Pleuroperitoneal Shunt Research Articles

Current practices for refractory chylothorax following congenital heart surgery.

Chylothorax following paediatric cardiac surgery is associated with significant morbidity, particularly those that are refractory to conservative therapy. It is our impression that there is important variability in the medical, surgical, and interventional therapies used to manage refractory chylothorax between congenital heart programmes. We therefore conducted a survey study of current practices for managing refractory chylothorax. The Chylothorax Work Group, formed with the support of the Pediatric Cardiac Critical Care Consortium, designed this multi-centre survey study with a focus on the timing and indication for utilising known therapies for refractory chylothorax. The survey was sent to one chylothorax expert from each Work Group centre, and results were summarised and reported as the frequency of given responses. Of the 20 centres invited to participate, 17 (85%) submitted complete responses. Octreotide (13/17, 76%) and sildenafil (8/17, 47%) were the most utilised medications. Presently, 9 (53%) centres perform pleurodesis, 15 (88%) perform surgical thoracic duct ligation, 8 (47%) perform percutaneous lymphatic interventions, 6 (35%) utilise thoracic duct decompression procedures, and 3 (18%) perform pleuroperitoneal shunts. Diagnostic lymphatic imaging is performed prior to surgical thoracic duct ligation in only 7 of the 15 (47%) centres that perform the procedure. Respondents identified barriers to referring and transporting patients to centres with expertise in lymphatic interventions. There is variability in the treatment of refractory post-operative chylothorax across a large group of academic heart centres. Few surveyed heart centres have replaced surgical thoracic duct ligation or pleurodesis with image-guided selective lymphatic interventions.

Bowel perforation as a late complication of pleuroperitoneal shunt.

Bowel perforation as a late complication of pleuroperitoneal shunt.

Congenital chylothorax in a preterm infant with non-immune hydrops: A case report with literature review on treatment options

Congenital chylothorax is rare with an incidence of 1:10,000-24,000 live births. Congenital chylothorax occurs in lymphatic disorders, heart diseases, cancers, chromosomal abnormalities, tracheoesophageal fistula, etc. Acquired causes are due to surgical thoracic duct trauma. Many cases of chylothorax are idiopathic. The case fatality rate is 15% to 57% and reaches 98% in hydrops foetalis. There is no set standard of treatment for congenital chylothorax. Prenatally, thoracentesis or pleuro-amniotic shunts are done. Postnatally, management of cause, drainage, dietary changes, Octreotide, and Sildenafil have variable results. Pleurodesis, pleuroperitoneal shunt, abrasion, thoracic duct ligation, and anastomoses are surgical options.

#4062 PERITONEAL DIALYSIS CATHETER SURVIVAL: A TEN-YEAR SINGLE CENTER STUDY

Abstract Background and aims Timely insertion and adequate management of peritoneal dialysis catheter (PDC) related complications are crucial for the success of Peritoneal Dialysis (PD). The aim of the present study was to review the peritoneal dialysis catheter outcomes at our center and evaluate variables influencing catheter survival. Methods We conducted a retrospective study including 146 patients who had their first PD catheter implanted between 1st of August 2012 and 31st of July 2022 in our institution. The primary endpoint was PD catheter failure, defined as removal of the PD catheter due to catheter-related complications. Kaplan-Meier curves were used to estimate catheter survival. Cox regression model was used to identify factors that were independently associated with catheter survival. All demographic and clinical characteristics of the patients and PD complications were included as covariates. A p value of less than 0.05 was considered statistically significant. Results The study population included 85 men and 61 women, aged 55.1 $ \pm {\rm{\ }}$ 16.7 years. Mean follow-up was 26.5 +/- 22.7 months. Diabetes was the most common etiology of the stage 5 chronic kidney disease (n = 41, 28%), followed by chronic glomerulonephritis (n = 30, 20.5%). Ninety patients (61.2%) had one or more comorbidities and seventeen (11,6%) had previous abdominal surgery. In 98 patients (60.1%), the PDC was inserted using a mini-laparotomy approach, whereas the laparoscopic method was used in 54 patients (33.1%). Only 8 patients (4.9%) had their catheter placed percutaneously using the Seldinger technique. The total number of patients with one or more PD-related infectious complications during follow-up was 99 (67%): 51 patients (31%) had a single episode and 29 (17.8%) had multiple episodes of peritonitis; 34 patients (20.9%) had a single episode of PD catheter related exit site or tunnel infection, while 47 (28.8%) had more than 1 event. Sixty-six patients (45%) had PD-related mechanical complications, mostly due to outflow failure (19 patients with catheter migration, 11 with omental wrapping). The remaining non-infectious complications were hernia (n = 20, 13.7%), hemoperitoneum (n = 8, 5,5%), leakage (n = 4, 2.7%) and pleuroperitoneal shunt (n = 4, 2.7%). Fourteen patients required intervention due to mechanical complications, namely repositioning of the catheter with fluoroscopic technique in 8 patients and surgical repositioning in 6. Removal of the catheter was required in 49 patients (33.6%). The leading cause of catheter removal was infection (n = 29, 59%): peritonitis in 28 patients and refractory tunnel infection in 1. Mechanical complications were also a significant factor, accounting for 40.8% of the removals (n = 20). Overall PD catheter survival rates over 12, 24 and 36 months were 80.2%, 72.4% and 61.6%, respectively. PD catheter-related non-infectious complications was the only independent variable significantly associated with catheter survival (Hazard ratio 2.573; 95% CI 1.426–4.645). No significant association was observed between the PD catheter survival and other risk factors including age, diabetic status, comorbidities, previous abdominal surgeries, method of catheter insertion or infectious complications. Conclusions PDC non-infectious complications were the only independent factor significantly associated with catheter survival. Despite the significant number of infectious complications, including peritonitis, it was found that these complications did not result in a significant decrease in catheter survival. These findings highlight the crucial role of proper management of peritoneal dialysis catheter-related non-infectious complications for successful and long-term usage of PDC.

Diagnosis and Management of Malignant Pleural Effusion: A Narrative Literature Review

Malignant pleural effusion (MPE) is defined as an effusion that occurs in association with malignancy, as evidenced by the finding of malignant cells on pleural fluid cytology or pleural biopsy. The pathophysiology of MPE is not yet clear, but several hypotheses have been developed to explain the mechanism of MPE. Accumulation of effusion in the pleural cavity occurs due to increased vascular permeability due to the inflammatory reaction caused by the infiltration of cancer cells in the parietal and/or visceral pleura. Other possible mechanisms are the direct invasion of the tumor adjacent to the pleura, obstruction of the lymph nodes, hematogenous spread, and primary pleural tumor. Pleural fluid from a malignant process is usually an exudate. To distinguish between exudate and transudate is to assess the protein and LDH levels of the pleural fluid. Hemorrhagic pleural fluid with a red blood cell count >100,000/mm3 suggests an MPE. Pleural fluid glucose levels at low < 60 mg/dl at about 15-20% MPE. The definitive diagnosis of MPE is by finding malignant cells in the pleural fluid (cytology) or pleural tissue (pathological histology). Management of malignant pleural effusions is principally palliative. Management that is often done in cases of MPE is therapeutic thoracentesis, pleurodesis, drainage with long-term indwelling catheter, manufacture of the pleuroperitoneal shunt, intrapleural therapy, and radiotherapy.

Gorham-Stout disease with life-threatening pleural effusion treated with a pleuro-peritoneal shunt: a case report.

SummaryGorham–Stout disease (GSD) is a rare bone disease characterized by massive osteolysis and lymphatic proliferation. The origin of the condition is unknown, and no established treatment protocol exists. Massive pleural effusion is a frequent complication of GSD in the thoracic region. We present the case of a 23-year-old male with thoracic GSD, subsequent paraparesis, and life-threatening pleural effusion. The patient was managed by a multidisciplinary team with a good recovery. The pleural effusion was successfully treated with a pleuro-peritoneal shunt. This is the first report of the use of this mini-invasive technique in the management of pleural effusion related to GSD. Further, we present the potential role of interleukin-6 and bone resorption markers in the measurement of the disease activity.Learning pointsMultidisciplinary approach is important in the management of rare and severe disorders such as Gorham-Stout disease.Pleuro-peritoneal shunting is a valuable option in the treatment of pleural effusion related to GSD.Interleukin-6 and bone resorption markers appear useful in measuring the disease activity of GSD.

Pleuroperitoneal shunt insertion for super-aged elderly patients with intractable pleural effusion

Pleuroperitoneal shunt insertion for super-aged elderly patients with intractable pleural effusion

TRAPPED LUNG AS A COMPLICATION OF PLEURAL METASTASES FROM SQUAMOUS CELL CARCINOMA OF BUCCAL MUCOSA

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Trapped lung is an uncommon complication of malignant pleural effusion (MPE). It presents as post-thoracentesis hydropneumothorax (known as pneumothorax ex vacuo, PEV) or pleural effusion that cannot be completely drained due to development of chest pain [1]. It is important to recognize PEV, as although it may appear alarming, it is an asymptomatic process that is not amenable to chest tube placement. CASE PRESENTATION: 60 year old male with squamous cell carcinoma (SCC) of buccal mucosa for which he underwent surgery with radiotherapy 2 years ago, presented with 1 week of dyspnea. Chest X-ray showed a large right-sided pleural effusion with ipsilateral displacement of mediastinum [Figure 1]. He underwent thoracentesis but procedure was terminated prematurely due to development of chest pain. Post-thoracentesis CT chest [Figure 2] to evaluate for underlying lung pathology showed pleural thickening. Fluid cytology was positive for malignant squamous cells. He subsequently underwent thoracoscopy showing extensive involvement of visceral and parietal pleural surfaces with malignant appearing lesions. Pleural biopsies, done to obtain more tissue for next generation sequencing, were consistent with malignant squamous cells. An indwelling pleural catheter was placed at the end of the procedure for long term management of his malignant pleural effusion. Post-procedure chest X-ray showed a partially expanded right lung with a large PEV [Figure 3]. The patient was asymptomatic at this point with good oxygenation on room air. Pleural manometry was performed using a digital pleural manometer showing a negative pleural pressure. DISCUSSION: Pleura is a relatively rare site of metastases from head and neck SCC [2]. Trapped lung can develop due to pleural adhesions or involvement of visceral pleura with malignant lesions [3]. Diagnosis should be suspected when chest x-ray shows large pleural effusion with ipsilateral shift of mediastinum as was seen in our patient. The patients may also have chest pain with drainage of pleural effusion. Effective management of trapped lung and PEV in MPEs remains challenging. Various treatment modalities exist, including minimally invasive procedures such as thoracocentesis or indwelling pleural catheters, as well as invasive procedures such as pleuroperitoneal shunt, thoracotomy, and decortication. The optimal treatment approach should balance therapeutic benefit versus required period of convalescence for a disease with poor life expectancy [4]. CONCLUSIONS: We present a rare complication (PEV from trapped lung) in a relatively rare disease process (pleural metastases in head and neck cancer). In cases of pneumothorax after pleural drainage, it is important to consider PEV due to trapped lung as it will direct treatment approaches. REFERENCE #1: Huggins JT, Doelken P, Sahn SA. The unexpandable lung. F1000 Med Rep. 2010;2:77. Published 2010 Oct 21. doi:10.3410/M2-77 REFERENCE #2: Ferlito A, Shaha AR, Silver CE, Rinaldo A, Mondin V. Incidence and sites of distant metastases from head and neck cancer. ORL J Otorhinolaryngol Relat Spec. 2001 Jul-Aug;63(4):202-7. doi: 10.1159/000055740. PMID: 11408812 REFERENCE #3: Petrov, D., Mihalova, T., Valchev, D.. Malignant pleural effusions and trapped lung. AME Medical Journal, North America, 5, mar. 2020. Available at: <https://amj.amegroups.com/article/view/5466> DISCLOSURES: No relevant relationships by Sudeepthi Bandikatla, source=Web Response No relevant relationships by James Bradley, source=Web Response No relevant relationships by Apaar dadlani, source=Web Response No relevant relationships by Umair Gauhar, source=Web Response No relevant relationships by Vatsala Katiyar, source=Web Response No relevant relationships by Adam Rojan, source=Web Response

Infected simple renal cyst due to Streptococcus pneumoniae rapidly diagnosed by the melting temperature mapping method: a case report

BackgroundSpontaneous infection of preexisting solitary renal cysts has been documented in adults but is extremely rare in children. To date, no cases of simple renal cysts infected with Streptococcus pneumoniae have been described. Recently, reports have described the diagnosis of bacterial infection using the 16 S rRNA gene as well as the accompanying antimicrobial stewardship for microorganisms that are difficult to culture and for culture-negative cases after preceding antibacterial administration.Case presentationA four-year-old Japanese girl who had a pleuroperitoneal shunt inserted to drain a right pleural effusion due to occlusion of the hepatic portion of the inferior vena cava at three years old visited our hospital due to fever and respiratory discomfort. She was incidentally found to have a right simple renal cyst 10 months before admission. The patient was suspected to have pneumonitis or catheter-related blood stream infection on chest X-ray, which showed right-side pleural effusion. She was diagnosed with invasive pneumococcal infection, as Streptococcus pneumoniae was detected from blood culture on admission. Transient improvements in her symptoms and decreases in the white blood cell count and C-reactive protein level were observed after effective antibiotic administration, but her respiratory condition deteriorated. Enhanced CT showed right renal cyst enlargement and enhancement and thickening of the surrounding wall. Using the melting temperature (Tm) mapping method, S. pneumoniae was rapidly detected directly from pus 4.5 hours after drainage. The specimen culture was negative, but the extracted 16 S rDNA sequence revealed 100 % identity for S. pneumoniae from the same specimen the subsequent day. We successfully performed optimal treatment and reduced medical cost based on the positive Tm mapping method result.ConclusionsWe report the first case of a S. pneumoniae-infected simple renal cyst. The drainage culture was negative, but the Tm mapping method rapidly detected S. pneumoniae directly from the drainage. The Tm mapping method may have great impacts on rapid diagnosis and effective antimicrobial stewardship.

Modern Treatment Options for Postoperative Chylothorax: a Systematic Review

Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis. The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the "PubMed" database. Publications older than ten years were excluded from this review. The literature search employed the keyword "chylothorax". The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations. The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3-90 %). Non-invasive or semi-invasive procedures are successful in 50 to 100 % of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100 %. The morbidity and mortality rate can reach values up to 25 %. Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patient's health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.

Effectiveness of a pleuroperitoneal shunt for refractory hepatic hydrothorax that appeared after ligation of a communicating hydrocele

A 73-year-old man was admitted because of abdominal fullness and systemic oedema. He had been followed up as alcoholic cirrhosis for 3 years. He had been drinking about 70–80 g...

Interventional management of recurrent malignant pleural effusion: state of the art in 2021.

This narrative review aims to describe and compare different interventional methods for the management of recurrent malignant pleural effusion and offers perspectives for the future era. Dyspnea as a result of the recurrent malignant pleural effusion is one of the main factors decreasing the quality of life in patients with oncologic diseases. To date, there is no strict guideline for the management of malignant pleural effusions. Several different techniques are available to prevent production of the effusion or to provide intermittent drainage, however, the principle of these methods remains palliative. The choice of treatment in any patient depends mainly on the preferences of the patient, speed of the fluid production, expandability of the lung, and predicted survival of the patients. The interventional methods of managing malignant pleural effusions are described in detail, including thoracocentesis, chemical pleurodesis, talc poudrage pleurodesis, slurry pleurodesis, thoracoscopic procedures, indwelling pleural catheters, implantable pleural ports, and pleuroperitoneal shunting. Pleurodesis and fully implantable devices such as pleural ports may become the most useful techniques in the future, mainly because of better comfort for the patients and no need for repeated pleural punctures (Ref. 55).

Successful Treatment of Intractable Chylothorax with Povidone-Iodine Pleurodesis in Extremely Preterm Infant

Chylothorax is pleural collection of fluid formed by the escape of chyle from the thoracic duct or lymphatics into the thoracic cavity. In children, it frequently occurs after thoracic duct injury as a complication of cardiothoracic surgery. It can be treated with enteral feedings with a low-fat or medium-chain triglyceride, high-protein diet, and total parenteral nutrition. Somatostatin and octreotide have been used in advanced cases and surgical treatment could be considered including a pleuroperitoneal shunt, thoracic duct ligation, and pleurodesis with sclerosing agent such as tetracyclin, bleomycin, OK-432, talc, or iodopovidone. We report a case of preterm infant with 24+4 weeks of gestation who developed chylothorax after ligation of patent ductus arteriosus. The chylothorax was intractable to any medical and conservative treatments but was treated successfully by pleurodesis with 3.4% povidone-iodine without complications.

Surgical Treatment Procedures in Management of Pleural Effusions: Therapeutic Pleural Aspiration, Intercostal Tube Drainage, Chemical Pleurodesis with Sclerosant Agent, Placement of an Indwelling Pleural Catheter, Pleuroperitoneal Shunts, and Pleurectomy/Decortication

Surgical Treatment Procedures in Management of Pleural Effusions: Therapeutic Pleural Aspiration, Intercostal Tube Drainage, Chemical Pleurodesis with Sclerosant Agent, Placement of an Indwelling Pleural Catheter, Pleuroperitoneal Shunts, and Pleurectomy/Decortication

Malignant pleural effusions and trapped lung

: Malignant pleural effusions (MPEs) are of great importance for the prognosis of patients with oncological diseases. The current review focuses on the problem of the management of patients with MPEs complicated with trapped lung, which is still a subject of discussion. “Trapped lung” describes the situation in advanced malignant pleural disease in which the lung is unable to fully expand to fill the hemithorax, rendering the parietal and visceral pleura either partly or completely unopposed, with the presence of a residual cavity. A variety of diagnostic approach for the condition of a trapped lung (imaging or invasive) are analyzed. Nowadays the optimal approach to MPE with a trapped lung is still a subject of discussion. In general, the management is a challenge for the thoracic surgeon and medical oncologists and focuses on palliative relieving of the symptoms and reduction of the hospitalization rates rather than on cure, because of the end-stage of the neoplastic disease Different strategies for palliative treatment are debated, including placement of indwelling pleural catheters, surgical decortications (open thoracotomy or closed VATS), pleuroperitoneal shunts and intra-pleural fibrinolytic therapy. The last two are not routinely applicable. Any planned treatment should balance the therapeutic benefit provided against the required period of convalescence for a disease with a limited life expectancy. Randomized controlled multicenter clinical trials in patients with comparable diseases and comorbidity are needed to clarify which is the most appropriate treatment modality. To the present date, VATS decortication seems to be an excellent therapeutic method offering as large as possible macroscopic reduction of the tumor and re-expansion of the lung in surgically fit patients. VATS has a significantly less operative risk than radical invasive surgical interventions, minimizes the surgical trauma and pain, shortens the postoperative in-hospital stay, resulting respectively in susceptible Quality of Life improvement.

Malignant Pleural Effusion: Still a Long Way to Go.

Malignant pleural effusion, which is a common clinical problem in patients with cancer, may be due to both primary thoracic tumours or to a metastatic spread in the chest and constitutes the first sign of disease in approximately 10% of patients. Almost all cancers can potentially produce a pleural effusion. The presence of malignant tumour cells in the pleural fluid is generally indicative of advanced disease and is associated with high morbidity and mortality with reduced therapeutic options. Dyspnoea during mild physical activity or at rest is generally the typical sign of restrictive respiratory failure. This is a systematic review of all the main articles in the English language on the topic of malignant pleural effusion and reported by the Pubmed database from 1959 to 2018. I reviewed the literature and guidelines with the aims to focus on what is known and on future pathways to follow the diagnosis and treatment of malignant pleural effusions. The main goal of palliation of a malignant pleural effusion is a quick improvement in dyspnoea, while thoracentesis under ultrasound guidance is the treatment of choice for patients with a limited life expectancy or who are not candidates for more invasive procedures such as drainage using an indwelling small pleural catheter, chemical pleurodesis with sclerosing agents, pleurectomy or pleuro-peritoneal shunt. Despite progress in therapeutic options, the prognosis remains severe, and the average survival is 4-9 months from the diagnosis of malignant pleural effusion. Moreover, mortality is higher for patients with malignant pleural effusion compared with those with metastatic cancer but no malignant pleural effusion. Therefore, the prognosis of these patients primarily depends on the underlying disease and the extension of a primary tumour. This review focuses on the most relevant updates in the management of malignant pleural effusion.

Modern Treatment Options for Postoperative Chylothorax: a Systematic Review

Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis. The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the "PubMed" database. Publications older than ten years were excluded from this review. The literature search employed the keyword "chylothorax". The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations. The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3 - 90%). Non-invasive or semi-invasive procedures are successful in 50 to 100% of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100%. The morbidity and mortality rate can reach values up to 25%. Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patient's health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.

ES 06.05 Approach to Malignant Pleural Effusions

The onset of an MPE usually indicates a significant reduction in prognosis, with a median life expectancy of 3 to 12 months from onset. MPE associated with breast cancer is usually associated with a better than average prognosis whilst lung cancer has the worst prognosis. Confirmation of malignancy and determination of the cell type may be established by increasingly invasive techniques; pleural aspiration cytology, facilitated by ultrasound guidance if the effusion is small or loculated, pleural biopsy, blind or image guided, thoracoscopy (usually now video-assisted) under local or general anesthesia. Whilst it is reasonable to start with the least invasive procedure suitable in the circumstances, in patients who are reasonably fit it is important to avoid an escalating cascade of failed procedures, each with the risk of causing pleural adhesions and clot formation, making effective palliation more difficult. There is much to commend early acceptance of an approach which combines the best chance of a tissue diagnosis with the best chance of effective palliation. This decision will be influenced by an assessment of prognosis. Prognosis once an MPE has been confirmed is dependent upon the extent of metastatic disease and associated co-morbidity. In a surgically palliated population in-hospital and 30-day mortality was statistically related to blood albumen levels, being 0% and 0.98% in those with normal albumen levels and 6.8% and 19% in those with hypoalbumenaemia (p =0.001).1 In a series of 278 patients referred to the Department of Thoracic Surgery at the Royal Brompton Hospital over a 72 month period 195 underwent thoracoscopic talc pleurodesis, 39 had a pleuro-peritoneal shunt inserted, 38 had pleurodesis through an intercostal drain, 29 had pleural biopsy alone and 9 were treated with long-term pleural drainage, a total of 310 surgical procedures. Overall median survival was 211 days post operatively. Survival was not significantly different for tumor type or method of palliation but was related to leucocytosis (p<0.0001), hypoxemia (p =0.014) and hypoalbumenaemia (p<0.0001).2 The summative effect of these factors is shown in the table. How this information might be used to personalize treatment options in patients for whom effective systemic therapy does not exist. Those whose prognosis is judged to be less than 2 months (having all 3 adverse prognostic factors) palliation may be achieved by repeated pleural aspiration. If prognosis is judged to be greater than 2 months, and especially if the patient is in a poor general condition, adequate palliation could be achieved by the insertion of an indwelling pleural catheter under local anesthesia. In fitter patients with an estimated survival greater than 6 months VATS insufflation of talc or the insertion of a pleuro-peritoneal shunt should be considered. The choice of talc or shunt will be dictated by the adequacy of lung expansion during positive pressure ventilation. In many respects these 2 techniques are complementary but having both of these techniques available at thoracoscopy allows affective long-term palliation to be achieved in 95% of patients.3 However pleuro-peritoneal shunts can be complicated by occlusion within 4 months in 15% of cases but spontaneous pleurodesis has usually been achieved by this time.4 Pleurectomy is rarely indicated in the palliation of MPE. 1. Pilling JE, Dusmet M, Ladas G, Goldstraw P. Predictors of early mortality and morbidity follwoing surgical palliation of malignant pleural effusion. Journal of Thoracic Oncology 2[8], s430. 2007. 2. Pilling JE, Dusmet ME, Ladas G, Goldstraw P. Prognostic Factors for Survival after Surgical Palliation of malignant Pleural Effusion. J Thorac Oncol 5, 1544-1550. 2010. 3. Petrou M, Kaplan D, Goldstraw P. The management of recurrent malignant pleural effusions: The complementary role of talc pleurodesis and pleuroperitoneal shunting. Cancer 75, 801-805. 1995. 4. Genc O, Petrou M, Ladas G, Goldstraw P. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. European Journal of Cardio-thoracic Surgery 18, 143-146. 2000. Malignant effusions, palliation, pleural malignancyTabled 1No of factorsnMedian survival (days)95% CIpNone39702473-931<0.00001One or two74200111-289Three234223-61 Open table in a new tab

胸腔腹腔シャントにてコントロールし得た右心不全・腎不全に伴う両側難治性胸水の1例

胸腔腹腔シャントにてコントロールし得た右心不全・腎不全に伴う両側難治性胸水の1例

Optimal Time Points for Scintigraphic Imaging of Pleuroperitoneal Shunts.

Nuclear imaging can confirm pleuroperitoneal shunt as the cause of pleural effusion. No society guidelines exist for scintigraphic pleuroperitoneal shunt detection. Our institutional protocol was evaluated to determine optimal imaging time points for shunt detection. Pleuroperitoneal shunt studies over 4 years were blindly reviewed by 2 nuclear radiologists. Data from blinded review included presence or absence of pleuroperitoneal shunt, laterality of shunt and time points for shunt detection. Chart review yielded 30 studies. Three cases were excluded because of improper injection. Imaging was positive for pleuroperitoneal shunt in 81% (22/27) of cases. In positive cases, activity was identified in the right hemithorax in 82% (18/22), left hemithorax in 9% (2/22), and bilaterally in 9% (2/22). One-hour imaging demonstrated 91% (20/22) of positive cases. The remaining 2 positive cases were negative at 1 hour but positive after 4 hours. No study was negative at 1 and 4 hours and positive at 24 hours. All negative cases (5/27) were confirmed on 24-hour imaging. The majority of positive pleuroperitoneal shunt examinations will demonstrate activity in the right hemithorax on 1-hour imaging. Although no case was negative at 1 and 4 hours and positive at 24 hours, imaging at 24 hours may still be necessary to confirm absence of shunt. Therefore, optimal imaging time points consist of early 1-hour and delayed 24-hour images if the 1-hour time point was negative. The 4-hour time point may be considered optional, thereby potentially optimizing patient safety and resource utilization.