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Subcutaneous access ports with fenestrated catheters for improved management of recurrent pleural effusions
HOW I DO IT
Subcutaneous Access Ports with Fenestrated Catheters for Improved Management of Recurrent Pleural Effusions Donald N. Reed, Jr., MD, James J. Vyskocil, MD, Venkat Rao, MD, Flint, Michigan
Repeated percutaneous thoracentesis can involve serious complications, such as pneumothorax or infection. Alternatives such as placement of chest tubes or pleurodesis have their own potential complications. Creative options such as pleuroperitoneal shunting and video thoracoscopy have previously been used to avoid the disadvantages of repeated percutaneous thoracentesis. This paper describes an easy and effective method for managing these patients without repeated percutaneous thoracentesis. A port is inserted that can be accessed percutaneously and immediately for needed aspirations. We have successfully performed this procedure on 6 patients. Our hope is that the easy access using a short needle into the port aperture will allow the thoracentesis to be performed by appropriately instructed and supervised paramedical personnel. Also, with fewer postprocedure chest radiographs or hemothoraceses, future benefits from this procedure could include cost effectiveness. Am J Surg. 1999;177:145–146. © 1999 by Excerpta Medica, Inc.
tion, we have developed a method for managing these patients that is easy and effective and could prove to be cost effective.
METHODS With the patient in the supine position in the operating room, the lower thorax on the affected side is prepared and draped in a standard fashion, and the patient is given intravenous sedation. After injecting a local anesthetic, a transverse incision is made approximately 5 to 6 cm in length, and a subcutaneous pocket is created with electrocautery. A subcutaneous reservoir, similar to those used for chemotherapy, is sutured to the fascia superficial to the rib cage. Then, a length of catheter is cut that will extend from the port to the fifth or sixth interspace, and then down into the pleural gutter. This length is estimated using fluoroscopy. The interspace is opened on top of the selected rib just prior to inserting the catheter. The precut catheter is fenestrated with multiple side
I
t has been estimated that more than one million cases of pleural effusions occur annually in this country, from myriad causes such as congestive heart failure, pneumonia, peritonitis, primary and secondary pulmonary malignancies, renal failure, and the like.1 Surgeons and pulmonologists alike are often called upon to palliate symptoms by percutaneous thoracentesis. This procedure, however, has complications, such as pneumothorax or infection, when used repeatedly. Alternatives such as placement of chest tubes or pleurodesis have their own potential complications.2– 4 More creative options such as pleuroperitoneal shunting and video thoracoscopy have been previously described in an ongoing effort by physicians to avoid the disadvantages of repeated percutaneous thoracentesis.5,6 At our institu-
From the Departments of Surgery (DNR) and Pulmonary Medicine (JJV, VR), McLaren Regional Medical Center, an affiliated hospital of the Michigan State University College of Human Medicine, Flint, Michigan. Request for reprints should be addressed to Donald N. Reed, MD, Department of Surgery, University of Louisville, Louisville, Kentucky 40292. Manuscript submitted June 2, 1998, and accepted in revised form November 18, 1998.
© 1999 by Excerpta Medica, Inc. All rights reserved.
Figure 1. Chest wall (cutaway view) showing the incisions and access area for aspiration. Lower incision has pocket for port, and upper incision is for the insertion site where catheter goes through chest wall. 0002-9610/99/$–see front matter PII S0002-9610(98)00321-3
145
MANAGING RECURRENT PLEURAL EFFUSIONS/REED ET AL
Figure 2. Drawing of design for a better catheter, with precut side holes, built-in curve to go over the ribs, and weighted tip to help keep catheter in the gutter. Pictured is a modified double-lumen catheter, but a single lumen can also be used.
holes using surgical scissors to create defects that are about 3 to 6 mm long, placed at 1 to 1.5 cm intervals, and staggered on alternate sides of the catheter. After opening the interspace, it is then directed down into the gutter, preferably using digital guidance to better assure accurate placement. The final position is then confirmed with fluoroscopy. If desired, an absorbable purse string can be placed at the interspace to decrease possible leakage around the catheter. The skin incision is closed in two layers. A chest radiograph should be obtained at the end of the procedure to confirm position. This port can be accessed percutaneously and immediately for needed aspirations (see Figure 1).
RESULTS This technique has been successfully performed on 6 patients. It was first used in April 1996 and most recently in September 1997. In this population of patients who often have guarded prognoses, it is problematic to show improved survival, or the equivalent, as an endpoint to justify this new procedure. Two of the patients died from their underlying disease before their ports were used for very long. One port was removed owing to wound infection, but there have been no other known complications thus far. Three patients are still alive with the devices in place. One of the three has been in use for more than 3 months.
CONCLUSIONS One prior report, in 1986, described a similar procedure but did not describe the catheter modifications we have made in an effort to avoid catheter occlusion.1 Our hope is that the easy access using a short needle into the port
146
aperture will allow the thoracentesis to be done by appropriately instructed and supervised paramedical personnel. Also, with fewer postprocedure chest radiographs or hemothoraceses, it could be quite cost effective. We feel that improvements such as a larger diameter catheter with thick walls to prevent collapse upon aspiration, a weighted tip to help keep it in the gutter, and a semirigid sleeve that slides over the catheter to avoid kinking and aid its angulation over the rib will make this device even better. A drawing of these improvements can be seen in Figure 2. Also, the catheter could be designed to be placed with an introducer kit and peel-away sheath to improve ease of placement. Surgeons may find our method useful in the management of recurrent pleural effusions in this difficult group of patients.
REFERENCES 1. Leff RS, Eisenberg B, Baisden CE, et al. Drainage of recurrent pleural effusion via an implanted port and intrapleural catheter. Ann Intern Med. 1986;104:208 –209. 2. Seneff MG, Corwin RW, Gold LH, Irwin RS. Complications associated with thoracentesis. Chest. 1986;90:97–100. 3. Lee KA, Harvey JC, Reich R, Beattie EJ. Management of malignant pleural effusions with pleuroperitoneal shunting. J Am Coll Surg. 1994;178:586 –588. 4. Robinson RD, Fullerton DA, Albert JD, et al. Use of pleural Tenckhoff catheter to palliate malignant pleural effusion. Ann Thorac Surg. 1994;57:286 –288. 5. Milanez RC, Vargas FS, Filomeno LB, et al. Intrapleural talc for the treatment of malignant pleural effusions secondary to breast cancer. Cancer. 1995;75:2688 –2692. 6. Chang Y-C, Patz EF, Goodman PC. Pneumothorax after smallbore catheter placement for malignant pleural effusions. AJR. 1996; 166:1049 –1051.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999
Subcutaneous Access Ports with Fenestrated Catheters for Improved Management of Recurrent Pleural Effusions Donald N. Reed, Jr., MD, James J. Vyskocil, MD, Venkat Rao, MD, Flint, Michigan
Repeated percutaneous thoracentesis can involve serious complications, such as pneumothorax or infection. Alternatives such as placement of chest tubes or pleurodesis have their own potential complications. Creative options such as pleuroperitoneal shunting and video thoracoscopy have previously been used to avoid the disadvantages of repeated percutaneous thoracentesis. This paper describes an easy and effective method for managing these patients without repeated percutaneous thoracentesis. A port is inserted that can be accessed percutaneously and immediately for needed aspirations. We have successfully performed this procedure on 6 patients. Our hope is that the easy access using a short needle into the port aperture will allow the thoracentesis to be performed by appropriately instructed and supervised paramedical personnel. Also, with fewer postprocedure chest radiographs or hemothoraceses, future benefits from this procedure could include cost effectiveness. Am J Surg. 1999;177:145–146. © 1999 by Excerpta Medica, Inc.
tion, we have developed a method for managing these patients that is easy and effective and could prove to be cost effective.
METHODS With the patient in the supine position in the operating room, the lower thorax on the affected side is prepared and draped in a standard fashion, and the patient is given intravenous sedation. After injecting a local anesthetic, a transverse incision is made approximately 5 to 6 cm in length, and a subcutaneous pocket is created with electrocautery. A subcutaneous reservoir, similar to those used for chemotherapy, is sutured to the fascia superficial to the rib cage. Then, a length of catheter is cut that will extend from the port to the fifth or sixth interspace, and then down into the pleural gutter. This length is estimated using fluoroscopy. The interspace is opened on top of the selected rib just prior to inserting the catheter. The precut catheter is fenestrated with multiple side
I
t has been estimated that more than one million cases of pleural effusions occur annually in this country, from myriad causes such as congestive heart failure, pneumonia, peritonitis, primary and secondary pulmonary malignancies, renal failure, and the like.1 Surgeons and pulmonologists alike are often called upon to palliate symptoms by percutaneous thoracentesis. This procedure, however, has complications, such as pneumothorax or infection, when used repeatedly. Alternatives such as placement of chest tubes or pleurodesis have their own potential complications.2– 4 More creative options such as pleuroperitoneal shunting and video thoracoscopy have been previously described in an ongoing effort by physicians to avoid the disadvantages of repeated percutaneous thoracentesis.5,6 At our institu-
From the Departments of Surgery (DNR) and Pulmonary Medicine (JJV, VR), McLaren Regional Medical Center, an affiliated hospital of the Michigan State University College of Human Medicine, Flint, Michigan. Request for reprints should be addressed to Donald N. Reed, MD, Department of Surgery, University of Louisville, Louisville, Kentucky 40292. Manuscript submitted June 2, 1998, and accepted in revised form November 18, 1998.
© 1999 by Excerpta Medica, Inc. All rights reserved.
Figure 1. Chest wall (cutaway view) showing the incisions and access area for aspiration. Lower incision has pocket for port, and upper incision is for the insertion site where catheter goes through chest wall. 0002-9610/99/$–see front matter PII S0002-9610(98)00321-3
145
MANAGING RECURRENT PLEURAL EFFUSIONS/REED ET AL
Figure 2. Drawing of design for a better catheter, with precut side holes, built-in curve to go over the ribs, and weighted tip to help keep catheter in the gutter. Pictured is a modified double-lumen catheter, but a single lumen can also be used.
holes using surgical scissors to create defects that are about 3 to 6 mm long, placed at 1 to 1.5 cm intervals, and staggered on alternate sides of the catheter. After opening the interspace, it is then directed down into the gutter, preferably using digital guidance to better assure accurate placement. The final position is then confirmed with fluoroscopy. If desired, an absorbable purse string can be placed at the interspace to decrease possible leakage around the catheter. The skin incision is closed in two layers. A chest radiograph should be obtained at the end of the procedure to confirm position. This port can be accessed percutaneously and immediately for needed aspirations (see Figure 1).
RESULTS This technique has been successfully performed on 6 patients. It was first used in April 1996 and most recently in September 1997. In this population of patients who often have guarded prognoses, it is problematic to show improved survival, or the equivalent, as an endpoint to justify this new procedure. Two of the patients died from their underlying disease before their ports were used for very long. One port was removed owing to wound infection, but there have been no other known complications thus far. Three patients are still alive with the devices in place. One of the three has been in use for more than 3 months.
CONCLUSIONS One prior report, in 1986, described a similar procedure but did not describe the catheter modifications we have made in an effort to avoid catheter occlusion.1 Our hope is that the easy access using a short needle into the port
146
aperture will allow the thoracentesis to be done by appropriately instructed and supervised paramedical personnel. Also, with fewer postprocedure chest radiographs or hemothoraceses, it could be quite cost effective. We feel that improvements such as a larger diameter catheter with thick walls to prevent collapse upon aspiration, a weighted tip to help keep it in the gutter, and a semirigid sleeve that slides over the catheter to avoid kinking and aid its angulation over the rib will make this device even better. A drawing of these improvements can be seen in Figure 2. Also, the catheter could be designed to be placed with an introducer kit and peel-away sheath to improve ease of placement. Surgeons may find our method useful in the management of recurrent pleural effusions in this difficult group of patients.
REFERENCES 1. Leff RS, Eisenberg B, Baisden CE, et al. Drainage of recurrent pleural effusion via an implanted port and intrapleural catheter. Ann Intern Med. 1986;104:208 –209. 2. Seneff MG, Corwin RW, Gold LH, Irwin RS. Complications associated with thoracentesis. Chest. 1986;90:97–100. 3. Lee KA, Harvey JC, Reich R, Beattie EJ. Management of malignant pleural effusions with pleuroperitoneal shunting. J Am Coll Surg. 1994;178:586 –588. 4. Robinson RD, Fullerton DA, Albert JD, et al. Use of pleural Tenckhoff catheter to palliate malignant pleural effusion. Ann Thorac Surg. 1994;57:286 –288. 5. Milanez RC, Vargas FS, Filomeno LB, et al. Intrapleural talc for the treatment of malignant pleural effusions secondary to breast cancer. Cancer. 1995;75:2688 –2692. 6. Chang Y-C, Patz EF, Goodman PC. Pneumothorax after smallbore catheter placement for malignant pleural effusions. AJR. 1996; 166:1049 –1051.
THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 FEBRUARY 1999