Single versus multiple access video-assisted thoracic surgery in the treatment of malignant pleural effusion

Abstract

Talc pleurodesis for malignant pleural effusion (MPE) is a procedure which, undoubtedly, is useful in the approach to advanced stage cancer patients whose quality of life is severely impaired by this clinical occurrence. In this setting, we really appreciate the report from Stefani and co-workers [1] that, even within the limits of a prospective nonrandomized trial, gives a clear and evidence-based rationale to support talc poudrage for MPE per se and suggests some valuable criteria to support the decision-making process towards the indication for a videothoracoscopic procedure (thoracoscopic talc poudrage—TP) or a bedside one (talc slurry—TS). We now had time to evaluate retrospectively our experience with 317 patients with MPE who, in the period from January 1995 to December 2006, underwent TP. In the same period, 76 patients underwent bedside TS, due to very poor clinical conditions. The comparison of these two groups in terms of efficacy (successful pleurodesis within 90 days from procedure) largely confirms the authors’ conclusion that TP is better than TS (87.5% vs 72.3%, p < 0.01). Unlike the figures reported in [1], the incidence of post-procedural pain was different, but not significantly, in the two groups. Herein we would like to report our results when a single access thoracoscopic procedure is compared with a multiple accesses procedure (two or more). Of the 317 patients, in fact, 187 underwent a single access procedure (group A) in which a 5 mm camera was introduced in the same port (12 mm) along with instruments for suction, pleurolysisbiopsy and poudrage (pneumatically atomized talc — 6 g — through a soft silicone tube); a single chest drain, 28 Fr, was inserted through the same hole. The remaining 130 cases underwent a standard, multiple accesses procedure (group B). Morbidity and mortality (30-day procedure related, nil in both groups) did not differ between the two groups. Analgesic drug administration (elastomeric pump for continuous infusion of 20 mg morphine plus 150 mg ketorolac at 2 ml/h/48 h) was discontinued after 48 h in 81% of the patients in group A and in 61% in group B (p = 0.0001). No statistical differences in terms of procedure efficacy (endpoint: MPE recurrence) were found between the two groups. Our results strongly support the value of TP in the treatment of MPE as reported in [1]. We would really appreciate the authors’ reflection and reaction in considering and discussing a single approach for TP.