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Use of pleural tenckhoff catheter to palliate malignant pleural effusion
ORIGINAL ARTICLES
Use of Pleural Tenckhoff Catheter to Palliate Malignant Pleural Effusion Robert D. Robinson, BS, David A. Fullerton, MD, James D. Albert, MD, Julie Sorensen, and Michael R. Johnston, MD Department of Surgery, University of Colorado Health Sciences Center, Denver, Colorado, and Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
Malignant pleural effusion and its treatment both cause substantial morbidity in patients with advanced neoplastic disease. We hypothesized that this morbidity might be ameliorated by placement of an indwelling Tenckhoff catheter into the involved pleural space. Catheters were placed in 9 patients under local anesthesia. Three patients underwent bilateral catheter placement, for a total of 12 catheters placed. Four of the 9 patients had undergone previous unsuccessful pleurodesis (using tetracycline or bleomycin). Whenever it became symptomatic, the malignant pleural effusion was simply drained into a calibrated container and the volume recorded. Patients were followed on a weekly basis until their death (mean, 16 weeks). The mean drainage was 477 mL per 24 hours (range, 200 to 1,100 mL). No pleural space infections
M
alignant pleural effusion and its treatment both cause substantial morbidity in patients with advanced neoplastic disease. Not only do such effusions give rise to substantial pulmonary embarrassment, but the currently available treatments may have limited efficacy, cause considerable pain, or require multiple hospitalizations during the remaining life expectancy of these patients. Options for the treatment of malignant pleural effusions include repeated thoracentesis, tube thoracostomy with chemical sclerosis, talc pleurodesis, thoracotomy with mechanical sclerosis or decortication, irradiation or chemotherapy, and pleural peritoneal shunts. However, the failure rate associated with all these therapies is at least 20%, particularly in those cases in which the lung is trapped or a thick cortical peel precludes pleural apposition. Thus, the short remaining life span in these unfortunate patients is complicated not only by the direct sequelae of the effusion but also by the invasive procedures required to treat the effusions. We hypothesized that the morbidity associated with malignant pleural effusion and its treatment could be minimized through placement of an externally draining Tenckhoff catheter (Quinton Instrument, Seattle, WA) Presented at the Poster Session of the Twenty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 2527, 1993. Address reprint requests to Dr Fullerton, Department of Surgery, Campus Box C-310, University of Colorado Health Science Ctr, Denver, CO 80262.
0 1994 by The Society of Thoracic Surgeons
occurred, although local cellulitis developed in 3 patients around the catheter exit site; all patients responded to oral antibiotics. There were no significant changes in either the serum albumin or total protein levels. No catheters malfunctioned and no patients required further treatment or hospitalization for symptoms of malignant pleural effusion. We conclude that this technique may reduce the morbidity stemming from malignant pleural effusion and its treatment by allowing patients to conveniently and painlessly drain the effusion at home when it becomes symptomatic. This technique may provide superior palliation in patients with malignant pleural effusion.
(Ann Thorac Surg 1994;57:286-8)
into the involved pleural space. In this way, patients would be able to evacuate the pleural fluid conveniently and painlessly at home whenever it became symptomatic. We report our results with this treatment in 9 patients with malignant pleural effusion.
Material and Methods Catheters were placed in 9 patients (mean age, 55 years; range 31 to 80 years). All patients had cytologically confirmed symptomatic malignant pleural effusions. Primary tumor types included lung carcinoma (n = 3), breast carcinoma (n = 2), lymphoma (n = l),renal cell carcinoma (n = l), osteogenic sarcoma (n = l), and multiple myeloma (n = 1).Catheters were placed bilaterally in 3 of the 9 patients, bringing the total to 12 catheters. Five of 9 patients were enrolled in an ongoing prospective study of pleural interferon administration, but had shown no objective results. In 4 of 9 patients, previous tube thoracostomy and chemical pleurodesis (using tetracycline or bleomycin) had failed. The effusion in all patients was symptomatic, as manifested by dyspnea at rest and on exertion, orthopnea, increasing oxygen requirement, and chest pain. All patients gave informed consent for the procedure.
Technique of Catheter Insertion The Tenckhoff catheter is made of translucent silicone rubber tubing and contains a radiopaque stripe. A felt cuff comes attached to the catheter and is positioned at place0003-4975/94/$7.00
ROBINSON ET AL TENCKHOFF FOR MALIGNANT EFFUSION
Ann Thorac Surg 1994;57286-8
287
between each drainage procedure. The patients or visiting nurses would simply drain the fluid into a calibrated container whenever the effusion was symptomatic. The volume of the drainage fluid was recorded in a daily log. Patients were examined approximately each week in the oncology clinic and follow-up data were collected by our data manager. Routine blood chemistry, including serum total protein and albumin levels, and chest x-ray studies were checked at each clinic follow-up visit. Pleural fluid was cultured weekly. Statistical evaluation employed paired Student’s t tests.
Results
A Catheter----//
=cuff Pull-apart Transducer\
l/fi
,Skin
B Fig 1 . ( A ) The catheter is brought through a 15-cm subcutaneous tunnel before being introduced into the pleural space. The felt cuff is positioned just within the skin exit site. ( B ) The Tear Apart Introducer Kit (Quinton Instrument, Seattle, WA) is used to insert the catheter into the pleural space.
ment just within the skin exit site. The catheter is equipped with a plastic occluding device, which may be opened to drain the fluid. Patients underwent catheter placement under local anesthesia in the operating room. To perform the procedure, the chest was elevated approximately 30 degrees and two small incisions were made. As shown in Figure 1, the catheter was brought through a 15-cm subcutaneous tunnel between these two small incisions. The intercostal membrane and pleura of the sixth or seventh intercostal space were cannulated with a needle. Using the Seldinger technique and a Tear Apart Introducer Kit (Quinton Instrument), the catheter was introduced and positioned so that the felt cuff on the catheter lay just within the exit wound. The catheter was secured to the skin exit site and the wound was sterilely dressed.
Patient Follow-up After placement, the catheter was cared for in a sterile fashion and was dressed with a sterile gauze dressing
Patients were followed up until their death (range, 8 days to 56 weeks; mean, 16 weeks). One operative death occurred in a moribund patient who suffered respiratory arrest as a result of intravenous sedation, and who had previously directed that she not be resuscitated. All catheters acutely drained approximately 75% of the malignant pleural effusion, as estimated from the roentgenogram obtained after catheter placement. All patients reported excellent palliation. The 5 patients enrolled in the intrapleural interferon study were so impressed by the palliation, that, once the study ended, they refused to allow catheter removal. The mean volume of drainage was 477 mLl24 h (range, 200 to 1,000 mL/24 h). The serum protein level before catheter placement was 6.5 +- 0.5 g/dL (mean 2 standard error of the mean), and this was unchanged at end of follow-up, at 6.2 2 0.5 g/dL ( p = 0.80). Likewise, the serum albumin level before catheter placement was 3.4 t 0.4 gIdL, and this was unchanged at the end follow-up, at 3.2 2 0.4 g/dL ( p = 0.8). Local wound cellulitis developed at 3 of the 12 catheter exit sites, but this resolved with oral antibiotic therapy. However, pleural space infection developed in no patients and no positive blood cultures were reported. Three patients were found to have an asymptomatic pneumothorax on their initial chest roentgenogram obtained after catheter placement, but this resolved within 48 hours. No patients demonstrated pneumothorax on subsequent chest roentgenograms. There were no catheter failures and no patient reported subsequent hospitalization for the treatment of malignant pleural effusion. Chest radiographs obtained in a patient with a catheter in place for 56 weeks are provided in Figure 2.
Comment The life expectancy of patients with malignant pleural effusion is only approximately 4 months [l].Therefore, the objective of treatment of malignant pleural effusion is successful palliation of the pulmonary symptoms with as little attendant morbidity as possible. Unfortunately, the modes of therapy available produce considerable morbidity. Repeated thoracentesis may be painful and inconvenient, and carries with it the risk of causing infection in the pleural space and of precipitating pneumothorax.
288
A n n Thorac Surg
ROBINSON ET AL TENCKHOFF FOR MALIGNANT EFFUSION
A
B Fig 2. (A) Chest radiograph obtained before insertion of catheter into left pleural space. ( B ) Chest radiograph of same patient obtained after catheter had been in place for 55 weeks.
Furthermore, there is often rapid reaccumulation of the malignant effusion. Tube thoracostomy with chemical sclerosis requires hospitalization and an invasive procedure. In addition, both tube thoracostomy and chemical sclerosis may be extremely painful to patients who are frequently quite ill. Before its removal from the market, tetracycline pleurodesis was found to have a success rate of approximately 70% [2, 31. Doxycycline and bleomycin are currently used for chemical sclerosis, but their success rate is probably comparable to that of tetracycline. As high as a 93% rate of successful pleurodesis has been reported for aerosolized talc [ 2 ] . However, in situations of a trapped lung or thick pleural peel, talc sclerotherapy is often unsuccessful. Furthermore, aerosolized talc is generally administered via thoracoscopy under general anesthesia, which is a potentially risky procedure in patients who may be quite ill. Use of a pleuroperitoneal catheter was stimulated by concern about the considerable morbidity associated with tube thoracostomy and sclerosis. However, the shunt requires regular pumping by the patient, which may be
1994;57286-8
not only painful but also difficult to perform for patients who are terminally ill [4]. The acute failure rate for these shunts is reported to range as high as 17% to 20% [5, 61. Most authors have placed the shunts under general anesthesia, and some have even reported using a limited thoracotomy incision for placement [ 6 ] . We therefore sought an effective mode of palliation for these patients that would entail less morbidity than the currently available treatment options. Our findings suggest that placement of a Tenckhoff catheter into the pleural space may be a valuable procedure in the treatment of malignant pleural effusion. All patients in this small series reported excellent symptomatic improvement. The catheters were conveniently managed and drained by the patients or visiting nurses. No pumping was required. No catheters malfunctioned and none required removal during the course of follow-up. Pneumothorax also developed in no patients during follow-up, although no special precautions were taken to prevent it. The reason for this is unclear, but perhaps pleural adhesions prevented pneumothorax formation. Infection, of course, remains a concern with any permanent indwelling catheter; however, no serious infections occurred in our patients. All cases of local cellulitis were easily cured with oral antibiotics, and no pleural space infections or positive blood cultures were encountered. Perhaps because all of these patients are cancer victims and are accustomed to caring for permanent indwelling lines in a sterile fashion, contamination of the catheter was not an important problem. Furthermore, despite the large volumes of pleural fluid drained, there were no striking changes in the total serum protein or albumin levels. A final advantage is that the procedure can be performed under local anesthesia on an outpatient basis. Therefore, in these very debilitated patients, general anesthesia and a protracted hospital course are avoided. We, therefore, conclude that this technique may bring about a reduction in the morbidity associated with malignant pleural effusion and its treatment by allowing patients to conveniently and painlessly drain the effusion at home when it becomes symptomatic. This technique may be especially valuable in those patients with malignant pleural effusion who have failed other modes of therapy or who are especially debilitated.
References 1. Chernow B, Sahn SA. Carcinomatous involvement of the pleura. Am J Med 1977;63:695-702. 2. Fentiman IS. Effective treatment of malignant pleural effusions. Br J Hosp Med 1987;37421-8. 3. Good JT Jr, Sahn SA. Intrapleural therapy with tetracycline in malignant pleural effusions. The importance of proper technique. Chest 1978;74:602. 4. Ponn RB, Blancaflor J, DAgostino RS, Kiernan ME, Toole AL, Stern H. Pleuroperitoneal shunting for intractable pleural effusions. Ann Thorac Surg 1991;51:605-9. 5. Little AG, Kadowaki MH, Ferguson MK, Staszek VM, Skinner DJ. Pleuro-peritoneal shunting:alternative therapy for pleural effusions. Ann Surg 1988;208:443-50. 6. Tsang V, Fernando HC, Goldstraw P. Pleuroperitoneal shunt for recurrent malignant pleural effusions. Thorax 1990;45:
369-72.
Use of Pleural Tenckhoff Catheter to Palliate Malignant Pleural Effusion Robert D. Robinson, BS, David A. Fullerton, MD, James D. Albert, MD, Julie Sorensen, and Michael R. Johnston, MD Department of Surgery, University of Colorado Health Sciences Center, Denver, Colorado, and Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
Malignant pleural effusion and its treatment both cause substantial morbidity in patients with advanced neoplastic disease. We hypothesized that this morbidity might be ameliorated by placement of an indwelling Tenckhoff catheter into the involved pleural space. Catheters were placed in 9 patients under local anesthesia. Three patients underwent bilateral catheter placement, for a total of 12 catheters placed. Four of the 9 patients had undergone previous unsuccessful pleurodesis (using tetracycline or bleomycin). Whenever it became symptomatic, the malignant pleural effusion was simply drained into a calibrated container and the volume recorded. Patients were followed on a weekly basis until their death (mean, 16 weeks). The mean drainage was 477 mL per 24 hours (range, 200 to 1,100 mL). No pleural space infections
M
alignant pleural effusion and its treatment both cause substantial morbidity in patients with advanced neoplastic disease. Not only do such effusions give rise to substantial pulmonary embarrassment, but the currently available treatments may have limited efficacy, cause considerable pain, or require multiple hospitalizations during the remaining life expectancy of these patients. Options for the treatment of malignant pleural effusions include repeated thoracentesis, tube thoracostomy with chemical sclerosis, talc pleurodesis, thoracotomy with mechanical sclerosis or decortication, irradiation or chemotherapy, and pleural peritoneal shunts. However, the failure rate associated with all these therapies is at least 20%, particularly in those cases in which the lung is trapped or a thick cortical peel precludes pleural apposition. Thus, the short remaining life span in these unfortunate patients is complicated not only by the direct sequelae of the effusion but also by the invasive procedures required to treat the effusions. We hypothesized that the morbidity associated with malignant pleural effusion and its treatment could be minimized through placement of an externally draining Tenckhoff catheter (Quinton Instrument, Seattle, WA) Presented at the Poster Session of the Twenty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 2527, 1993. Address reprint requests to Dr Fullerton, Department of Surgery, Campus Box C-310, University of Colorado Health Science Ctr, Denver, CO 80262.
0 1994 by The Society of Thoracic Surgeons
occurred, although local cellulitis developed in 3 patients around the catheter exit site; all patients responded to oral antibiotics. There were no significant changes in either the serum albumin or total protein levels. No catheters malfunctioned and no patients required further treatment or hospitalization for symptoms of malignant pleural effusion. We conclude that this technique may reduce the morbidity stemming from malignant pleural effusion and its treatment by allowing patients to conveniently and painlessly drain the effusion at home when it becomes symptomatic. This technique may provide superior palliation in patients with malignant pleural effusion.
(Ann Thorac Surg 1994;57:286-8)
into the involved pleural space. In this way, patients would be able to evacuate the pleural fluid conveniently and painlessly at home whenever it became symptomatic. We report our results with this treatment in 9 patients with malignant pleural effusion.
Material and Methods Catheters were placed in 9 patients (mean age, 55 years; range 31 to 80 years). All patients had cytologically confirmed symptomatic malignant pleural effusions. Primary tumor types included lung carcinoma (n = 3), breast carcinoma (n = 2), lymphoma (n = l),renal cell carcinoma (n = l), osteogenic sarcoma (n = l), and multiple myeloma (n = 1).Catheters were placed bilaterally in 3 of the 9 patients, bringing the total to 12 catheters. Five of 9 patients were enrolled in an ongoing prospective study of pleural interferon administration, but had shown no objective results. In 4 of 9 patients, previous tube thoracostomy and chemical pleurodesis (using tetracycline or bleomycin) had failed. The effusion in all patients was symptomatic, as manifested by dyspnea at rest and on exertion, orthopnea, increasing oxygen requirement, and chest pain. All patients gave informed consent for the procedure.
Technique of Catheter Insertion The Tenckhoff catheter is made of translucent silicone rubber tubing and contains a radiopaque stripe. A felt cuff comes attached to the catheter and is positioned at place0003-4975/94/$7.00
ROBINSON ET AL TENCKHOFF FOR MALIGNANT EFFUSION
Ann Thorac Surg 1994;57286-8
287
between each drainage procedure. The patients or visiting nurses would simply drain the fluid into a calibrated container whenever the effusion was symptomatic. The volume of the drainage fluid was recorded in a daily log. Patients were examined approximately each week in the oncology clinic and follow-up data were collected by our data manager. Routine blood chemistry, including serum total protein and albumin levels, and chest x-ray studies were checked at each clinic follow-up visit. Pleural fluid was cultured weekly. Statistical evaluation employed paired Student’s t tests.
Results
A Catheter----//
=cuff Pull-apart Transducer\
l/fi
,Skin
B Fig 1 . ( A ) The catheter is brought through a 15-cm subcutaneous tunnel before being introduced into the pleural space. The felt cuff is positioned just within the skin exit site. ( B ) The Tear Apart Introducer Kit (Quinton Instrument, Seattle, WA) is used to insert the catheter into the pleural space.
ment just within the skin exit site. The catheter is equipped with a plastic occluding device, which may be opened to drain the fluid. Patients underwent catheter placement under local anesthesia in the operating room. To perform the procedure, the chest was elevated approximately 30 degrees and two small incisions were made. As shown in Figure 1, the catheter was brought through a 15-cm subcutaneous tunnel between these two small incisions. The intercostal membrane and pleura of the sixth or seventh intercostal space were cannulated with a needle. Using the Seldinger technique and a Tear Apart Introducer Kit (Quinton Instrument), the catheter was introduced and positioned so that the felt cuff on the catheter lay just within the exit wound. The catheter was secured to the skin exit site and the wound was sterilely dressed.
Patient Follow-up After placement, the catheter was cared for in a sterile fashion and was dressed with a sterile gauze dressing
Patients were followed up until their death (range, 8 days to 56 weeks; mean, 16 weeks). One operative death occurred in a moribund patient who suffered respiratory arrest as a result of intravenous sedation, and who had previously directed that she not be resuscitated. All catheters acutely drained approximately 75% of the malignant pleural effusion, as estimated from the roentgenogram obtained after catheter placement. All patients reported excellent palliation. The 5 patients enrolled in the intrapleural interferon study were so impressed by the palliation, that, once the study ended, they refused to allow catheter removal. The mean volume of drainage was 477 mLl24 h (range, 200 to 1,000 mL/24 h). The serum protein level before catheter placement was 6.5 +- 0.5 g/dL (mean 2 standard error of the mean), and this was unchanged at end of follow-up, at 6.2 2 0.5 g/dL ( p = 0.80). Likewise, the serum albumin level before catheter placement was 3.4 t 0.4 gIdL, and this was unchanged at the end follow-up, at 3.2 2 0.4 g/dL ( p = 0.8). Local wound cellulitis developed at 3 of the 12 catheter exit sites, but this resolved with oral antibiotic therapy. However, pleural space infection developed in no patients and no positive blood cultures were reported. Three patients were found to have an asymptomatic pneumothorax on their initial chest roentgenogram obtained after catheter placement, but this resolved within 48 hours. No patients demonstrated pneumothorax on subsequent chest roentgenograms. There were no catheter failures and no patient reported subsequent hospitalization for the treatment of malignant pleural effusion. Chest radiographs obtained in a patient with a catheter in place for 56 weeks are provided in Figure 2.
Comment The life expectancy of patients with malignant pleural effusion is only approximately 4 months [l].Therefore, the objective of treatment of malignant pleural effusion is successful palliation of the pulmonary symptoms with as little attendant morbidity as possible. Unfortunately, the modes of therapy available produce considerable morbidity. Repeated thoracentesis may be painful and inconvenient, and carries with it the risk of causing infection in the pleural space and of precipitating pneumothorax.
288
A n n Thorac Surg
ROBINSON ET AL TENCKHOFF FOR MALIGNANT EFFUSION
A
B Fig 2. (A) Chest radiograph obtained before insertion of catheter into left pleural space. ( B ) Chest radiograph of same patient obtained after catheter had been in place for 55 weeks.
Furthermore, there is often rapid reaccumulation of the malignant effusion. Tube thoracostomy with chemical sclerosis requires hospitalization and an invasive procedure. In addition, both tube thoracostomy and chemical sclerosis may be extremely painful to patients who are frequently quite ill. Before its removal from the market, tetracycline pleurodesis was found to have a success rate of approximately 70% [2, 31. Doxycycline and bleomycin are currently used for chemical sclerosis, but their success rate is probably comparable to that of tetracycline. As high as a 93% rate of successful pleurodesis has been reported for aerosolized talc [ 2 ] . However, in situations of a trapped lung or thick pleural peel, talc sclerotherapy is often unsuccessful. Furthermore, aerosolized talc is generally administered via thoracoscopy under general anesthesia, which is a potentially risky procedure in patients who may be quite ill. Use of a pleuroperitoneal catheter was stimulated by concern about the considerable morbidity associated with tube thoracostomy and sclerosis. However, the shunt requires regular pumping by the patient, which may be
1994;57286-8
not only painful but also difficult to perform for patients who are terminally ill [4]. The acute failure rate for these shunts is reported to range as high as 17% to 20% [5, 61. Most authors have placed the shunts under general anesthesia, and some have even reported using a limited thoracotomy incision for placement [ 6 ] . We therefore sought an effective mode of palliation for these patients that would entail less morbidity than the currently available treatment options. Our findings suggest that placement of a Tenckhoff catheter into the pleural space may be a valuable procedure in the treatment of malignant pleural effusion. All patients in this small series reported excellent symptomatic improvement. The catheters were conveniently managed and drained by the patients or visiting nurses. No pumping was required. No catheters malfunctioned and none required removal during the course of follow-up. Pneumothorax also developed in no patients during follow-up, although no special precautions were taken to prevent it. The reason for this is unclear, but perhaps pleural adhesions prevented pneumothorax formation. Infection, of course, remains a concern with any permanent indwelling catheter; however, no serious infections occurred in our patients. All cases of local cellulitis were easily cured with oral antibiotics, and no pleural space infections or positive blood cultures were encountered. Perhaps because all of these patients are cancer victims and are accustomed to caring for permanent indwelling lines in a sterile fashion, contamination of the catheter was not an important problem. Furthermore, despite the large volumes of pleural fluid drained, there were no striking changes in the total serum protein or albumin levels. A final advantage is that the procedure can be performed under local anesthesia on an outpatient basis. Therefore, in these very debilitated patients, general anesthesia and a protracted hospital course are avoided. We, therefore, conclude that this technique may bring about a reduction in the morbidity associated with malignant pleural effusion and its treatment by allowing patients to conveniently and painlessly drain the effusion at home when it becomes symptomatic. This technique may be especially valuable in those patients with malignant pleural effusion who have failed other modes of therapy or who are especially debilitated.
References 1. Chernow B, Sahn SA. Carcinomatous involvement of the pleura. Am J Med 1977;63:695-702. 2. Fentiman IS. Effective treatment of malignant pleural effusions. Br J Hosp Med 1987;37421-8. 3. Good JT Jr, Sahn SA. Intrapleural therapy with tetracycline in malignant pleural effusions. The importance of proper technique. Chest 1978;74:602. 4. Ponn RB, Blancaflor J, DAgostino RS, Kiernan ME, Toole AL, Stern H. Pleuroperitoneal shunting for intractable pleural effusions. Ann Thorac Surg 1991;51:605-9. 5. Little AG, Kadowaki MH, Ferguson MK, Staszek VM, Skinner DJ. Pleuro-peritoneal shunting:alternative therapy for pleural effusions. Ann Surg 1988;208:443-50. 6. Tsang V, Fernando HC, Goldstraw P. Pleuroperitoneal shunt for recurrent malignant pleural effusions. Thorax 1990;45:
369-72.