Diseases of the pleura: the use of talc for pleurodesis

Risk factors related to pleural empyema after talc slurry pleurodesis

OBJECTIVE

Empyema is a complication of talc-pleurodesis that may lead to further surgical intervention and death. Therefore, the present study's objective was to identify the risk factors for the development of post-pleurodesis empyema after talc slurry pleurodesis in order to better select patients for this procedure and minimize its morbidity.

METHODS

Patients with malignant pleural effusion who underwent talc slurry pleurodesis at the present institution from January 2018 to January 2020 were retrospectively analyzed. Post-pleurodesis empyema was defined as pleural infection up to 30 days after pleurodesis. Using Cox regression analysis, significant prognostic factors for the development of empyema were examined.

RESULTS

Of the 86 patients identified for inclusion in the study, 62 were women (72%). Their mean age was 56.3±12.6 years. The median pleural drainage time was 9 days, and 20 patients (23.3%) developed empyema. In the univariate analysis, both drainage time (p = 0.038) and the use of antibiotics prior to pleurodesis (p < 0.001) were risk factors for pleural empyema. Multivariate analysis also identified the use of antibiotics as an independent risk factor (Odds Ratio [OR] 9.81; 95% Confidence Interval [95% CI] 2.87‒33.54). Although the pulmonary expansion was not associated with empyema in the multivariate analysis, patients with less than 50% pulmonary expansion had a 4.5-times increased risk of empyema (95% CI 0.90‒22.86; p = 0.067), and patients with 50‒70% pulmonary expansion had a 3.8-times increased risk of empyema (95% CI 0.98‒15; p = 0.053) after pleurodesis.

CONCLUSION

The study suggests that antibiotic therapy prior to talc slurry pleurodesis may increase the risk of developing empyema. Furthermore, pleurodesis should be considered with caution in patients with long-duration chest tube placement and incomplete lung expansion.

A left lung with four lobes: a new discovery during the thoracotomy for recurrent primary spontaneous pneumothorax

Background

The right and left lung anatomy are similar but asymmetrical. The right lung consists of three lobes, and the left lung consists of two lobes. Our study is unique because of discovering a very rare morphological feature of the left lung which has not been reported yet. By the way, we compared two different available chemical agents for pleurodesis (talc and bleomycin) according to side effects, complications, and pneumothorax recurrence.

Case presentation

We reported a case of bilateral primary spontaneous pneumothorax, who underwent talc slurry and bleomycin pleurodesis at right and left side retrospectively, and then complicate with left-sided recurrent spontaneous pneumothorax, so underwent open thoracotomy and was surprisingly and accidentally found to have 4 lobes and 3 fissures in left lung.

Conclusion

In our case report, there were one main oblique fissure and two accessory fissures which divided the lung into 4 separated lobes, and this discovery in human’s and other animals’ lung anatomy has not been previously reported. In our case study, the talc slurry was more effective in preventing spontaneous pneumothorax recurrence, but with more side effects than bleomycin. We could hypothesize that the morphological variation of the lung might affect spontaneous pneumothorax development and recurrence.

Comparison of Hydroxyethyl starch 130/0.4 (6%) with commonly used agents in an experimental Pleurodesis model

Background

Hydroxyethyl Starch (HES) 130/0.4 (6%) is a commonly used intravascular volume expander with anti-inflammatory and antioxidant properties. In this study, we aimed to compare the histopathologic activity of HES 130/0.4 (6%) with various widely-used agents in pleurodesis.

Methods

Forty male Wistar-Albino rats were divided into five groups: controls, povidone-iodine recipients (PI group), sterile talcum recipients (Talcum group), autologous blood recipients (AB group) and HES 130/0.4 (6%) recipients (HES group). Thirty days after application of agents, pleural and lung tissues were resected. Evaluation was performed via macroscopic scoring (adhesion) and specimens were stained with H&E for microscopic examination (inflammation and fibrosis).

Results

HES recipients had significantly higher adhesion compared to controls (lower grade 0, higher grade 1 frequency vs. controls), they were found to have significantly lower frequency of grade 2 adhesion (vs. PI, Talc and AB) and grade 3 adhesion (vs. AB), indicating that the adhesion-generating properties of HES were only superior to the control group. HES recipients had significantly higher inflammatory grades compared to controls (lower grade 0, higher grade 1 frequency), while they had lower grades compared to the PI, Talc and AB groups. Although the PI, Talc and AB groups were statistically similar in most comparisons, we observed a trend towards higher success with the use of Talc and especially AB.

Conclusion

Our results do not support a role for HES in pleurodesis. We believe that the autologous blood method remains as an effective and successful procedure without side effects.

New options for pneumothorax management

Introduction: Pneumothorax is defined as the presence of air in the pleural space. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is classified as primary or secondary. There are substantial inconsistencies in international guidelines for the treatment of pneumothorax. Moreover, many geographical variations exist in daily clinical practice.Areas covered: In this article, we focus on novel treatment modalities for this significant health problem in young adults.Expert opinion: In part, these discrepancies have been caused by the lack of high-quality trials or evidence. Currently, the pathophysiological mechanisms underlying pneumothorax are better understood and have implications for clinical management. Studies have demonstrated that the judicious use of pleurodesis can decrease its rate of recurrence, both in surgical and nonsurgical patients.

Comparisons of doxycycline solution with talc slurry for chemical pleurodesis and risk factors for recurrence in South Korean patients with spontaneous pneumothorax

Purpose

Talc slurry (TS) has been commonly used with high success rates in managing spontaneous pneumothroax (SP), but there were concerns of post-procedural complications. Alternatively, doxycycline solution (DS) was used successfully. This retrospective study aims to compare the effectiveness and safety between talc and doxycycline as a sclerosing agent and to investigate risk factors for recurrence in patients with SP.

Methods

The review of medical records between January 2011 and December 2014 was conducted on 83 patients with SP who underwent pleurodesis with either TS (n=16) or DS (n=67). Recurrence and complications were compared between the DS and TS groups. Associations between recurrence after DS treatment and various factors were analysed.

Results

Recurrence was significantly higher in the DS group than in the TS group (P=0.033), whereas complications were higher in the TS group than the DS group: fever was significantly higher in the TS group (P=0.001). Recurrences associated with doxycycline use were found significantly more often in patients with recurrent diagnosis of SP, height/weight ≥3.25 cm/kg and weight <55 kg.

Conclusion

Talc was more effective without recurrence compared with doxycycline. Clinically insignificant fever associated with pleurodesis was more common with talc. Low weight, high height to weight ratio and recurrent diagnosis of SP were associated with higher recurrence after doxycycline treatment.

Hemoptysis following Talc Pleurodesis in a Pneumothorax Patient

The purpose of this article is to report a case of hemoptysis occurring in combination with secondary spontaneous pneumothorax following chemical pleurodesis by talc. A Japanese male with cancer of renal pelvis was found with the left pneumothorax and multiple lung metastases. A computed-tomography scan revealed severe emphysema throughout the lungs. Talc pleurodesis was employed to arrest air leakage. The patient developed hemoptysis 45 minutes after talc injection into the thorax. This is the first report of hemoptysis following talc pleurodesis. The agent could induce severe inflammation in capillary vessels of the lung following visceral pleura infiltration.

Outcome of indwelling tunneled PleurX® catheter placement in pediatric and young adult patients with malignant effusions

Malignant effusions may cause significant morbidity and mortality for cancer patients. Indwelling tunneled PleurX® catheter placement for intermittent drainage of malignant effusions has been shown to be efficacious in adults but has not been studied in children. We performed a retrospective review of nine children and young adults who underwent PleurX® catheter placement for the palliation of symptoms associated with malignant effusions. Eight of nine demonstrated symptomatic improvement and seven of nine were discharged from the hospital after catheter placement. No patients experienced catheter-associated complications. PleurX® catheter placement should be considered for palliation of symptoms due to malignant effusions in pediatric oncology patients.

Chemical pleurodesis for spontaneous pneumothorax

Pneumothorax is defined as the presence of air in the pleural cavity. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is sub-divided into primary and secondary. The severity of pneumothorax could be varied from asymptomatic to hemodynamically compromised. Optimal management of this benign disease has been a matter of debate. In addition to evacuating air from the pleural space by simple aspiration or chest tube drainage, the management of spontaneous pneumothorax also focused on ceasing air leakage and preventing recurrences by surgical intervention or chemical pleurodesis. Chemical pleurodesis is a procedure to achieve symphysis between the two layers of pleura by sclerosing agents. In the current practice guidelines, chemical pleurodesis is reserved for patients unable or unwilling to receive surgery. Recent researches have found that chemical pleurodesis is also safe and effective in preventing pneumothorax recurrence in patients with the first episode of spontaneous pneumothorax or after thoracoscopic surgery and treating persistent air leakage after thoracoscopic surgery. In this article we aimed at exploring the role of chemical pleurodesis for spontaneous pneumothorax, including ceasing air leakage and preventing recurrence. The indications, choice of sclerosants, safety, effects, and possible side effects or complications of chemical pleurodesis are also reviewed here.

Blood patch for persistent air leak: a review of the current literature

PURPOSE OF REVIEW

Persistent air leak (PAL) poses a significant challenge to the thoracic surgeon. Of the numerous methods employed to manage this problem, autologous blood 'patch' pleurodesis (ABPP) remains one of the most controversial, seemingly due to a lack of robust data and consensus of opinion regarding its efficacy, technique of application and its role in clinical practice. Despite a lack of randomized control trials, the evidence to-date has shown ABPP to be an efficacious, cheap, simple, well tolerated and readily available treatment, with minimal side effects and broad range of applications, allowing for earlier chest drain removal, decreased complications and decreased hospital stay. A review is therefore required to assess the role for ABPP in contemporary clinical practice.

RECENT FINDINGS

Recent studies have demonstrated that ABPP is an effective management for PAL in specific patient groups and there is an argument that it has the potential to be the gold-standard or first-line treatment in certain clinical scenarios such as for patients with interstitial lung disease or acute respiratory distress syndrome.

SUMMARY

This review aims to discuss the relevance of recent findings and to suggest a firm role for ABPP in current practice. In addition, the evidence for the efficacy of ABPP will be assessed and compared with other established methods of pleurodesis. Finally, the review will include a summary of relevant research to-date in order to suggest an evidence-based standardized protocol for the application of ABPP.

Single-Center Experience With 250 Tunnelled Pleural Catheter Insertions for Malignant Pleural Effusion

INTRODUCTION

Malignant pleural effusions (MPEs) are a common cause of dyspnea in patients with advanced cancer. Tunnelled pleural catheters (TPCs) can be used in patients with this condition, but the published experience with them is limited.

OBJECTIVE

To describe the use of TPCs in the management of MPE in a large group of patients in a clinical setting.

METHODS

Retrospective analysis of 250 sequential TPC insertions in patients with MPEs in a single center.

RESULTS

Two hundred fifty TPC procedures for MPE were performed in 223 patients (19 contralateral procedures and 8 repeat ipsilateral procedures) during a 3-year period. Symptom control was complete following 97 procedures (38.8%), was partial in 125 procedures (50%), and was absent in 9 procedures (3.6%); in addition, there were 10 failed TPC insertions (4.0%) and 9 TPC insertions (3.6%) without assessment of symptoms at the 2-week follow-up visit. Spontaneous pleurodesis occurred following 103 of the 240 successful TPC procedures (42.9%) and was more frequent when < or = 20% of the hemithorax contained fluid at the 2-week follow-up visit (57.2% vs 25.3%, respectively; p < 0.001). Catheters stayed in place for a median duration of 56 days. Following successful TPC placement, no further ipsilateral pleural procedures were required in 90.1% of cases. The overall median survival time following TPC insertion was 144 days. Complication rates were low and compared favorably with those seen with other treatment options.

CONCLUSIONS

TPC placement is an effective method of palliation for MPE that allows outpatient management and low complication rates. The insertion of a TPC should be considered as a first-line treatment option in the management of patients with MPE.

Thoracoscopic Management of Primary Spontaneous Pneumothorax

Primary spontaneous pneumothorax is defined as that which appears in patients without history of previous pathology that could explain the event. Management includes pleural drainage with or without pleurodesis and surgical resection of affected lung tissue with pleurodesis. Thoracoscopic approach has proved to be useful with low morbidity and mortality as well as low recurrence rate. This paper describes the experience with thoracoscopic management of primary spontaneous pneumothorax with pulmonary wedge resection of affected tissue, parietal pleurectomy, and pleural abrasion of remaining parietal and diaphragmatic pleura. Fifty-five patients have been submitted to this approach (24 female, 31 male). Fifty-three patients had past history of at least one previous pneumothorax (second event, n = 41; third event, n = 9; fourth event or more, n = 3). Computed tomography was abnormal in 19 patients. Operative time was 57 minutes (±17). There were no transoperative complications. Macroscopic findings were presence of small type I bullae in the lung apex in 48; three more had apical pleural thickening. None of the patients presented postoperative air leak. Chest tubes were removed after 24–48 hours on average. Adequate pain control was achieved in 51 patients; 4 patients presented mild chronic intercostal pain for 3–5 months. Median follow-up was 48 months (range 6–72); no recurrence has been observed. Primary spontaneous pneumothorax can be managed thoracoscopically; management should include wedge resection of affected lung, apical pleurectomy, and pleural abrasion of remaining parietal and diaphragmatic pleura.

Centromere DNA, proteins and kinetochore assembly in vertebrate cells

The centromere is a specialized region of the chromosome that is essential for faithful chromosome segregation during mitosis and meiosis in eukaryotic cells. It is the site at which the kinetochore, the functional nucleoprotein complex responsible for microtubule binding and chromosome movement, is assembled through complex molecular mechanisms. Herein, I review recent advances in our understanding of centromeric DNAs as sites for kinetochore assembly and the mechanisms underlying kinetochore assembly in vertebrate cells.

Video-assisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients

BACKGROUND

The treatment of primary spontaneous pneumothorax in young adults has been controversial. Conventional treatment consisting of chest tube thoracostomy may be associated with morbidity at the time of tube insertion, prolonged hospitalization, and interval operation in many patients. As spontaneous pneumothorax in young adults is usually associated with apical blebs, we hypothesized that video-assisted thoracic surgical (VATS) resection of the blebs at the time of the first pneumothorax may be an effective treatment associated with low morbidity and short hospital stays.

METHODS

From July 1992 to February 2001, 156 young adults were treated for spontaneous pneumothorax. Within 12 hours of presentation to the emergency department patients underwent semielective VATS with bleb resection and pleuradesis. During follow-up patients were observed for recurrent pneumothorax.

RESULTS

There were 69 men (44%) and 87 women (56%). The median age was 19 years old (range 14 to 38 years old). Patients were predominantly tall and thin. Patients were mildly symptomatic at the time of presentation. Apical blebs were seen in all patients and the presence of blebs was confirmed in the pathologic specimen. In 23 patients bleeding was associated with bleb rupture. There were no postoperative air leaks. The mean hospital stay was 2.4 +/- 0.5 days. Follow-up ranged from 2 to 96 months (median 62 months). There were no recurrences on the index side.

CONCLUSIONS

VATS resection of apical blebs is associated with low morbidity and short hospitalization and provides an attractive alternative to the conventional treatment of initial tube thoracostomy and possible interval repeat thoracostomy or operation. VATS may be an effective first line treatment for spontaneous pneumothorax in young adults. Due to the pathophysiology of this disease, patients should be closely followed for the occurrence of pneumothorax on the contralateral side.

[Spontaneous pneumothorax: pleurodesis with an iodo-povidone hydroalcoholic solution]

OBJECTIVE

To analyze the efficacy of an iodo-povidone hydroalcoholic solution for the chemical pleurodesis of spontaneous pneumothorax.

MATERIAL AND METHOD

A descriptive, retrospective study of 81 patients with spontaneous pneumothorax. The patients were treated by video-assisted thoracoscopy and chemical pleurodesis with an iodo-povidone hydroalcoholic solution at the thoracic surgery unit of Hospital de la Santa Creu i Sant Pau in Barcelona (Spain) between January 1993 and December 1999.

RESULTS

Eighty-one patients, 59 men (73%) and 22 women (27%), between 14 and 82 years old (mean age 33 years) were treated. Pneumothorax was most often on the right side (43 cases, 53%). The main indications for surgery were recurrence (52 cases, 64%) and persistent air leaks (25 cases, 31%). All were treated by video-assisted thoracoscopy, with resection of the pulmonary parenchyma in 30 cases (37%) and pleural instillation of the iodo-povidone hydroalcoholic solution as the irritant in all cases. Air leaks were observed during early postoperative recovery in 10 patients (12.3%), self-limited fever in 5 (6.1%) and infection of drainage openings in 2 (2.4%). During the postoperative follow-up period of 6 to 67 months (mean 24 months), 5 recurrences (6.1%) were seen.

CONCLUSIONS

An iodo-povidone hydroalcoholic solution is easy to apply by video-assisted thoracoscopy and is highly effective for pleurodesis in cases of spontaneous pneumothorax.

Distribution of calibrated talc after intrapleural administration: an experimental study in rats

STUDY OBJECTIVE

Many reports have shown that talc is the most effective and least expensive agent for the creation of a pleural symphysis. However, its use still remains controversial due to severe acute respiratory side effects possibly related to the systemic dissemination of talc particles. The purpose of this study was to assess the distribution of calibrated talc after intrapleural administration in rats. MATERIAL AMD METHODS: Thirty-seven Wistar male rats were randomly assigned to undergo pleurodesis by talc slurry (33 rats) or by simple chest tube drainage (control group; 4 rats). Forty milligrams of calibrated talc suspended in 1 mL sterile saline solution was injected into rats in the treated group. The animals were randomly assigned for autopsy at 24 or 72 h after pleural injection. Lungs, parietal pleura, diaphragm, liver, kidneys, spleen, pericardium, brain, and blood were assessed by polarized light for birefringent talc particle detection and counting.

RESULTS

No deaths were observed. The autopsies showed no pleurodesis at 24 and 72 h. Despite high doses of talc (extrapolated from the dose of 10 g in a 70-kg adult man), few talc particles were found in the liver of two rats, in the spleen of one rat, and only one particle of talc was observed at the brain surface of the rat studied by scanning electron microscopy. No particles were found in the other organs, in particular in the contralateral lung and blood, contrasting with previously published results using noncalibrated talc particles.

CONCLUSIONS

The lack of systemic dispersion of talc particles, with the packaging talc we currently use in our clinical practice, is probably due to the size of the talc particles, which are larger than the other talc preparations. Calibrated talc is required in case of intrapleural administration for pleurodesis to avoid systemic dissemination and potential secondary acute respiratory failures.

Serious complications with talc slurry pleurodesis

OBJECTIVE

Talc is a highly efficacious and commonly employed agent for chemical pleurodesis, which has generally been felt to be well tolerated. However, increasing reports of adult respiratory distress syndrome (ARDS) have heightened safety concerns. A recent case of ARDS prompted us to review our experience with talc pleurodesis.

METHODOLOGY

We conducted a retrospective review of all patients who received talc slurry pleurodesis at Green Lane Hospital, Auckland, New Zealand, between 1 January 1998 and 31 December 1999 and documented all complications occurring within 48 h of the procedure.

RESULTS

Thirty-three talc pleurodesis were performed on 29 patients, most commonly for a malignant pleural effusion. Complications occurred in 15 patients (52% of procedures). Minor complications included tachycardia (n = 11; 33%), pain (n = 9; 27%), fever (n = 8; 24%) and dyspnoea (n = 4; 12%). Major complications occurred in seven patients with hypoxaemia and hypotension. Two of these patients died; one death directly attributable to ARDS, the other hastened by a talc pleurodesis-related tachycardia.

CONCLUSIONS

These results challenge the assumption that talc pleurodesis is a safe procedure. There were a significant number of serious complications, including a death, from ARDS. Physicians and patients should be aware that complications occur frequently after talc pleurodesis which may be life-threatening or fatal.