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ABSTRACT Objective: Talc pleurodesis is a widely used treatment option for malignant pleural effusion (MPE). However, the optimal form of administration remains controversial. Thus, we performed a systematic review and meta-analysis to assess the effectiveness of talc slurry (TS) in comparison with thoracoscopic talc insufflation/poudrage (TTI) for MPE treatment. Methods: We searched PubMed, EMBASE, and Cochrane Library databases for studies that compared TS with TTI in patients with MPE. We used a random-effects model with a 95% CI to pool the data. Heterogeneity was assessed with I2 statistics. Results: We included eight studies involving 1,163 patients, 584 of whom (50.21%) underwent TS. Pleurodesis failure rates were similar between the procedures (OR = 1.07; 95% CI: 0.56-2.06; p = 0.83; I2 = 62%); and 68% of patients (95% CI: 0.31-1.47; p = 0.33; I2 = 58%) had postoperative complications, which were lower in patients in the TS group than in the TTI group. In a subgroup analysis considering only randomized clinical trials, the failure rate was significantly lower in the TS treatment group (OR = 0.62; 95% CI: 0.42-0.90; p = 0.01; I2 = 0%). Similarly, dyspnea was less common in the TS group (OR = 0.74; 95% CI: 0.41-1.34; p = 0.32; I2 = 55%). Adverse effects were reported in 86 patients, and no significant difference was seen between the TS and TTI groups: empyema (OR = 1.43; 95% CI: 0.36-5.64; p = 0.86; I2 = 0%), pain (OR = 1.22 (95% CI: 0.67-2.21; p = 0.51; I2 = 38%), and pneumonia (OR = 1.15; 95% CI: 0.30-4.46; p = 0.86; I2 = 27%). Conclusions: Our findings suggest that TS is an effective treatment for MPE, with no significant increase in adverse events. Results suggest equivalent efficacy and safety for both procedures.

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BACKGROUND: A well-recognized therapy to improve the symptoms of patients with malignant pleural effusion (MPE), indwelling pleural catheters (IPCs) can also achieve spontaneous pleurodesis. Chemical pleurodesis is associated with a significant pro-coagulation and fibrinolytic environment. Hence, anticoagulation could theoretically interfere with this process. OBJECTIVE: The aim of this study was to evaluate if anticoagulation can interfere with successful spontaneous pleurodesis in patients treated with IPC. METHODS: This was a cohort study of all patients with MPE treated with IPC. The primary objective was to determine if anticoagulant use after IPC placement decreased the rate of spontaneous pleurodesis. The secondary objective was to identify other factors associated with spontaneous pleurodesis. We used a Fine-Gray subdistribution hazard model and a direct acyclic graph to identify variables associated with time to spontaneous pleurodesis. RESULTS: Of the included 410 patients, 210 patients (51.2%) achieved pleurodesis and had their IPC removed. We found no association between anticoagulation and likelihood of pleurodesis. Multivariate analyses revealed that prior chemotherapy, ECOG score of 2-4 were associated with unsuccessful pleurodesis, while chemotherapy or radiotherapy after IPC placement remained associated with increased likelihood of spontaneous pleurodesis. CONCLUSIONS: We failed to demonstrate an association between anticoagulation and pleurodesis. We found that better performance status and chemotherapy or radiotherapy after IPC placement can increase the rate of pleurodesis and catheter removal.

Assuntos

Derrame Pleural Maligno , Humanos , Derrame Pleural Maligno/terapia , Pleurodese/efeitos adversos , Estudos de Coortes , Cateteres de Demora/efeitos adversos , Anticoagulantes

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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.

Assuntos

Empiema Pleural , Derrame Pleural Maligno , Adulto , Idoso , Antibacterianos , Empiema Pleural/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pleural Maligno/etiologia , Derrame Pleural Maligno/terapia , Pleurodese/efeitos adversos , Pleurodese/métodos , Estudos Retrospectivos , Fatores de Risco , Talco/efeitos adversos

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Introducción: La fuga gaseosa persistente es la complicación posoperatoria más frecuente en cirugía torácica. En la actualidad no hay estudios con suficiente evidencia científica que permitan establecer una norma para el tratamiento de esta complicación. Objetivo: Ofrecer una actualización de los factores predisponentes de la fuga gaseosa, así como las modalidades de tratamiento que han surgido en los últimos años. Métodos: Se realizó una revisión bibliográfica en bases de datos MEDLINE (PubMed), SciELO, así como Google académico. Se tuvieron en cuenta variables como tipo de resección pulmonar, tiempo quirúrgico, complicaciones posoperatorias, se emplearon las palabras claves en idioma español e inglés y se seleccionaron un total de 44 artículos publicados desde el 1998 hasta el 2020. Desarrollo: Aunque por lo general esta complicación se considera leve, puede llegar a tener una incidencia de un 46 por ciento, asociándose a un aumento en la estadía hospitalaria, con repercusión en el costo sanitario, así como incomodidad y morbilidad para el paciente. En dependencia del momento en que se presente y su localización el tratamiento incluirá diferentes alternativas que abarcan desde la conducta conservadora, hasta diferentes modalidades de pleurodesis, tratamiento endoscópico o quirúrgico. Conclusiones: La resolución de esta entidad se produce en la mayoría de los pacientes mediante el empleo de sonda pleural, mientras que en el resto se requerirán estrategias alternativas, siendo importante el conocimiento por parte de los cirujanos de su forma de prevención, así como de todas las opciones terapéuticas, para su adecuado empleo en base a su criterio o experiencia(AU)

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Introduction: Persistent gas leak is the most common postoperative complication in thoracic surgery. Currently there are no studies with sufficient scientific evidence to establish a standard for the treatment of this complication. Objective: To offer an update of the predisposing factors of gas leak, as well as the treatment modalities that have emerged in recent years. Methods: A bibliographic review was carried out in MEDLINE (PubMed), SciELO databases, as well as in academic Google. Variables such as type of lung resection, surgical time, and postoperative complications were taken into account. The keywords in Spanish and English were used and a total of 44 articles published from 1998 to 2020 were selected. Discussion: Although this complication is generally considered mild, it can have 46 percent incidence, being associated with an extra time of the hospital stay, affecting health costs, as well as discomfort and morbidity for the patient. Depending on when it occurs and its location, the treatment will include different alternatives that range from conservative management, to different modalities of pleurodesis, endoscopic or surgical treatment. Conclusions: The resolution of this entity occurs in most patients through the use of a chest tube, while alternative strategies will be required for the rest. It is important for surgeons to know their form of prevention, as well as all the therapeutic options, for their proper use based on their criteria or experience(AU)

Assuntos

Humanos , Complicações Pós-Operatórias , Cirurgia Torácica , Estratégias de Saúde , Literatura de Revisão como Assunto , Bases de Dados Bibliográficas

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Abstract 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.

RESUMO

Resumen Objetivo: Comunicar el caso de una paciente de 77 años tratada de un angiosarcoma de cuero cabelludo, que evoluciona con neumotórax bilateral, cuyo estudio histopatológico informa enfermedad metastásica. Materiales y Método: Revisión de ficha clínica electrónica, registro informático de imagenología e informes de biopsias. Seguimiento ambulatorio en policlínico de cirugía. Resultados: Se realiza manejo por videotoracoscopía bilateral, con bulectomía más pleurodesis. Discusión: El neumotórax secundario por enfermedad metastásica es poco frecuente, aproximadamente 1% a 2% de los casos. De los tumores que más frecuentemente metastizan al pulmón se encuentran los sarcomas. Conclusión: El neumotórax metastásico es poco frecuente y requiere un alto índice de sospecha. Su manejo va a depender del pronóstico y de las condiciones generales del paciente.

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Aim: To report the case of a 77-year-old patient treated for angiosarcoma of the scalp, who evolves with bilateral pneumothorax, whose histopathological study reports metastatic disease. Materials and Method: Review of electronic clinical record, computerized imaging record and biopsy reports. Outpatient follow-up at the polyclinic of surgery. Results: Management was performed by bilateral videothoracoscopy, with bulectomy plus pleurodesis. Discussion: Secondary pneumothorax due to metastatic disease is rare, approximately 1 to 2% of cases. Sarcomas are among the tumors that most frequently metastasize to the lung. Conclusion: Metastatic pneumothorax is infrequent and requires a high index of suspicion. Its management will depend on the prognosis and the general conditions of the patient.

Assuntos

Humanos , Feminino , Idoso , Pneumotórax/diagnóstico por imagem , Couro Cabeludo/patologia , Metástase Neoplásica/terapia , Pneumotórax/terapia , Hemangiossarcoma/complicações , Neoplasias Pulmonares/diagnóstico por imagem

RESUMO

Introducción: El derrame pleural recidivante maligno se reproduce en breve tiempo y requiere el diagnóstico etiológico positivo de malignidad, la etiología más frecuente es el cáncer de pulmón. La pleurodesis química es el tratamiento de elección con la aplicación intrapleural de sustancias sinfisiantes. Objetivo: Describir la respuesta clínica y radiológica de los enfermos con derrame pleural recidivante maligno con el uso de bleomicina. Método: Estudio observacional comparativo en 30 pacientes con derrame pleural recidivante maligno divididos en dos grupos, en uno se aplicó la bleomicina intrapleural y al otro yodo povidona. Resultado: El 33,3 por ciento fueron del sexo masculino, 60 por ciento perteneció al grupo de edades de 60-69 años. El grupo tratado con bleomicina presentó una respuesta clínica favorable en los síntomas, p<0,005 después de la pleurodesis. En la evaluación de la respuesta radiológica, 66,6 por ciento pacientes tratados con la bleomicina tuvieron una resolución completa. Conclusiones: Se logró una buena respuesta clínica-radiológica con la pleurodesis química similar entre ambas modalidades de tratamiento. Se obtuvieron mejores resultados y menos reacciones adversas con la bleomicina intrapleural(AU)

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Introduction: The malignant recurrent pleural effusion reproduces in short time and it requires a positive etiological diagnosis of malignancy, the most frequent etiology is lung cancer. Chemical pleurodesis is the treatment of choice with the intrapleural application of symphysiating substances. Objective: To describe the clinical and radiological response of patients with malignant recurrent pleural effusion with the use of bleomycin. Method: A comparative observational study in 30 patients with recurrent malignant pleural effusion was carried out. They were divided into two groups, one used intrapleural bleomycin and the other group used povidone iodine. Result: 33.3 percent were male, 60 percent belonged to the 60-69 age group. The group treated with bleomycin presented favorable clinical response in symptoms, p <0.005 after pleurodesis. At the evaluation of the radiological response, 66.6 percent patients treated with bleomycin had a complete resolution. Conclusions: Good clinical-radiological response was achieved with similar chemical pleurodesis between both treatment modalities. Better results and fewer adverse reactions were obtained with intrapleural bleomycin(AU)

Assuntos

Humanos , Masculino , Feminino , Bleomicina/uso terapêutico , Derrame Pleural Maligno/tratamento farmacológico , Neoplasias Pulmonares/etiologia , Estudo Observacional

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Introdution: To determine the role of Pleural Mesothelial Cells (PMC) and/or Neoplasic Cells (NC) in the initiation and regulation of acute inflammatory response after exposure to talc for evaluating inflammatory mediators and cellular alterations. MATERIALS AND METHODS: PMC cultures, human lung (A549) and breast (MCF7) adenocarcinoma cells were divided in 5 groups: 100% PMC, 100% NC, 25% PMC + 75% NC, 50% of each type and 75% PMC + 25% NC. All groups were exposed to talc and measured IL-6, IL-1ß, IL-10, TNF-α, TNFRI, pH, LDH, apoptosis and necrosis. STATISTICAL ANALYSIS: One-way Anova. RESULTS: High IL-6, IL-1ß and TNFRI levels were found in PMC and NC exposed to talc. IL-6 was higher at the points of more confluence of PMC. The highest levels of IL-1ß and TNFRI were found in mixed cultures. In pure cultures TNFRI was higher in A549 followed by PMC and MCF7. LDH was higher in A549 than PMC. The lowest pH was found in 100% NC. All cell line exposed to talc reduced viability and increased necrosis. Apoptotic cells exposed to talc were higher in pure cultures of NC than in PMC. Mixed cultures of PMC and A549 showed lower levels of apoptosis in cultures with more NC. CONCLUSIONS: PMC after talc exposure participates in the inflammatory process contributing to production of molecular mediators, necessary for effective pleurodesis. Talc acted in NC causing higher rates of apoptosis, contributing in a modest way to tumoral decrease. Different types of tumor cells may respond differently to exposure to talc.

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BACKGROUND: Malignant pleural effusion (MPE) is an important sign of advanced disease in metastatic cancer. Pleurodesis is one option to treat recurrent MPE. The Inflammatory response after pleurodesis may lead to important adverse events (AE) in a set of very ill patients. METHODS: Retrospective analysis of patients submitted to pleurodesis (2009-2013). Clinical and laboratory data were collected. We compare the values in the day of pleurodesis, 2nd, 5th and 10th days after. RESULTS: One hundred fourteen patients were undergone to pleurodesis with silver nitrate (46%), iodine (52%) and talc (2%). Female was the most frequent (86%) and the breast cancer was the most common primary site. The most frequent adverse event was low hemoglobin account (37), followed by pain (31). 68% of patients presented AEs and 28% had at least one AE with grade 3 or higher. The most altered was CRP that peaked in the 5th day after pleurodesis. Changes in CRP curve were less severe with the use of iodine when compared with the other two agents. CONCLUSIONS: Pleurodesis leads to important systemic inflammatory response detected by different serum markers. The occurrence of adverse events in this set of patients was great number of events with being marked as grade 3 or higher.

RESUMO

PURPOSE: Experimental study aimed at evaluating whether pleural neoplastic disease is associated with the degree of pleural fibrosis over time caused by talc pleurodesis. The study describes changes in levels of inflammatory mediators and determines whether the course of time involved in progression of neoplastic pleural disease is the factor that influences safety of talc pleurodesis usage in mice. MATERIALS AND METHODS: Animals were randomized into two groups: Cancer group (CG) that received intrapleural injection of Lewis cells or Saline group (SG) that received saline injection. After, the animals were subdivided into Early (pleurodesis 3 days after pleural injection) and Late (pleurodesis 7 days after pleural injection) groups. Half of the animals in each group were euthanized 24 hours after pleurodesis (to obtain the inflammatory data); the remaining animals were killed after 8 days (to obtain the scores of pleural fibrosis). RESULTS: CGs had lower fibrosis scores than SGs comparing early phases to late phases. Inflammation scores were lower in CGs, particularly in Late group. In SGs the inflammation was intense in 100% of the animals. In Late CG group pleural adhesions had the lowest scores; we found intense fibrosis only in SGs. VEGF and LDH levels had increased in animals with cancer, particularly in Late group. Systemic distribution of talc occurred only in Late CG. CONCLUSIONS: The time for pleural neoplasia to evolve is inversely proportional to the degree of pleural fibrosis. Earlier pleurodesis yielded the best results related to fibrosis, with less systemic inflammation and is safer in mice.

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Introduction: In developing countries where talc may not be readily available, video-assisted thoracoscopic (VATS) iodopovidone pleurodesis offers an excellent alternative for the treatment of malignant pleural effusions (MPEs). Methods: This study analyzes a retrospective experience using VATS iodopovidone pleurodesis for malignant pleural effusions at a single cardiothoracic center in the capital of Colombia evaluating success according to LENT (Lactate, Eastern Cooperative Oncology Group-ECOG, Neutrophil-Lymphocyte ratio, Tumor type) scores. A total of 75 records of patients taken to VATS iodopovidone pleurodesis for MPEs were retrieved from our institutional database during a 5-year period from 2014-2019. Of these, 45 had complete clinical history data necessary to analyze both LENT scores and post-op follow-up imaging. Results: Of the 45 patients evaluated, 93.3% (42 patients) had either complete resolution of pleural effusions or partial resolution with an asymptomatic recovery within the first month post op. Chest pain was the most common postoperative complaint, which was present in 20% of patients. The mean postoperative ECOG score was 2±1.7. Patients with moderate to high-risk LENT scores had success rates of 96.7% and 92.3% respectively. Conclusion: Video-assisted thoracoscopic pleurodesis using Iodopovidone-iodine is an effective approach for MPEs. In developing countries where Iodopovidone iodine is readily available and affordable, patients may benefit from this agent with excellent results and minimal complications.

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Objetivo: verificar a eficácia e analisar possíveis alterações toxicológicas da indução de pleurodese com hipoclorito de sódio a 1% em modelos animais. Métodos: ensaio pré-clínico, randomizado com coelhos albinos (G1 e G2). Em G1 realizou-se pleurodese através da instilação 10ml de solução de hipoclorito de sódio a 1%. Em G2, 10ml de solução fisiológica a 0,9%. Traçaram-se perfis bioquímicos, de ambos os grupos, prés e pós-operatórios, para identificar alterações toxicológicas, comparados através do Teste Wilcoxon. Os animais foram eutanasiados, aleatoriamente, após 1, 7 ou 30 dias para autópsia, determinando a eficácia da pleurodese conforme a presença ou não de aderências na cavidade torácica. Os grupos foram comparados através do teste qui-quadrado (p<0,05). O projeto de pesquisa foi aprovado pelo comitê de ética em pesquisa em animais da Universidade Regional de Blumenau sob o protocolo 022/04. Resultados: foram incluídos 44 coelhos, 21 pertencentes ao G1 e 23 ao G2. 90,48% dos animais de G1 apresentaram aderências pleurais e apenas 10% de G2 (p <0,001). Quanto à análise da toxicidade, verificaram-se alterações significativas referentes às enzimas preditoras das funções cardíaca e hepática em ambos os grupos. Conclusões: a pleurodese com hipoclorito de sódio mostrou-se eficaz. As alterações bioquímicas em ambos os grupos devem-se, provavelmente, a um fator intrínseco do procedimento e não às substâncias. Não foram evidenciados prejuízos significativos decorrentes da solução proposta.

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Aims: to verify the efficacy and possible toxicological alterations of the 1% sodium hypochlorite solution in the induction of pleurodesis in albino rabbits. Methods: randomized preclinical trial (G1 and G2) with rabbits. In the G1 the pleurodesis was done by the instilation of 10ml of a 1% sodium hypochlorite solution (SHS), and in the G2 by the instilation of 10ml of physiological solution (0,9%). Preoperatory and postopetary biochemical profiles were done in both groups in order to identify toxicological alterations. These profiles were compared by the Wilxcoxon Test. The animals were randomly euthanized after one, seven or thirty days for an autopsy. The efficiency of the pleurodesis was measured according to the presence or not of macroscopic adhesions in the thoracic cavity. Findings in both groups were compared by the chi-square test (p<0,05). The research project was approved by the ethical committee envolving animals research of the Regional University of Blumenau under the protocol 022/04. Results: 44 rabbits were included. 21 from G1 and 23 from G2. 90,48% of the G1 animals showed pleural adhesions while 10% of the G1 did. Concerning the toxicologycal analysis, signifficant alterations were found in the cardiac and hepatic enzymes in both groups. Conclusion: pleurodesis induced by the SHS was shown to be effective. G1 and G2 exhibited toxicologycal alterations probably due to an intrinsic factor of the procedure and not caused by the different solutions used. The animals responded well to the proposed agent, no systemic effects were evidenced.

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BACKGROUND: Malignant pleural effusion is one of the most important complications of metastatic cancer, and recurrent pleural effusions do not only have an impact on survival but also cause a huge repercussion on a patient's quality of life. OBJECTIVES: The main objective was to describe quality of life status before and after pleurodesis in patients with malignant pleural effusion. Secondary, we aimed to find predictors of quality of life improvement in such a population. METHODS: Retrospective analysis of a database collected prospectively. We included patients who underwent pleurodesis from June 2004 to July 2014. Quality of life was evaluated through the WHOQOL-BREF questionnaire and applied before and 30 days after pleurodesis. We used a paired t test and the Wilcoxon rank-sum to compare pre-/post-pleurodesis results, Kaplan-Meier curves for survival analysis, and multiple linear regressions to find predictors of quality of life improvement. RESULTS: 183 patients were included (145 were women). Mean age was 58.3 ± 12.3 years, the most numerous primary tumor was breast cancer. Median survival time was 9 months. Dyspnea was the most prevalent symptom. Baseline results showed that patients had low quality of life scores. After pleurodesis, there was a significant improvement in respiratory symptoms, physical domain, and general health. Linear regression showed an improvement in physical domain with the sclerosing agent nitrate (p = 0.005). Male gender (p = 0.002) and a higher lymphocyte count (p = 0.01) were inversely associated with improvement in physical domain. CONCLUSIONS: Pleurodesis improved symptoms and quality of life in patients with malignant pleural effusion. Gender, lymphocyte count, and sclerosing agent might interfere with quality of life improvement.

Assuntos

Derrame Pleural Maligno/terapia , Pleurodese/métodos , Pleurodese/psicologia , Qualidade de Vida , Idoso , Brasil , Bases de Dados Factuais , Feminino , Humanos , Iodo/administração & dosagem , Estimativa de Kaplan-Meier , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Nitratos/administração & dosagem , Derrame Pleural Maligno/diagnóstico por imagem , Derrame Pleural Maligno/mortalidade , Prognóstico , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Talco/administração & dosagem , Resultado do Tratamento

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BACKGROUND: A malignant pleural effusion (MPE) in patients with cancer is evidence of the underlying disease progression, resulting in many symptoms, and may lead to hospitalization. The treatment options include talc pleurodesis (TP) or the implantation of an indwelling pleural catheter. The costs of the latter approach are often seen to be inhibitive for the Brazilian and other emerging markets' public health system. OBJECTIVES: To assess the feasibility of utilizing a low-cost device (LunGO) through a case-control study. METHODS: Eighteen patients with recurrent neoplastic pleural effusion and contraindications to pleurodesis were recruited between June 2016 and November 2017. The patients were submitted to pleural catheter prototype implantation. Data on the underlying disease and hospital length of stay after the procedure were collected and compared with patients who underwent pleurodesis in the same period (control group, n = 34). RESULTS: In the LunGO group, 7 patients died due to the natural evolution of the underlying disease with the drain, whereas it was removed in 11 patients at a median of 43 days. Recurrence requiring an intervention was seen with the LunGO in 2, compared to 5 (OR = 1.37, p = 1) with TP. Complications were observed in only 1 with the LunGO, compared to 5 with TP. The chances of recurrence in both cohorts do not have a statistically significant difference, with an OR = 1.08 (p = 0.93). There was a tendency towards lower mortality in the LunGO cohort, despite that fact that we did not observe statistical significance (OR = 0.16, p = 0.23). CONCLUSION: LunGO was shown to be a viable and safe device for the treatment of symptomatic MPE.

Assuntos

Cateteres de Demora , Tubos Torácicos , Drenagem , Dispneia/terapia , Derrame Pleural Maligno/terapia , Toracostomia , Adulto , Idoso , Neoplasias da Mama/complicações , Estudos de Casos e Controles , Dispneia/etiologia , Empiema Pleural/epidemiologia , Estudos de Viabilidade , Feminino , Humanos , Neoplasias Pulmonares/complicações , Masculino , Pessoa de Meia-Idade , Derrame Pleural Maligno/etiologia , Pleurodese

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El hidrotórax hepático (HH) se define como un derrame pleural mayor de 500 ml en pacientes con cirrosis e hipertensión portal. Representa una complicación infrecuente por lo general asociada con ascitis y su origen se relaciona con el paso de líquido ascítico a través de pequeños defectos en el diafragma de predominio en el hemitórax derecho. Una vez establecido el diagnóstico por imágenes, la toracentesis diagnostica permite confirmar un trasudado. La terapia inicial está basada en la restricción de sodio y el uso combinado de diuréticos. El 20-25% de los pacientes desarrolla un HH refractario, el cual requiere intervenciones invasivas tales como la derivación percutánea portosistémica intrahepática (DPPI), la reparación de los defectos diafragmáticos por videotoracoscopia asistida asociada a pleurodésis química y el uso de un catéter pleural tunelizado. No se recomienda la inserción de un tubo de tórax por su elevada morbilidad y mortalidad. El tratamiento definitivo del HH es el trasplante hepático el cual alcanza una excelente sobrevida. Presentamos tres casos de hidrotórax hepático con diferentes enfoques terapéuticos que incluyeron el manejo conservador con dieta y diuréticos, la inserción fallida de un tubo de tórax con pleurodesis y una DPPI.

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Hepatic hydrothorax is uncommon transudative pleural effusion greater than 500 ml in association with cirrhosis and portal hypertension. Ascites is also present in most of the patients and the pathophysiology include the passage of ascites fluid through small diaphragmatic defects. After diagnostic thoracentesis studies, the first line management is restricting sodium intake and diuretics combination including stepwise dose of spironolactone plus furosemide. Therapeutic thoracentesis is a simple and effective procedure to relief dyspnea. Hepatic hydrothorax is refractory in approximately 20-25% and treatments options include repeated thoracentesis, transjugular intrahepatic portosystemic shunts (TIPS) placement, chemical pleurodesis with repair diaphragmatic defects using video-assisted thoracoscopy surgery (VATS), and insertion of an indwelling pleural catheter. Chest tube insertion carries significant morbidity and mortality with questionable benefit. Hepatic transplantation remains the best treatment option with long term survival. We present three cases of hepatic hydrothorax with different therapeutic approach including first line management, failed chest tube insertion and TIPS placement.

Assuntos

Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Hidrotórax/terapia , Derrame Pleural/terapia , Ascite/terapia , Tubos Torácicos , Transplante de Fígado , Hepatite C/complicações , Terapia Combinada , Pleurodese , Derivação Portossistêmica Transjugular Intra-Hepática , Síndrome Metabólica/complicações , Diuréticos/uso terapêutico , Toracentese , Tratamento Conservador , Hidrotórax/cirurgia , Hidrotórax/etiologia , Hipertensão Portal/complicações , Cirrose Hepática/complicações

RESUMO

Se reportó un caso de paciente femenina, mestiza de 29 años de edad con antecedentes de hipotiroidismo y conización por neoplasia intraepitelial cervical grado II, que realizó tres neumotórax en un plazo de 2 años, estando en reposo y durante el segundo día del ciclo menstrual. Es ingresada en la sala de Neumología del Hospital General "Dr. Juan Bruno Zayas Alfonso", con el diagnóstico probable de neumotórax secundario a endometriosis pleural. Se le realizó videotoracoscopia y laparoscopia con toma de muestra para estudio histológico. Se estableció el diagnóstico definitivo de neumotórax catamenial, se le hizo pleurodesis química con talco, tratamiento hormonal y antiinflamatorios no esteroideos (AINES), con lo que presentó una evolución satisfactoria(AU)

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A case of a 29-year-old female, mixed race patient with a history of hypothyroidism and conization due to cervical intraepithelial neoplasia grade II was reported, who performed three pneumothorax within 2 years, being at rest and during the second day of the menstrual cycle. She is admitted to the Pulmonology ward of the General Hospital Dr. Juan Bruno Zayas Alfonso, with the probable diagnosis of pneumothorax secondary to pleural endometriosis. He underwent videotoracoscopy and laparoscopy with sampling for histological study. The definitive diagnosis of catamenial pneumothorax was established, chemical pleurodesis was made with talc, hormonal treatment and nonsteroidal anti-inflammatory drugs (NSAIDs), which presented a satisfactory evolution(AU)

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Foi relatado o caso de uma paciente do sexo feminino, 29 anos, de raça mista, com história de hipotireoidismo e conização por neoplasia intraepitelial cervical grau II, que realizou três pneumotórax em 2 anos, estando em repouso e durante o segundo dia do ciclo menstrual. Ela é internada na enfermaria de Pneumologia do Hospital Geral "Dr. Juan Bruno Zayas Alfonso", com provável diagnóstico de pneumotórax secundário à endometriose pleural. Foi submetido a videotoracoscopia e laparoscopia com amostragem para estudo histológico. Foi estabelecido o diagnóstico definitivo de pneumotórax catamenial, realizada pleurodese química com talco, tratamento hormonal e antiinflamatórios não esteróides (AINEs), que apresentaram evolução satisfatória(AU)

Assuntos

Humanos , Feminino , Adulto , Pneumotórax/diagnóstico , Pneumotórax/terapia , Pneumotórax/diagnóstico por imagem

RESUMO

Comparar el uso del talco estéril versus yodopovidona como agentes químicos en pleurodesis para el tratamiento del derrame pleural maligno.Materiales y Métodos: Estudio clínico, analítico, observacional, prospectivo, el cual incluyó 12 pacientes con diagnóstico clínico e histopatológico de derrame pleural maligno, a quienes se les practicó pleurodesis empleando talco estéril y yodopovidona.Resultados : Edad promedio fue de 46,25 ± 17,3 y la neoplasia primaria más común fue el cáncer de mama, representando el 50% de los casos estudiados. El grupo de pacientes tratados con yodopovidona tuvo 100% de efectividad en la fusión pleural posterior a la pleurodesis, y presentaron menos complicaciones durante el procedimiento y 24 horas posteriores al mismo con respecto al grupo tratado con talco estéril, el cual tuvo un 71,4% de efectividad y un 28,6% de falla al procedimiento; asimismo, estos últimos presentaron mayor porcentaje de complicaciones. Por otra parte, no se evidenció recidiva del derrame pleural en los 30 días de valoración posteriores al procedimiento. Estas diferencias no fueron estadísticamente significativas.Conclusiones : Ambos agentes esclerosantes fueron eficaces para lograr la fusión de las pleuras en pacientes con derrame pleural maligno, siendo el talco estéril el agente con mayor tendencia a producir complicaciones y fallo del procedimiento, en comparación a la yodopovidona(AU)

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To compare the use of sterile talc versus povidone-iodine as chemical agents on pleurodesis for the treatment of malignant pleural effusion.Materials and Methods : A total of 12 patients with clinical and histopathologic diagnose of malignant pleural effusion were enrolled in a clinical, analytic, observational and prospective trial, to whom sterile talc and povidone-iodine pleurodesis was applied.Results : The mean age was 46,25 ± 17,3 and the most common primary neoplasm was breast cancer, which was present in 50% of the surveyed cases. The group of patients who received povidone-iodine had 100% of effectiveness on post-pleurodesis pleural fusion, and had fewer complications during the procedure and 24 hours afterwards vis-à-vis the group who received sterile talc powder, which had 74.4% of effectiveness and 28.6% of procedure failure; furthermore, the last mentioned had higher percentage of complications. Moreover, there was no evidence of recurrence of pleural effusion in the 30 days post-procedure assessment.Conclusions : Both sclerosant agents were efficient to accomplish pleural fusion in patients with malignant pleural effusion, with sterile talc being the agent with higher tendency to generate more complications and procedure failure compared to povidone-iodine(AU)

Assuntos

Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Povidona-Iodo , Derrame Pleural Maligno/patologia , Pleurodese , Cirurgia Geral , Talco , Neoplasias da Mama , Diagnóstico Clínico , Esterilização

RESUMO

Malignant pleural effusion (MPE) is a very disabling condition that often affects patients with advanced neoplasm. Conservative approach, repeated thoracentesis, pleurodesis and use of indwelling pleural catheters (IPC) are the main methods to deal with this condition. The ideal treatment must focus on symptom relief and has to take into account patient underlying diseases, performance status and necessity of adequate tissue sample for diagnosis. In a video we show techniques to perform video assisted thoracic surgery (VATS) pleural biopsy and talc poudrage pleurodesis.