Indwelling Pleural Catheter Placement Research Articles

Comparison of outcomes of surgical and other invasive treatment modalities for malignant pleural effusion in patients with pleural carcinomatosis.

Treatment modalities for malignant pleural effusion (MPE) are diverse. The objectives were to analyze actual clinical data from patients with MPE and pleural carcinomatosis and to compare the outcomes of different treatment modalities with regard to effectiveness, survival, morbidity, and mortality as well as the duration of hospitalization. Patients with pathologically proven pleural carcinomatosis or MPE from 2018 to 2020 were included in this retrospective-observational study with additional questionnaires. We identified four treatment modalities: (I) video-assisted thoracic surgery with pleurodesis (VATS, mechanical/chemical); (II) VATS with pleurodesis combined with indwelling pleural catheter (IPC) placement; (III) VATS (without pleurodesis) combined with IPC placement; and (IV) management with IPC placement alone. We enrolled 91 patients aged 38-90 years who were treated by either VATS-pleurodesis (N=22), VATS-IPC placement (N=21), a combination of VATS with pleurodesis and IPC placement (N=22), or IPC placement alone (N=26). The mean survival time was 138.3 days. No significant differences were detected among treatment groups regarding the outcome of pleurodesis failure, either initially or later. Patients in the VATS-pleurodesis with IPC group experienced significantly more complications than those in the other treatment modality groups [odds ratio (OR): 3.288, P=0.026]. However, no statistically significant differences were observed regarding the type of adverse event and survival. Hypoalbuminemia, systemic therapy, and successful pleurodesis (P=0.008; P=0.011; P=0.044, respectively) were significantly correlated with survival. In multiple linear regression, hypoalbuminemia persisted as an independent predictor of survival (P=0.031). The type of intervention showed significant differences regarding the duration of hospitalization (P=0.017). IPC placement alone shortened the mean total hospitalization time by 7.9, 5.9, and 7.0 days compared to VATS-pleurodesis (P≤0.001), VATS-IPC placement (P=0.004), and VATS-pleurodesis with IPC placement (P≤0.001), respectively. The survival time was very short, and each treatment group had pros and cons. Therefore, decisions should be made on a case-by-case basis. The use of an IPC, even if the lung is not trapped, can significantly reduce the length of hospital stay. VATS is needed when histology is needed. The ideal method for treating recurrent MPE should be simple, effective, and inexpensive, with minimal disturbance to the patient.

Tract seeding in indwelling pleural catheter placement for the drainage of malignant pleural effusions: Incidence and related clinical and imaging factors

BackgroundThe incidence of tract seeding after the placement of indwelling pleural catheter (IPC) for malignant pleural effusion drainage has been variable in the literature. Research questionTo evaluate the incidence of IPC-related cancer tract seeding and find out related demographic, clinical or imaging factors to the tract seeding. Study design and methodsThis retrospective study included 124 consecutive patients seen between January 2011 and December 2021 who underwent IPC placement for malignant pleural effusion drainage. Chest radiographs before IPC placement and serial chest CT studies were obtained. One patient was diagnosed pathologically, and the other patients were diagnosed as tract seeding radiologically. The incidence of and related factors to tract seeding were assessed by reviewing medical records and imaging studies. ResultsThe incidence of IPC tract seeding was 21.7% (27 of 124 malignant effusions). Of 27 patients, 15 had primary lung cancer and remaining 12 had extra-thoracic malignancy. Adenocarcinoma (19 of 27, 70.3%) either from the lung (N = 12) or extra-thoracic malignancy (N = 7) was the most common cell type. Mean time elapsed until tract seeding occurrence after IPC placement was 96 days (ranges; 28–306 days). The survival in seeding group after IPC placement was 185 days (ranges, 32–457 days). On odd ratio analysis, the presence of mediastinal pleural thickening (OR [95% CI]; 9.79 (2.67–35.84), p = 0.001) was significantly related to the occurrence of tract seeding. Neither tumor volume within pleural space (p = 0.168), duration of IPC indwelling (p = 0.142), days of survival after IPC placement (p = 0.26), nor pleural effusion amount (p = 0.481) was related to the tract seeding. InterpretationIPC tract seeding is seen in 27 (21.7%) of 124 malignant pleural effusion patients, particularly with adenocarcinoma cytology. CT features of mediastinal pleural thickening are related to the occurrence of tract seeding.

Indwelling pleural catheters for persistent pleural effusions secondary to post lung resection for malignancies.

Malignant and nonmalignant pleural effusions (NMPEs) such as those due to hepatic hydrothorax have been successfully treated with an indwelling pleural catheter (IPC) with a low complication rate. There is no literature on the utility or safety of this treatment modality for NMPE post lung resection. We aimed to assess the utility of IPC for recurrent symptomatic NMPE secondary to post lung resection in lung cancer patients over a period of 4 years. Patients who underwent lobectomy or segmentectomy as part of the treatment plan for lung cancer between January 2019 and June 2022 were identified, these patients were screened for post-surgical pleural effusion. A total of 422 underwent lung resection, of which 12 had recurrent symptomatic pleural effusions requiring IPC placement and were selected for final analysis. The primary end points were improved symptomatology and successful pleurodesis. Mean time to IPC placement was 78.4 days post-surgery. The mean length of IPC catheter was 77.7 days standard deviation (SD) 23.8. All 12 patients achieved spontaneous pleurodesis (SP), there was no second pleural intervention or re-accumulation of fluid on follow up imaging in any of the subjects after IPC removal. Two patients (16.7%) had skin infection related to catheter placement that was managed with oral antibiotics, there were no cases of pleural infections that required catheter removal. IPC is a safe and effective alternative in managing recurrent NMPE post lung cancer surgery with high rate of pleurodesis and acceptable complication rates.

Assessing Factors That May Impact Physician-based Decisions for Placing Indwelling Pleural Catheters.

Malignant pleural effusion is a common finding in patients with advanced cancer and is a frequent cause of dyspnea. Current guidelines indicate thoracentesis for symptomatic patients, while indwelling pleural catheters (IPC) are recommended for patients who develop pleural fluid re-accumulation. IPC maintenance, however, requires a significant level of financial and social support. This study aims to analyze potential influencing factors that may play a role in the decision for placing IPCs in patients with recurrent malignant pleural effusions. This study retrospectively collected baseline sociodemographic and laboratory data in patients who underwent thoracentesis for malignant pleural effusion from August 2016 to October 2021, and selected patients who presented with re-accumulation of pleural fluid within 30 days or had a pulmonary physician's note documenting that IPC is a potential management option. Of these selected patients (IPC candidates), we stratified patients who underwent IPC placement and those who did not, and performed statistical analysis between these 2 groups. One hundred seventy-six patients who underwent thoracentesis were regarded as IPC candidates. Almost all baseline sociodemographic characteristics, including ethnicity ( P =0.637), sex ( P =0.655), and marital status ( P =0.773) were similar between the 2 groups, but significantly higher ECOG scores ( P =0.049) were noted in the IPC group. No statistically significant differences were noted in age, body mass index, platelet, PTT, international normalized ratio, creatinine, white blood cell, red blood cells, fluid protein, or fluid lactate dehydrogenase. Fluid albumin ( P =0.057) and serum neutrophil:lymphocyte ratio ( P =0.003) were significantly higher in patients without IPC placement. This study did not recognize any baseline sociodemographic factors that may contribute to the decision to place IPCs.

Impact of a Dedicated Pleural Clinic on Indwelling Pleural Catheter Related Outcomes: A Retrospective Single Center Experience.

Recurrent pleural effusions are a major cause of morbidity and frequently lead to hospitalization. Indwelling pleural catheters (IPCs) are tunneled catheters that allow ambulatory intermittent drainage of pleural fluid without repeated thoracentesis. Despite the efficacy and safety of IPCs, data supporting postplacement follow-up is limited and variable. Our study aims to characterize the impact of a dedicated pleural clinic (PC) on patient outcomes as they relate to IPCs. Patients who underwent IPC placement between 2015 and 2021 were included in this retrospective study. Differences in outcomes were analyzed between patients with an IPC placed and managed by Interventional Pulmonology (IP) through the PC and those placed by non-IP services (non-PC providers) before and after the PC implementation. In total, 371 patients received IPCs. Since the implementation of the PC, there was an increase in ambulatory IPC placement (31/133 pre-PC vs. 96/238 post-PC; P=0.001). There were fewer admissions before IPC placement (18/103 vs. 43/133; P=0.01), and fewer thoracenteses per patient (2.7±2.5 in PC cohort vs. 4±5.1 in non-PC cohort; P<0.01). The frequency of pleurodesis was higher in the PC cohort (40/103 vs. 41/268; P<0.001). A Fine and Gray competing risks model indicated higher likelihood of pleurodesis in the PC cohort (adjusted subhazard ratio 3.8, 95% CI: 2.5-5.87). Our experience suggests that the implementation of a dedicated PC can lead to improved patient outcomes including fewer procedures and admissions before IPC placement, and increased rates of pleurodesis with IPC removal.

The Impact of Anticoagulation on Indwelling Pleural Catheter Removal due to Pleurodesis in Patients with Malignant Pleural Effusion

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.

Subcutaneous Emphysema Risk Following Indwelling Pleural Catheter Insertion During Rigid Local Anesthetic Thoracoscopy: Via Thoracoscopy Port Versus Separate Incision Site.

Local anesthetic thoracoscopy (LAT) is important in the diagnosis of unilateral pleural effusions. Indwelling pleural catheters (IPC) can be inserted during LAT if a nonexpandable lung is suspected. Subcutaneous emphysema (SCE) is a known complication and is associated with increased morbidity and length of stay. It is unclear however if the incidence of SCE is affected if IPC is inserted through a separate incision to the LAT port. We aim to establish the incidence and grading of SCE when IPC is inserted during LAT and to determine if the site of IPC placement influences this. Retrospective analysis of LAT electronic records and radiology images over 8 years in a University Hospital. The incidence of SCE was assessed during admission and follow-up with the severity of SCE graded 0 to 4 (0 none; 1 at IPC site; 2 ipsilateral chest wall; 3 ipsilateral neck; 4 contralateral chest wall). 55 combined LAT and IPC procedures were performed. In 28 patients the IPC was inserted through the LAT port and in 27 the IPC was inserted in a separate intercostal space (ICS) to the LAT port. On day zero, the incidence of any SCE was lower if the IPC was inserted using a separate ICS to the LAT port compared with the same site as the LAT port( P =0.01). This was similarly reduced on discharge chest radiographs and subsequent follow-up. IPC insertion at LAT using a separate ICS to the LAT port is associated with a reduction in the incidence of SCE during admission and follow-up.

INDWELLING PLEURAL CATHETERS FOR TREATMENT OF RECURRENT PLEURAL EFFUSION DUE TO CONGESTIVE HEART FAILURE: A SINGLE CENTER EXPERIENCE

INDWELLING PLEURAL CATHETERS FOR TREATMENT OF RECURRENT PLEURAL EFFUSION DUE TO CONGESTIVE HEART FAILURE: A SINGLE CENTER EXPERIENCE

ISSUES IN CONTINUITY OF CARE AND COMPLICATIONS IN INDWELLING PLEURAL CATHETER PLACEMENT: A QUALITY IMPROVEMENT STUDY IN A THREE-HOSPITAL NY SYSTEM

ISSUES IN CONTINUITY OF CARE AND COMPLICATIONS IN INDWELLING PLEURAL CATHETER PLACEMENT: A QUALITY IMPROVEMENT STUDY IN A THREE-HOSPITAL NY SYSTEM

Quality of life in patients with malignant pleural effusion treated with an indwelling pleural catheter in an emerging country

BackgroundThe use of Indwelling Pleural Catheter (IPC) in the care of patients with Malignant Pleural Effusion (MPE) is well established, however studies involving public health systems of low and middle-income countries are still lacking. This study aimed to determine the effect of IPC on the respiratory symptoms and Quality of Life (QoL) of patients with MPE in the setting of a Brazilian public health system. MethodsFrom August 2015 to November 2019, patients with MPE underwent IPC placement and were prospectively followed. QoL and respiratory symptoms were assessed by the EORTC questionnaires (QLQ-30; LC13) and Visual Analogue Scale (VAS), respectively, at pre-treatment, 30 , and 60 days after IPC placement. Results56 patients were enrolled with 57 catheters inserted. The mean age was 63 (23‒88) years, of which 17 (30%) were men and 39 (70%) were women. Breast 24 (42%) and lung 21 (37%) were the main primary neoplasms. Cellulitis was the most common complication and all patients recovered with appropriate antimicrobial therapy. QoL did not change significantly over time, however, the VAS showed a significant improvement in dyspnea (+1.2: -0.5; p = 0.001). ConclusionIPC relieves respiratory symptoms without compromising the QoL, with a low complication rate. It represents a suitable option for patients with MPE and short LE in an emerging country.

DEVELOPMENT OF A MALIGNANT PLEURAL EFFUSION CLINIC WITHIN A CANCER CENTER

TOPIC: Practice Management and Administration TYPE: Original Investigations PURPOSE: In response to patient and medical oncologist concerns that malignant pleural effusion (MPE) needs were not easily met, a clinic dedicated to MPE was developed within a healthcare system’s cancer institute. We examined the impact of this clinic, which continued during the COVID-19 pandemic at a time when home health services were less available. Secondary objectives include comparing outcomes of patients undergoing medical pleuroscopy versus direct indwelling pleural catheter (IPC) placement. METHODS: Sequential cases were reviewed in a newly developed clinic, staffed by a pulmonologist (JS) and Advanced Practice APP (CS), dedicated to patients with MPE from January 2019 through December 2020. Data collected included primary histological type, interventions required, common complications, and duration of need for IPC. RESULTS: 75 patients were evaluated in the first 24-month period since the clinic began. Malignancies associated with MPE were Lung (30), Breast (13), Gynecological (12), and Hematological (9). Of the 80 IPCs placed, 53 were placed by an interventional radiologist (IR) and 27 by pulmonologist via medical pleuroscopy. The average number of days required for an IPC were 42.5 days after pleuroscopy and 79.6 days after direct placement. Of the 75 patients, 25 received talc pleurodesis and 27 received fibrinolytic therapies. Pleuroscopy had 8 non-life-threatening complications consisting of small pneumothorax (7) or increased pain (1) and required 7.2 average follow up visits. IR placement had 12 non-threatening complications consisting of bleeding (2), infection (2), or small pneumothorax (8) and required 4.1 average follow up visits. Notably, 15 patients had pleural effusions with trapped lung physiology prior to IPC placement. CONCLUSIONS: We have demonstrated that a clinic dedicated to patients with MPE's is viable and provides clinical value, including the ability to facilitate patient care during the COVID-19 pandemic. Prior to the clinic’s establishment, patients seen in the general pulmonary setting were unable to undergo pleurodesis nor intrapleural thrombolytics, emphasizing the importance of subspeciality clinics, as they are able to address important gaps in patient care. Consistent with previously published studies, a substantial number of MPE’s were from cancers other than lung. Importantly, many patients exhibited trapped lung at time of intervention, indicating the need to detect patients and intervene earlier in the pleural effusion process. Medical pleuroscopy seemed to offer reduction in IPC duration when compared to directed IPC placement. Despite limitations in our study, we aim to expand the scope of the MPE clinic. CLINICAL IMPLICATIONS: Many patients with MPE have unmet clinical needs, which were exacerbated during the pandemic with home health shortages. Having a pulmonary-driven presence within a cancer institute facilitated the care of these patients. This study affrims that general pulmonary clinics may be missing an important opportunity to care for patients with MPE and would benefit from creating services to manage these patients. Furthermore, medical pleuroscopy may reduce IPC duration, thus lowering costs and healthcare utilization. DISCLOSURES: No relevant relationships by Stephen Mitchell, source=Web Response Speaker/Speaker's Bureau relationship with Astra Zeneca Please note: Jan 2020- Oct 2020 Added 05/11/2021 by Cindy Sing, source=Web Response, value=Honoraria Advisory Committee Member relationship with Somnoware Sleep Solutions Please note: $1001 - $5000 Added 12/01/2020 by Jaspal Singh, source=Web Response, value=Consulting fee no disclosure on file for Michael Zgoda

PORCELAIN PLEURA: A RARE CASE OF METASTATIC CHONDROSARCOMA WITH EXTENSIVE PLEURAL CALCIFICATION

TOPIC: Disorders of the Pleura TYPE: Fellow Case Reports INTRODUCTION: Calcified pleural lesions have both benign and malignant etiologies. Benign lesions can originate from previous trauma, prior pleural infections, hemothorax, or asbestos exposures, and are often focal and limited1,2. Malignant lesions often involve metastatic disease from mesenchymal tumor origin, such as osteosarcoma, chondrosarcoma, or mesothelioma1,3. We describe a case of a patient with metastatic chondrosarcoma manifesting with extensive calcification of the parietal and visceral pleura. CASE PRESENTATION: A 67 year old man was referred to pulmonary for a new subcarinal soft tissue mass on chest CT. He had been previously diagnosed with chondrosarcoma in 2016 and underwent treatment via a radical right proximal humerus excision and shoulder arthroplasty, with final pathology revealing grade 2 conventional chondrosarcoma, mixed hyaline and myxoid, without metastatic foci.Screening chest CT in 2020 noted a new, partially calcified subcarinal soft tissue mass and adjacent lymphadenopathy with moderate hypermetabolism on a positron emission tomography scan (PET/CT). Bronchoscopy with endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) subcarinal lymph node and adjacent posterior mass confirmed metastatic disease.He subsequently developed rapidly progressive dyspnea on exertion over the following month. Repeat chest CT revealed extensive development of circumferential nodularity and calcification of the right visceral and parietal pleura with a large pleural effusion. Thoracentesis improved dyspnea despite limited reexpansion of the lung and noted loculation of the effusion. Pleuroscopic evaluation of the complicated space was undertaken to remove loculations and optimize placement of an indwelling pleural catheter (IPC) for his malignant effusion. Despite difficulty with trocar insertion into the calcified pleural space, placement of the IPC was successful with improvement in his dyspnea. DISCUSSION: Metastatic pleural involvement of chondrosarcoma is rare, and can occur in the setting of direct extension in locoregional disease or hematogenous spread from other sites of primary involvement. Metastatic disease has been noted to be more prevalent in the dedifferentiated and mesenchymal subtypes4. Manifestations of metastatic pleural involvement are typically pleural calcifications that can be profound in the rapid evolution and extent of calcified involvement. Management is often palliative, as in this case, with drainage of any associated pleural effusions and attempts to mitigate accompanying dyspnea. CONCLUSIONS: This case of metastatic chondrosarcoma with extensive visceral and parietal pleural involvement is rare and infrequently noted in the literature. Palliative management with thoracentesis and IPC placement was complicated by the pervasive pleural calcification that prevented ultrasound imaging and made access to the pleural space difficult and dangerous. REFERENCE #1: Sureka B, Thukral BB, Mittal MK, Mittal A, Sinha M. Radiological review of pleural tumors. Indian J Radiol Imaging. 2013;23(4):313-320 DISCLOSURES: No relevant relationships by Robert Browning, source=Web Response, value=Grant/Research Support Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Robert Browning, source=Web Response, value=Consulting fee Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Robert Browning, source=Web Response, value=Consulting fee Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Sean McKay, source=Web Response No relevant relationships by Philip Mullenix, source=Web Response No relevant relationships by Caitlin Nickens, source=Web Response No relevant relationships by John Shumar, source=Web Response

Pleural Drainage Strategy After IPC Placement: A Focused Clinical Review.

The first indwelling pleural catheter (IPC) received Federal Drug Administration approval in 1997, nearly 40 years after John Chambers first described instillation of talc into the pleural space for palliation of malignant pleural effusions. Since then IPCs have revolutionized the management of malignant pleural effusions, providing an effective means of controlling dyspnea in the end stages of life without the pain and prolonged hospital stays long associated with chemical sclerosing agents. While palliation of symptoms is the primary purpose of IPCs, development of pleurodesis in the outpatient setting is often an important secondary goal. Historically, decisions regarding IPC drainage frequency have been largely arbitrary and only recently has the evidence started to emerge regarding the effects of specific drainage strategies on both symptom control and pleurodesis development. This focused clinical review explores the current literature regarding IPC drainage strategies as well as novel methods designed to improve the efficacy of IPCs in a thorough and systematic manner. In addition, this review provides an in-depth analysis and synthesis of the data focusing on key considerations needed to develop patient-centered and cost-effective strategies for the use of IPCs in malignancy.

Recent Developments in the Management of Malignant Pleural Effusions: a Narrative Review

The goal of this paper is to evaluate the literature published over past 3 years and emphasize the most recent updates in the diagnosis and management of malignant pleural effusions (MPE). The management of MPE is focused on palliation of symptoms and should take into account patient preferences and anticipated survival. Chemical pleurodesis and indwelling pleural catheters (IPC) are both definitive options for recurrent symptomatic MPE. IPC placement reduces hospitalization and can result in spontaneous pleurodesis, but these advantages must be weighed against the cost of materials and ongoing care. IPC is preferred over attempted pleurodesis in the presence of nonexpandable lung. The use of vacuum bottles during therapeutic thoracentesis is associated with increased pain and complications, and drainage via manual aspiration or to gravity is preferred. The routine use of manometry does not appear to reduce procedure-related discomfort. Several new advances have been made and discovered in relation to procedural aspects of thoracentesis, diagnosis, and management of MPE. We summarized the most relevant trials and studies and discuss their application in the clinical practice.

Predictors of Indwelling Pleural Catheter Removal and Infection: A Single-center Experience With 336 Procedures.

Indwelling pleural catheters (IPCs) offer ambulatory management of symptomatic persistent pleural effusions, but their widespread use is somewhat hampered by the risk of pleural infection and the inconvenience of carrying a catheter for a prolonged period of time. Factors associated with these 2 limitations were analyzed in this study. Retrospective review of consecutive patients who had undergone IPC placement over a 5 ½-year period. Time to IPC removal was analyzed with the Fine and Gray competing risks survival model, with competing risk being death. A binary logistic regression method was used to evaluate factors influencing IPC-related pleural infections. A total of 336 IPCs were placed in 308 patients, mostly because of malignant effusions (83%). IPC removal secondary to pleurodesis was achieved in 170 (51%) procedures at a median time of 52 days. Higher rates of IPC removal were associated with an Eastern Cooperative Oncology Group (ECOG) grade of 0 to 2 [subhazard ratio (SHR)=2.22], an expandable lung (SHR=1.93), and development of a multiseptated pleural space (SHR=1.37). IPC-related pleural infections occurred in 8% of the cases, and were more often seen in hepatic hydrothoraces [odds ratio (OR)=4.75] and pleural fluids with a C-reactive protein <15 mg/L before the IPC insertion (OR=4.42). IPC removal is more likely to occur in patients with good performance status whose lungs fully expand after drainage. Hepatic hydrothorax is the most significant predictor of IPC-related infections.

Indwelling Tunneled Pleural Catheters for Refractory Hepatic Hydrothorax in Patients With Cirrhosis: A Multicenter Study

The outcome of indwelling pleural catheter (IPC) use in hepatic hydrothorax (HH) is unclear. This study aimed to review the safety and feasibility of the IPC in patients with refractory HH. A retrospective multicenter study of patients with HH from January 2010 to December 2016 was performed. Inclusion criteria were refractory HH treated with an IPC and an underlying diagnosis of cirrhosis. Records were reviewed for patient demographics, operative reports, and laboratory values. The Kaplan-Meier method was used to estimate catheter time to removal. The Cox proportional hazard model was used to evaluate for independent predictors of pleurodesis and death. Seventy-nine patients were identified from eight institutions. Indication for IPC placement was palliation in 58 patients (73%) and bridge to transplant in 21 patients (27%). The median insitu dwell time of all catheters was 156days (range, 16-1,978days). Eight patients (10%) were found to have pleural space infection, five of whom also had catheter-site cellulitis. Two patients (2.5%) died secondary to catheter-related sepsis. Catheter removal secondary to spontaneous pleurodesis was achieved in 22 patients (28%). Median time from catheter insertion to pleurodesis was 55days (range, 10-370days). Older age was an independent predictor of mortality on multivariate analysis (hazard ratio, 1.05; P= .01). We present, to our knowledge, the first multicenter study examining outcomes related to IPC use in HH. Ten percent infection risk and 2.5%mortality were identified. IPC placement may be a reasonable clinical option for patients with refractory HH, but it is associated with significant adverse events in this morbid population.

Indwelling pleural catheters for recurrent pleural effusions: A useful clinical tool with serious implications

Background: Indwelling pleural catheters (IPC) have been used increasingly in patients with recurrent pleural effusions. However, data about mortality after IPC use are limited. Objectives: We sought to determine the natural history following IPC placement in Lubbock, Texas, in terms of life expectancy and pleurodesis rates in patients with both malignant and benign effusions. Methods: A retrospective review of patients who had IPC insertion from March 2014 through December 2016 at University Medical Center in Lubbock, Texas, was performed. Patients 18 years and older who had IPC placement for recurrent pleural effusions were included. The duration of IPC placement, the type of pleural effusion, the volume of fluid, pleurodesis, complications, and mortality after IPC placement were retrieved from electronic medical records. Results: There were 45 patients included in the study; 20 patients (44%) were male, and 25 patients (56%) were female. The mean age was 63.5 years old. There were 33 patients with malignant pleural effusion and 12 patients with benign pleural effusion. No patients with malignant effusion were known to be alive at the time of mortality calculation, whereas two patients with benign effusion were known to be alive. Median survival was 468 days in the benign effusion group and 115 days in the malignant effusion group. The 30-day mortality was not significantly different between the two groups (malignant 34.5% vs. benign 25.0%). However, 1-year mortality was significantly higher in the malignant effusion group (89.7%) than in the benign effusion group (41.7%) (p &lt; 0.005). Conclusion: The use of indwelling pleural catheters in Lubbock, Texas, has comparable results to published studies. These catheters should be considered as a bridge to a long-term treatment rather than a definitive therapy.

Indwelling Pleural Catheters in Hepatic Hydrothorax: A Single-Center Series of Outcomes and Complications

Treatment of hepatic hydrothorax (HH) generally involves sodium restriction, diuretics, and serial thoracentesis. In more advanced cases, transjugular intrahepatic portosystemic shunt and liver transplantation may be required. Previously, indwelling tube drainage has been avoided due to concerns regarding high complication rates and overall poor outcomes. Recently, indwelling pleural catheters (IPCs) have been proposed as a novel treatment option for HH. This study was a retrospective review of patients who had undergone IPC placement for HH over a 10-year period at a large liver transplant referral center. We tracked outcomes, including complication rates and liver transplantation, as well as biomarkers of nutritional status. Sixty-two patients underwent IPC placement between 2007 and 2017, with 33 IPCs (53%) placed as a bridge to liver transplantation. Complications were recorded in 22 patients (36%); empyema was the most common, diagnosed in 10 patients (16.1%). Ten patients evaluated for liver transplantation underwent successful transplantation following IPC placement. There were statistically significant decreases in both BMI and serum albumin levels following IPC placement. IPCs represent a potential treatment for refractory HH and should be used with caution in patients eligible for liver transplantation. Ideally, IPC use for these patients would be evaluated by a multidisciplinary team. IPC use may lead to small decreases in BMI and serum albumin levels in patients over time.

Use of indwelling pleural catheters for the definitive treatment of malignant pleural effusion.

ABSTRACTObjective: To evaluate the safety and feasibility of the use of indwelling pleural catheters (IPCs) in patients with malignant pleural effusion (MPE). Methods: We prospectively collected data from patients with MPE undergoing IPC placement between January of 2014 and July of 2015. All patients submitted to IPC placement had a life expectancy > 30 days, in accordance with the MPE treatment guidelines established by the British Thoracic Society. The data collected included gender, age, body mass index, primary cancer site, duration of IPC drainage, IPC-related complications, length of hospital stay, pleural effusion recurrence, and occurrence of spontaneous pleurodesis. Results: A total of 19 patients underwent IPC placement during the study period. Median overall survival after IPC insertion was 145 days. The median follow-up among the surviving patients was 125 days (range, 53-485 days), and the median time between catheter insertion and removal was 31 days (range, 2-126 days). There were IPC-related complications in 5 patients (26.2%), and spontaneous pleurodesis was achieved in 8 (42.0%). Among those 8 patients, the IPC was removed between days 30 and 126 in 4, and spontaneous pleurodesis occurred within the first 30 days in 4. Conclusions: The use of IPCs seems to be feasible and safe in patients with MPE.

Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis

The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions. We conducted a systematic review and meta-analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study. Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3%(95%CI, 37.1%-65.6%). The estimated average rate of all complications was 17.2%(95%CI, 9.8%-24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3%(95%CI, 0.0%-4.7%); loculation, 2.0%(95%CI, 0.0%-4.7%); dislodgement, 1.3%(95%CI, 0.0%-3.7%); leakage, 1.3%(95%CI, 0.0%-3.5%); and pneumothorax, 1.2%(95%CI, 0.0%-4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7%(95%CI, 0.6%-4.9%); blockage anddrainage failure, 1.1%(95%CI, 0.0%-3.5%); subcutaneous emphysema, 1.1%(95%CI, 0.0%-4.0%); and other, 2.5%(95%CI, 0.0%-5.2%). One death was directly related to IPC use. IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high-quality studies such as randomized controlled trials are needed.