postoperative pain management, nonsteroidal anti-inflammatory drugs can be used,17 or an epidural catheter can be placed at the time of the operation.
Thoracoscopy is a safe and well-tolerated procedure with a low perioperative mortality rate (0.5%).4 The success rate for VATS pleurodesis (30-day freedom from radiographic evidence of malignant pleural effusion and equal to or greater than 90% expansion of the lung at the time of the procedure) is greater than 90%.4,15,17 In a large randomized study by Dresler et al.18 of talc poudrage (n = 251) versus talc slurry (n = 250), between 68% and 73% of the patients were able to have complete expansion of their lungs at the time of the procedure. Although there were no differences in recurrence among all the patients in the study, there was a slight improvement in the thoracoscopic success of talc poudrage (67%) compared with talc slurry (56%) with respect to complete lung reexpansion (p = 0.045). Respiratory complications (atelectasis, pneumonia, or respiratory failure) of thoracoscopic pleurodesis were observed more commonly in patients undergoing thoracoscopic pleurodesis as opposed to talc slurry (14% vs. 6%, respectively, p = 0.007), and were the most frequent causes of treatment-related deaths (2% to 3%). Dyspnea and pain are the most common complications of the procedure. Others include postoperative fever, persistent air leak, bleeding, subcutaneous emphysema, reexpansion pulmonary edema, deep vein thrombosis, and port-site recurrence of malignancy. The latter is seen in some mesothelioma patients, and controversy remains as to whether these recurrences can be prevented by postoperative local radiotherapy.4 In general, it is thought that thoracoscopic pleurodesis has the advantage of assessing lung expansion at the time of the operation and is associated with better results in breast and lung cancer effusions, however, bedside talc slurry injection is a simpler and less invasive technique.
Indwelling Pleural Catheter
The PleurX Catheter System (CareFusion Corp., San Diego, CA) is a soft Silastic chronic indwelling catheter. It is a 66-cm-long, 15.5 F flexible silicone rubber catheter with fenestrations along the distal 24 cm. A valve at the proximal end prevents inadvertent leakage of pleural fluid or entry of air. A polyester cuff is situated approximately 14 cm from the proximal end and lies within a subcutaneous tract to decrease bacterial dislocation and to anchor the catheter in position. Insertion of the PleurX catheter can be accomplished in the outpatient setting under local anesthesia. With careful monitoring, it is possible to accomplish complete drainage of the effusion at the time of placement. The patient or caregiver then drains the pleural fluid periodically by connecting the tubing to a disposable vacuum container to provide relief of dyspnea and potentially achieve spontaneous pleurodesis (Fig. 120-2A).
A. PleurX Catheter System, a vacuum device and setup for home management of recurrent pleural effusions. B. Positioning and placement of PleurX catheter for pleural effusions.
After localization of the pleural fluid by needle and administering a local anesthetic, the catheter is inserted using a modified Seldinger technique as follows. A flexible wire is passed through the needle into the thorax, and a 1.5-cm horizontal incision is made at this site (Fig. 120-2B). A counter-horizontal incision is made approximately 5 cm inferiorly and medially to the wire, and a subcutaneous tunnel is created for the pleural catheter. The catheter is drawn through the tunnel, and the Teflon cuff is placed within the tunnel, 1 cm away from the skin edge. A peel-away sheath over a removable stylet (dilator) is inserted over the wire and placed into the thorax. The stylet is withdrawn, and the catheter is threaded through the sheath into the thorax. The peel-away sheath is then withdrawn leaving the catheter in situ. The two skin incisions are closed with interrupted nonabsorbable sutures, and the catheter is secured to the skin. After insertion, 1000 to 1500 mL pleural fluid should be drained. A chest x-ray is obtained to confirm the position of the catheter and to rule out a pneumothorax, after which the patient is sent home.
Detailed written and oral instructions for home catheter care and drainage should be provided to patients and their caregivers. Complications of indwelling pleural catheter placement include local cellulitis, catheter obstruction, and pleural infection. Tumor seeding can be seen in some patients.
At home, patients should drain no more than 1000 to 1500 mL at a time to prevent reexpansion pulmonary edema. Drainage should be performed at a frequency that will prevent or relieve their dyspnea. If over time the output diminishes to less than 50 mL per day for three consecutive days, the catheter can be removed. If the catheter does not drain but the patient is still dyspneic, chest x-ray or CT scan should be performed to rule out a nondraining effusion. By using this method, spontaneous pleurodesis can be achieved in 46% to 70% of patients.3,8,19,20
The clinical course in a patient with mesothelioma receiving palliative care for a malignant pleural effusion is depicted in Figure 120-3.
Use of a PleurX catheter to palliate mesothelioma. A. CT scan reveals no evidence of right pleural effusion 12 months after left extrapleural pneumonectomy. B. Five months later, the patient presents with dyspnea and a large right cytologically malignant effusion. C. PleurX catheter is placed without difficulty under conscious sedation with complete drainage of the effusion.
Pleuroperitoneal shunt (Denver Biomedical, Inc., Golden, CO) insertion can provide effective and safe palliation for malignant pleural effusion when associated with the trapped lung syndrome. Since the development and manufacture of the PleurX catheter, use of this shunt has decreased dramatically. This procedure can be done under local or general anesthesia with either VATS or open thoracotomy depending on if there have been multiple previous interventions in the pleura, which may cause pleural adhesions. After the fluid has been drained and the entire pleura thoroughly examined, the degree of lung expansion is assessed. If it is not adequate to fill the entire hemithorax, pleuroperitoneal shunt can be an option for palliation.
A 3-cm transverse incision is made in the ipsilateral rectus sheath to expose the peritoneal cavity. The pleuroperitoneal shunt is tunneled under the skin from the chest to the abdomen, with the pumping chamber lodged in a subcutaneous pocket overlying the costal margin. The pleural and peritoneal limbs are then introduced into the respective cavities under direct vision. Normal saline can be introduced into the pleural space to prime the pump and check shunt function. The site of the pump can be marked on the skin to facilitate pumping by the nurse or the patient.10 Palliative efficacy should be monitored by chest x-ray films.
Common complications of pleuroperitoneal shunting are shunt occlusion and wound infection. Other complications are owing to surgical technique and anesthesia. Tumor implantation into the peritoneal cavity is rare but can occur.10,20,21