Early and late outcome after diagnostic thoracoscopy and talc pleurodesis

Early and Late Outcome After Diagnostic Thoracoscopy and Talc Pleurodesis Sunil K. Ohri, FRCS, Shashi K. Oswal, FRCS(E), Edward R. Townsend, FRCS, and S. William Fountain, FRCS Thoracic Surgical Unit, Harefield Hospital, Harefield, Middlesex, United Kingdom

Although thoracoscopy is now recognized to be of both diagnostic and therapeutic value, the risks of this procedure have not been fully addressed. We retrospectively reviewed our experience with 100 patients who underwent 110 thoracoscopies during the period January 1989 to February 1991. Sixty-five men and 35 women (ratio of 1.9:l) underwent thoracoscopy using general anesthesia and intubation with a double-lumen endotracheal tube. The mean age was 64.2 2 11.6 years (range, 13 to 85 years). The diagnosis was established in 48 (85.7%)of the 56 patients with undiagnosed pleural effusions. Fortyfour patients were referred for therapeutic thoracoscopic

talc pleurodesis. Pleurodesis was successful in 42 patients (95.5%).Four patients (4%) had five postoperative complications (two bronchopleural fistulas, two chest infections, and one arrhythmia). Five patients (5%)died after thoracoscopy; mean age was 67.8 2 8.1 years (range, 55 to 77 years). The causes of death were cardiac arrest in 2, respiratory failure in 1, and malignant cachexia in 2. The findings of this study confirm that thoracoscopy can achieve high rates of diagnostic and therapeutic success but is not without attendant mortality in a high-risk patient population. (Ann Thoruc Surg 1992;53:103841)

S

tory physicians for the establishment of diagnoses after failure of primary investigations, including blind pleural biopsies or pleural aspirations or both. Ten of these patients underwent a second thoracoscopy during the same or second admission for therapeutic talc (hydrous magnesium sulfate) pleurodesis. Forty-four patients were referred for therapeutic talc pleurodesis. Of these 44 patients, 28 had pleural effusions (malignant in 26: mesothelioma in 2 and metastatic disease in 2; benign in 2: yellow nail syndrome in 1 and empyema in l), 15 had pneumothoraces (emphysemahullous disease in 14 and secondary to tuberculosis in l), and 1 had a chylothorax resulting from advanced non-Hodgkin’s lymphoma. In all patients, thoracoscopy was performed under general anesthesia using a double-lumen endotracheal tube. Patients were placed in the lateral decubitus position, and the skin was prepared and draped as for a thoracotomy. A 2-cm incision was made in the fifth or sixth interspace, and air was introduced into the pleural cavity where a pneumothorax did not already exist. In patients with pleural effusion, needle aspiration was undertaken first to determine the location of the fluid; the thoracoscopy incision was then made over the aspiration site. A Storz rigid telescope (Karl Storz EndoscopyAmerica, Inc, Culver City, CA), was introduced through a 9-mm trocar. The pleural space was inspected, and any fluid aspirated was sent for cytological and bacteriological examination. Thoracoscopy was often assisted by singlelung anesthesia, and pleuropulmonary adhesions were broken down with biopsy forceps. Before talc pleurodesis, a second trocar was inserted 5 to 7 cm anterior to the first to allow escape of insufflated gas. Talc (2 to 5 g) was insufflated until the whole pleural

ince the description of thoracoscopy by Jacobaeus in 1910 for the division of pleuropulmonary adhesions to achieve collapse of a tuberculous infected lung [l], the technique has become established as both a diagnostic and a therapeutic tool. Thoracoscopy has been employed for the removal of foreign bodies [2], in the assessment of thoracic trauma [3], and in the drainage of empyemas [2]. With this diversification in role, the number of thoracoscopic techniques has also increased. Thoracoscopy can now be done using a rigid or flexible scope under general or local anesthesia [4, 51. However, because of the heterogeneity of reported techniques, identification of risk factors for morbidity and mortality associated with each method becomes difficult. Further, the long-term efficacy of talc pleurodesis in the clinical setting of malignant pleural effusions remains to be addressed. We reviewed our series of 100 consecutive patients who underwent thoracoscopy in our unit over a 24-month period and analyzed our results, in particular any procedure-associated morbidity or mortality. A follow-up of patients who were discharged from the hospital after talc pleurodesis for malignant effusions was also done.

Material and Methods One hundred patients underwent 110 thoracoscopies during the period January 1989 to February 1991 at Harefield Hospital. There were 65 men and 35 women (ratio of 1.9:l). The mean age was 64.2 ? 11.6 years. Fifty-six patients with pleural effusions were referred by respiraAccepted for publication Nov 26, 1991. Address reprint requests to h41 Ohri, Thoracic Surgical Unit, Harefield Hospital, Harefield, Middlesex, UB9 6JH, United Kingdom. 0 1992 by The Society of Thoracic Surgeons

0003-4975/92/$5.00

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Table 1. Cause of Pleural Effusions in 56 Patients Undergoing Diagnostic Thoracoscopy Cause

No. of

Patients

Primary

Mesothelioma

17"

Metastatic

Breast Lung

Pancreas Adenocarcinoma (? primary site) Squamous (? primary site) Benign Tuberculosis Pneumonia Eosinophilic pleuritis Cardiac failure Liver cirrhosis Primary biliary cirrhosis

1 1 1 14 4

Fibrosing alveolitis

Undetermined In 1 patient the diagnosis was made by minithoracotomy and open pleural biopsy.

cavity was seen to be coated on thoracoscopic examination. Both pleural and lung biopsies were performed when indicated, but in patients with undiagnosed large pleural effusions, pleurodesis was delayed until the diagnosis was established. The intercostal drain was positioned under direct vision of the thoracoscope using initially a needle to localize the area to be drained; this was particularly useful in patients with loculated pleural collections. After the drains had been positioned, the lung was fully expanded by positive-pressure ventilation to coapt the talc-covered parietal and visceral pleurae. Failure to fully expand the lung reduces the chances of achieving pleural symphysis.

Results

Group of 100 Patients The diagnosis was established in 48 (85.7%) of the 56 patients with pleural effusions. The causative factors are listed in Table 1. In 7 patients the diagnosis remained undetermined. In 1 patient the thoracoscopic view was inadequate because of pleuropulmonary adhesions, and a minithoracotomy and pleural biopsy were performed. The diagnosis was mesothelioma. Ten patients underwent a second thoracoscopy for therapeutic talc pleurodesis during the same or second admission after establishment of the diagnosis. Talc pleurodesis was successful in all 10 of these patients and in 42 (95.5%) of the 44 patients referred for talc pleurodesis alone. Two patients required a second chemical pleurodesis with quinacrine hydrochloride through the intercostal tube on the third and fourth postoperative days. In both, poor lung expansion with positive-pressure ventilation had been noted at the time of thoracoscopy and was due to a fibrous visceral pleura.

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The length of hospital stay was 6.0 -C 3.5 days (range, 2 to 23 days) for 85 patients undergoing a single procedure and 13 7.7 days (range, 3 to 31 days) for 10 patients having two thoracoscopies. Four patients (4%) had complications. Postoperative chest infections developed in 2 patients, postoperative atrial fibrillation in 1 patient, and bronchopleural fistulas in 2 (1 of whom also had a chest infection). Both patients with bronchopleural fistula had undergone lung biopsy during thoracoscopy. These patients were managed successfully by prolonged drainage through the intercostal tube. Five patients (5%) died after thoracoscopy: 3 with pleural effusions, 1 with pneumothorax, and 1 with hydropneumothorax (Table 2). Their mean age was 67.8 & 8.1 years (range, 55 to 77 years), which was not significantly different (p > 0.3, nonpaired t test) from that of the group of patients who survived. The causes of death were cardiac arrest in 2 patients, respiratory failure in 1patient, and malignant cachexia in 2. Of the 5 patients, 2 had severe chronic obstructive airway disease; the forced expiratory volume in 1 second to forced vital capacity ratios were 0.46 and 0.29. A third patient had mild chronic obstructive airway disease. No risk factors could be identified apart from advanced malignant disease in the other 2 patients. Postmortem examination was performed on 2 patients. Panlobular emphysema was found in the patient dying of respiratory failure, and cardiac failure without evidence of myocardial infarction was found in 1 of the patients who died of cardiac arrest.

*

Follow-up of Patients With Malignant Pleural Effusions or Chylothorax After Talc Pleurodesis Thirty-seven patients who underwent successful talc pleurodesis for primary or metastatic malignancies of the pleural cavity were followed up after discharge from the hospital (range, 6 to 31 months). Thirty-six had pleural effusions, and 1 patient was treated for a chylothorax secondary to lymphoma. Seven of the 37 patients were lost to follow-up, but information pertaining to the remaining patients (81.1%)was available. The mean survival was 17.7 weeks (range, 2 to 60 weeks). Twenty-three of the 30 patients had died, but 5 patients had survived 12 months or longer. One of these patients had a non-Hodgkin's lymphoma, 2 had metastatic carcinoma of the breast, and 2 had mesothelioma. Two patients required further treatment for recurrence of effusions after talc pleurodesis. Eighteen months after the initial pleurodesis, 1patient with mesothelioma had reaccumulation of the effusion, which was successfully managed by insertion of a pleuroperitoneal shunt. He is alive and well 3 months after shunt insertion. In the second patient, who had a metastatic adenocarcinoma, dyspnea developed secondary to recurrence of the effusion 3 months after pleurodesis. This was managed by simple aspiration by his physician. The patient died 3 months later.

Comment This study confirms the findings of previous authors [6, 71 that thoracoscopy can achieve a high diagnostic yield for

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Table 2. Summary of Data on Patients Who Died After Thoracoscopy Patient Variable

1

2

3

4

5

Age (Y) Sex Indication

77 M

68

68

55 M

71

Risk factors Procedure Disease Clinical cause of death Autopsy

Pleural effusion COAD, FEV,/FVC 0.46, diabetes Thoracoscopy and biopsy Metastatic adenocarcinoma Cardiac arrest Not done

COAD = chronic obstructive airway disease;

M Pneumothorax COAD, FEV,/FVC 0.29 Thoracoscopy and pleurodesis Emphysema Respiratory failure Panlobular emphysema FEV,/FVC

=

F

M Hydropneumothorax

Pleural effusion Mild COAD

Pleural effusion

...

...

Thoracoscopy and biopsy Not established Cardiac arrest

Thoracoscopy and biopsy Metastatic adenocarcinoma Malignant cachexia Not done

Thoracoscopy and pleurodesis Metastatic adenocarcinoma Malignant cachexia Not done

Cardiac failure

ratio of forced expiratory volume in 1 second to forced vital capacity.

pleural effusions and an equally high success rate for talc pleurodesis for pleural effusions or pneumothoraces. Further, the recurrence rate reported after talc pleurodesis for pneumothorax has been low. In a study of 241 patients followed up for up to 16.8 years, a mean recurrence rate of 6.6% was found [8]. This reflects the ability to visualize the whole pleural cavity with single-lung anesthesia and break down any pleuropulmonary adhesions under direct vision. Talc can then be delivered to the whole lung surface, ensuring the best chance of success. Performing the procedure under a general anesthetic not only permits excellent access but minimizes the pain to the patient from a chemical pleurodesis. It is important to note that in both our patients in whom talc pleurodesis was unsuccessful, failure of the lung to expand fully with positive-pressure ventilation was recognized during thoracoscopy, a finding that has also been reported by others [7]. In both our patients, a second chemical pleurodesis was required and a limited basal pneumothorax accepted as the best result possible before discharge. Further, our results for patients with malignancies of the pleural cavity who had undergone talc pleurodesis also support the value of this technique in a group of terminally ill patients. Only 2 (6.7%) of the 30 patients who were followed up had recurrence of symptoms because of redevelopment of effusions. Acute pneumonitis [9] and development of adult respiratory distress syndrome [lo] have been documented in patients who had talc introduced into the pleural cavity as a suspension in normal saline solution, rather than talc insufflated as a powder. Of the 3 patients in whom adult respiratory distress syndrome developed within 72 hours of pleurodesis, 1died. The possible pathogenesis remains unexplained, but there have been no further reports of this complication to date. In younger patients with pneumothoraces, we prefer the technique of pleural abrasion combined with oversewing or stapling of any obvious bullae [ll].Pleural abrasion avoids the potential morbidity of pleurectomy and the

uncertain long-term sequelae of talc pleurodesis in young patients with benign disease. Although talc poudrage has been associated with the development of mesothelioma from possible asbestos contamination of the talc, the link remains unproved [12]. Among 46 patients who had undergone talc pleurodesis and were followed up for 22 to 35 years, there were no cases of mesothelioma, and generalized pleural calcification and lung fibrosis developed in only 1patient [13]. Nevertheless, the latent period for the development of pleural neoplasia after exposure to asbestos may be as long as 40 years [12]. There has also been some concern about performing talc pleurodesis in patients with benign disease, as respiratory function may be impaired. In the study by Lange and associates [13], only a mild restrictive defect was found 22 to 35 years after talc pleurodesis for spontaneous pneumothorax; the total lung capacity averaged 89% of the predicted value. However, like other authors, we do not recommend talc pleurodesis for patients who may be future candidates for lung or heart-lung transplantation. To date, there has been a paucity of discussion in the literature as regards the complications after thoracoscopy; Table 3 provides the documented morbidity and mortality for patients who underwent thoracoscopy with general and local anesthesia. The development of surgical emphysema or bronchopleural fistula appears to be the most common complication. Both of our 2 patients who had a protracted air leak had undergone biopsy of lung that was covered in a thick visceral pleura infiltrated by metastatic carcinoma. In one of the largest series [16] to date, the incidence of clinically noticeable emphysema was 7%, which suggests that in most series this is probably an underreported complication. The risk of infection appears to be low, with only five infections recorded in a collected series of 1,145 patients (see Table 3); it is not our practice to administer prophylactic antibiotics to patients undergoing thoracoscopy. Patients with malignancies of the pleural cavity are at risk of development of tumor seeding at the site of the thoracoscopy incision, a finding present

OHRIETAL

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Table 3. Complications After Thoracoscopy Reported in the Literature Reference General Anesthesia Daniel et al, 1990 [7] Weissberg et al, 1980 [14] Ohri et al, 1992 [present series] Local Anesthesia Davidson et al, 1988 [15]

No. of Patients 40 (and 38 with eneral and 2 with ocal anesthesia) 73 100

K

30

Enk and Viskum, 1981 1161

566

Boutin et al, 1981 [17]

215

Decamp et al, 1973 [18]

121

in 6 of 215 patients discussed by Boutin and colleagues [17]. In a smaller series in which 2 of 30 patients had this problem, it was successfully palliated with radiotherapy [15]. Including the present series, we could find only three reported deaths after thoracoscopy. In the series of Boutin and co-workers [17], five deaths (2.3%) were recorded within 30 days of thoracoscopy. However, the authors stated that death was not due to thoracoscopy but to advanced disease. In our patients, advanced malignant disease was the only identifiable risk factor in 2 patients, but it was probably contributory to the death of another 1 of the remaining 3 patients who died. Patients with advanced malignancy are often malnourished with coexisting disease in other organ systems, a finding reflected in the long hospital stay after talc poudrage. This underscores the importance of patient selection for a group often containing terminally ill patients. There would appear to be little advantage in undertaking thoracoscopy with definite, albeit low risks of morbidity and mortality for a patient who has a very limited life expectancy, substantially compromised cardiorespiratory reserve, or both. In such patients, pleural effusions or pneumothoraces are best treated by repeated aspiration or tube drainage.

References Jacobaeus HC. Ueber die Moglichkeit die Zystoscopie bei Untersuchung serosen Hohlungen anzuwenden. Miinch Med Wochenschr 1910;572090-2. Oakes DD, Sherck JP, Brodsky JB, Mark JBD. Therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1984;87269-73. Jones JW, Kitahama A, Webb WR, McSwain N. Emergency thoracoscopy. A logical approach to chest trauma management. J Trauma 1981;21:2804. Bloomberg AE. Thoracoscopy in perspective. Surg Gynecol Obstet 1978;147433-43.

Morbidity

Mortality

Bronchopleural fistulas (2)

2 (5%): pulmona embolus, advanced lym$oma

Subcutaneous emphysema (2) Chest infection (2), bronchopleural fistulas (2), arrhythmia (1)

None 5 (5%) (see Table 2)

Tumor seeding at thoracoscopy site (2) Air embolism during insufflation (l), vasovagal attacks (2), emphysema (36) Intra leural hemorrhage (l), sufcutaneous emphysema (2), empyema (l),cardiac ischemia (l),tumor seeding at thoracoscopy site (6) “Minimal air leak hypotension” (6), empyema (1)

5 (2.3%): advanced malignancies

..

5. Senno A, Moallem S, Quijano ER, Adeyemo A, Clauss RH. Thoracoscopy with the fiberoptic bronchoscope. A simple method in diagnosing pleuropulmonary disease. J Thorac Cardiovasc Surg 1974;67606-11. 6. Atheme T. Thoracoscopy in the management of pleural effusions. Ir Med J 1982;75:406-7. 7. Daniel TM,Tribble CG, Rodgers BM. Thoracoscopy and talc poudrage for pneumothoraces and effusions. Ann Thorac Surg 1990;50:186-9. 8. Vanderschueren RG. Le talcage pleural dans le pneumothorax spontane. Poumon Coeur 1981;3727M. 9. Bouchama A, Chastre J, Gaudichet A, Soler P, Gibert C. Acute pneumonitis with bilateral pleural effusion after talc pleurodesis. Chest 1984;86:795-7. 10. Rinaldo JE, Owens GR, Rodgers BM. Adult respiratory distress syndrome following intrapleural instillation of talc. J Thorac Cardiovasc Surg 1983;85:523-6. 11. Nekere UU, Griffin SC, Fountain SW. Pleural abrasion: a new method of pleurodesis. Thorax 1991;46:596-8. 12. Research Committee of the British Thoracic Association and the Medical Research Council Pneumoconiosis Unit. A survey of the long-term effects of talc and kaolin pleurodesis. Br J Dis Chest 1979;73:285-8. 13. Lange P, Mortensen J, Groth S. Lung function 22-35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage. Thorax 1988;43: 559-61. 14. Weissberg D, Kaufman M, Zurkowski Z. Pleuroscopy in patients with pleural effusion and pleural masses. Ann Thorac Surg 1980;29:205-8. 15. Davidson AC, George RJ, Sheldon CD, Sinha G, Corrin G, Geddes D. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988;43:327-32. 16. Enk 8, Viskum K. Diagnostic thoracoscopy. Eur J Respir Dis 1981;62:34&51. 17. Boutin C, Viallat JR, Cargnino P, Farisse P.Thoracoscopy in malignant effusions. Am Rev Respir Dis 1981;124:588-92. 18. Decamp PT,Moseley PW, Scott ML, Hatch HB Jr. Diagnostic thoracoscopy. Ann Thorac Surg 1973;16:7p84.