1. Effective Treatment of Malignant Pleural effusion by Minimal Invasive Thoracic Surgery: Thoracoscopic Talc Pleurodesis and Pleuroperitoneal shunt in 101 Patients Ann Thorac Surg 2001;71:1890-12 Maren Schulze, MD, Arnd S. Boehle, MD, Roland Kurdow, MD, Peter Doharm, PhD and Henne-bruns, PhD. Department of General and Thoracic Surgery, Christian-Albrechts-University Hospital, Kiel, Germany

2. Introduction Malignant pleural effusion the mean survival is 13.5 months the mean survival is 13.5 months bronchial carcinoma 2.5months bronchial carcinoma 2.5months metastatic breast cancer 7months metastatic breast cancer 7months For patients with limited life expectancy effective palliation treatment require below effective palliation treatment require below high probability of symptomatic improvement high probability of symptomatic improvement low procedure-related mortality/morbidity low procedure-related mortality/morbidity short hospital stay short hospital stay

3. Introduction (II) Drainage of the pleural cavity alone not satisfactory palliation for patients with malignant pleural effusion not satisfactory palliation for patients with malignant pleural effusion The procedure of choice complete obliteration of the pleural space complete obliteration of the pleural space talc slurry through tube thoracostomy talc slurry through tube thoracostomy talc slurry through with VATS talc slurry through with VATS -homogenous distribution of the talc under visual control -homogenous distribution of the talc under visual control -maximizing the chances for complete pleurodesis -maximizing the chances for complete pleurodesis

4. Introduction (III) Retrospective survey 119 thoracoscopies in 101 patients with malignant pleural effusion 119 thoracoscopies in 101 patients with malignant pleural effusion follow up as long as 3years follow up as long as 3years

5. Material and Methods 101 patients, 56 women and 45 men mean age, 68 years mean age, 68 years As a single institution over a period 36months Diagnosis of pleural effusion chest x-ray and thoracic ultra-sonogram chest x-ray and thoracic ultra-sonogram thoracentesis thoracentesis cytopathologically and microbiologically for etiology cytopathologically and microbiologically for etiology

6. Material and Methods (II)

7. Material and Methods (III) The VATS under general anesthesia drainage of pleural effusion and biopsies of the pleura drainage of pleural effusion and biopsies of the pleura confirm reexpanded lung by direct vision confirm reexpanded lung by direct vision insufflate 2 to 4 g of talc into thoracic cavity insufflate 2 to 4 g of talc into thoracic cavity Lung trapped by tumor involvement of the visceral pleura alternative to talc insufflate alternative to talc insufflate pleuroperitoneal Denver shunt pleuroperitoneal Denver shunt

8. Material and Methods (IV) Patients with bilateral effusion sequential Talc with VATS sequential Talc with VATS before discharge, chest x-ray before discharge, chest x-ray followed by telephone interview followed by telephone interview The effectiveness of procedure relief of symptoms relief of symptoms absence or reduction of pleural fluid on chest x-ray absence or reduction of pleural fluid on chest x-ray

9. Material and Methods (V) Excellent result symptomatic improvement and no detectable fluid symptomatic improvement and no detectable fluid Satisfactory result symptomatic improvement but residual fluid in C-P angle, with no tendency for increase symptomatic improvement but residual fluid in C-P angle, with no tendency for increase Unsatisfactory result no symptomatic improvement or recurred pleural fluid no symptomatic improvement or recurred pleural fluid

10. Results In 119 VATS procedure 105 talc pleurodesis and 14 pleuroperitoneal shunt 105 talc pleurodesis and 14 pleuroperitoneal shunt of the VATS pleurodesis of the VATS pleurodesis -65.8% excellent result -65.8% excellent result -23.5 satisfactory result -23.5 satisfactory result -Initial Failure 7.8% -Initial Failure 7.8% Mean postoperative hospitalization, 10.7days Thirty-day mortality for VATS procedure, 2.3% Procedure related complication 2.8%(N=3) restrictive ventilation, soft tissue emphysema restrictive ventilation, soft tissue emphysema

11. Results (II) Mean postoperative survival, 6.7monts months mean follow up duration, 7.8months mean follow up duration, 7.8months at the time of review, 22 patients were alive at the time of review, 22 patients were alive Late recurred effusion in 6 patients at 6.6 months none of these survived longer than 8 week after recurrent effusion none of these survived longer than 8 week after recurrent effusion

12. Results (III) 14 patients with pleuroperitoneal shunt significant clinical improvement in 8 pts significant clinical improvement in 8 pts moderate improvement in 6 pts moderate improvement in 6 pts Mean length of hospital stay, 8.1days 3 pts died within 30 days of procedure 3 pts died within 30 days of procedure 2 pts had procedure related complication 2 pts had procedure related complication Follow up after procedure, 1 to 22 months mean survival, 4.3 months mean survival, 4.3 months 9 of 14 pts died during follow up period 9 of 14 pts died during follow up period only 2 alive at time of review only 2 alive at time of review

13. Comment Simple drainage 90% of pts will develop recurred effusion within 30days 90% of pts will develop recurred effusion within 30days Repetitive thoracentesis loculation, iatrogenic pneumothorax or contamination loculation, iatrogenic pneumothorax or contamination Tube thoracostomy reliable drainage, but more than 80% pts will have recurred effusion within 30days after remove of tube reliable drainage, but more than 80% pts will have recurred effusion within 30days after remove of tube

14. Comment (II) Drainage followed by obliteration of pleural space procedure of choice procedure of choice -of the sclerosing agent, talc has low incidence of side effect and more powerful effect -of the sclerosing agent, talc has low incidence of side effect and more powerful effect -asbestosis free talc minimize the risk of subsequent pleural mesothelioma. -asbestosis free talc minimize the risk of subsequent pleural mesothelioma. -extensive sclerosis with resultant restrictive ventilation rarely occurs with dose of 4 g or less -extensive sclerosis with resultant restrictive ventilation rarely occurs with dose of 4 g or less

15. Comment (III) Talc pleurodesis with VATS complete evacuation of all fluid complete evacuation of all fluid confirmation of complete lung expansion confirmation of complete lung expansion even distribution of insufflated talc even distribution of insufflated talc Pleuroperitoneal Denver shunt alternative method alternative method trapped lung by tumor extension onto visceral pleura trapped lung by tumor extension onto visceral pleura

16. Comment (IV) Early recurrence of effusion after VATS procedure mean survival of pts with initial failure, 8week mean survival of pts with initial failure, 8week but pts with successfully palliated, 7.8months but pts with successfully palliated, 7.8months More advance pleural disease, more earlier recurrence More earlier pleurodesis in the course of malignant pleural effusion, more successful result will occur

17. Comment (V) Pleuroperitoneal shunting pts with extensive involvement of visceral pleura with tumor pts with extensive involvement of visceral pleura with tumor It allows ventilation of diseased lung not to collapse It allows ventilation of diseased lung not to collapse the risk of metastasis into peritoneal cavity the risk of metastasis into peritoneal cavity the improvement in respiratory function make the risk acceptable in this group of patients the improvement in respiratory function make the risk acceptable in this group of patients

18. Images (I)

19. Images (II)

20. Conclusion Suggested algorithm for the management of malignant pleural effusion Thoracentesis for cytologic and microbiologic exam If lung completely reexpands after thoracentesis, If lung completely reexpands after thoracentesis, VATS pleurodesis is performed VATS pleurodesis is performed If lung fail to expand, a pleuroperitoneal shunt is placed If lung fail to expand, a pleuroperitoneal shunt is placed Pt who incapable of having general anesthesia, thoracentesis and instillation of talc slurry thoracentesis and instillation of talc slurry