Video-assisted Thoracoscopic Surgery Pleurodesis Research Articles

YELLOW NAIL SYNDROME PLEURAL ENTRAPMENT SUCCESSFULLY TREATED WITH INTRAPLEURAL CATHETER PLACEMENT FOLLOWED BY PLEURODESIS

TOPIC: Disorders of the Pleura TYPE: Fellow Case Reports INTRODUCTION: Yellow Nail Syndrome (YNS) is a rare cause of pleural effusions. The etiology of YNS remains unknown and treatment focuses on symptomatic management [1]. Therapies for YNS pleural effusions include thoracentesis, tunneled intrapleural catheters (IPC), pleurodesis, and pleurectomy [1,2,3]. Here we present a patient with YNS and bilateral pleural effusions successfully treated with staged IPC followed by video-assisted thoracoscopic surgery (VATS) pleurodesis. CASE PRESENTATION: A 79 year old woman who is a lifelong nonsmoker with a history of type one diabetes mellitus, hyperlipidemia, and hypothyroidism presented with chronic cough, bilateral lower extremity edema, and yellow nail discoloration. Chest computed tomography (CT) scan revealed bilateral lower lobe bronchiectasis and bilateral pleural effusions. A diagnosis of YNS was made recognizing the triad of yellow nails, lymphedema, and pulmonary disease. Thoracentesis revealed a clear-yellow, exudative pleural effusion with a lymphocytic predominance, normal triglyceride level, and negative cultures. Per patient preference, she underwent serial therapeutic thoracenteses. Over the following two years, her pleural effusions progressed requiring increased frequency of drainage, and she developed evidence of bilateral lung entrapment on manual pleural manometry with residual pleural fluid. She then opted to pursue VATS pleurodesis. Her right VATS pleurodesis was preceded by IPC placement, and her lung entrapment improved with serial IPC drainage over two months. She then underwent right VATS mechanical and doxycycline pleurodesis. This same staged procedure was performed on the left side. She has had successful resolution of her pleural effusions without evidence of recurrence at greater than 18 months of follow up. DISCUSSION: YNS is a rare diagnosis with less than 400 cases described and an estimated prevalence of <1:1,000,000 [1]. It is characterized by the triad of yellow discoloration of the nails, lymphedema, and respiratory system involvement [1]. The cause of YNS is unknown, but an anatomic or functional abnormality of lymphatic drainage is proposed as the cause of its clinical manifestations [1]. There are currently no guidelines for the management of YNS, and an individualized approach to the management of YNS pleural effusions should be taken [2,3]. As with other recurrent exudative pleural effusions, serial thoracenteses for YNS may be complicated by pleural entrapment and progression to trapped lung, limiting the efficacy of future pleurodesis. CONCLUSIONS: Our patient's case suggests a role for staged IPC placement followed by VATS pleurodesis in patients with YNS pleural effusions complicated by pleural entrapment. This may also suggest a role for IPC placement in patients who are not currently surgical candidates without sacrificing the potential for more definitive treatment in the future. REFERENCE #1: Vignes S, Baran R. Yellow nail syndrome: a review. Orphanet J Rare Dis. 02 2017;12(1):42. doi:10.1186/s13023-017-0594-4 REFERENCE #2: Kurin M, Wiesen J, Mehta AC. Yellow nail syndrome: a case report and review of treatment options. Clin Respir J. Jul 2017;11(4):405-410. doi:10.1111/crj.12354 REFERENCE #3: Valdés L, Huggins JT, Gude F, et al. Characteristics of patients with yellow nail syndrome and pleural effusion. Respirology. Oct 2014;19(7):985-92. doi:10.1111/resp.12357 DISCLOSURES: No relevant relationships by Peter Le, source=Web Response No relevant relationships by Eric Sumner, source=Web Response

RECURRENT SPONTANEOUS PNEUMOTHORAX IN A YOUNG FEMALE PATIENT

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spontaneous pneumothorax (PTX) has an incidence of 1.2 to 6 cases per 100,000 females. Catamenial PTX is a rare type of secondary spontaneous PTX concomitant with menstruation, with an incidence of 3-6% among women initially diagnosed with primary spontaneous PTX. The pathophysiology of catamenial PTX involves the presence of endometrial tissue within the thoracic cavity, involving the pleura, diaphragm, or tracheobronchial tree, also known as thoracic endometriosis. These symptoms occur within 72 hours before or after menstruation. Due to the rarity of catamenial PTX, this condition represents a diagnostic & therapeutic challenge. CASE PRESENTATION: A 30 year old African American female presents with chief complaint of right (Rt) sided chest pain & dyspnea. The patient had experienced bilateral chest pain one day after beginning menstruation, with the left-sided chest pain resolving & progression of Rt-sided chest pain over the following days. She also had a cough for one week that had resolved at the time of presentation. Past medical history was remarkable for a previous episode of PTX on the left side 2 yrs prior, treated initially with chest tube drainage & subsequently requiring Video-Assisted Thoracoscopic Surgery (VATS) pleurodesis for recurrence. Pleural biopsy at that time showed acute & chronic pleuritis with inflammatory cells and fibrin. Chest Computed Tomography (CT) showed no other significant pulmonary parenchymal abnormality or cystic disease. Other co-morbidities included obesity, hay fever and acid reflux disease. Besides occasional marijuana use, no cigarette smoking or alcohol use reported. Family history was negative for pulmonary disease, endometriosis or PTX. Physical exam upon admission showed normal vital signs & diminished breath sounds on the Rt side suspicious for PTX. Chest x-ray (CXR) showed large Rt PTX with 7 cm pleuropulmonary separation without mediastinal shift. Small bore pigtail chest tube was placed with resolution of PTX. Right-sided VATS with pleurodesis was performed for definitive treatment. Post-operative course was unremarkable & the patient was discharged 2 days later. Follow-up CXR a week later showed complete resolution of small right apical PTX. DISCUSSION: Catamenial PTX should be suspected in the differential for young women with recurrent PTX coinciding with menstrual periods & in the absence of other common etiologies. Early identification, acute management with chest tube insertion, & definitive treatment with VATS pleurodesis is usually needed. Other preventative treatment may include hormonal therapy. CONCLUSIONS: This case illustrates an example of diagnosis & management of catamenial PTX, a rare type of spontaneous PTX in women associated with menstruation & caused by thoracic endometriosis. Reference #1: Noppen, M. (2010). Spontaneous pneumothorax: Epidemiology, pathophysiology and cause. European Respiratory Review, 19(117), 217–219. DISCLOSURES: No relevant relationships by Asok Dasgupta, source=Web Response No relevant relationships by Reed Geisler, source=Web Response No relevant relationships by Ty Gilkey, source=Web Response No relevant relationships by Chelsea Leipold, source=Web Response No relevant relationships by Paresh Timbadia, source=Web Response

Division of inferior pulmonary ligament did not impact on the postoperative recovery or recurrence in patients undergoing video-assisted thoracoscopic surgery for primary spontaneous pneumothorax

Background: Division of inferior pulmonary ligament (IPL) after upper lobectomy was reported to prevent air leak. The research purpose is to investigate whether division of IPL for primary spontaneous pneumothorax (PSP) would decrease air leak and recurrence. Methods: Between 2013/10 and 2015/9, all the patients younger than 30 years old in our institution undergoing video-assisted thoracoscopic surgery (VATS) for PSP were included in this study. Patient with odd chart number underwent division of IPL in addition to VATS wedge resection and pleurodesis for PSP, whereas patients with even chart number underwent VATS wedge resection and pleurodesis without division of IPL. The patient’s age, gender, operative time, and recurrence were all recorded. Chest plain films were taken on the postoperative day 1 (POD1), postoperative day 7 (POD7), and two months after discharge to observe residual pleural space. Results: A total of 110 patients were included in this study. The IPL was divided in 51 patients (rIPL group), and preserved in the other 59 patients (control group). The operative time increased in rIPL group slightly without significant difference (rIPL 81.1 verse control 88.4 minutes, P=0.539). The residual pleural space on the follow-up chest X-ray did not differ between these two groups. They both had similar chest tube drainage days (rIPL 2.7 days versus control 3.1 days, P=0.393). During the follow-up period, one patient in rIPL group (2.0%) and three patients (5.1%) in control group had recurrent pneumothorax (P=0.622). Conclusions: Division of IPL for PSP did not provide clinical benefit of reduction air leak or recurrence rate.

CATAMENIAL PNEUMOTHORAX: A MANAGEMENT CHALLENGE

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Catamenial pneumothorax (CP) is a rare clinical entity presenting with recurrent pneumothorax in women of reproductive age (1). Presence of ectopic endometrial tissue in thorax leads to their activation with each menstrual cycle. We report a unique case of a young female who presented with recurrent spontaneous pneumothorax despite video assisted thoracoscopic surgery (VATS). CASE PRESENTATION: A 36-year-old female with history of endometriosis, CP status post VATS about 4 months prior to this presentation, DVT, was referred to our ER for admission after she was found to have large right pneumothorax on a CT chest done as outpatient for chest discomfort. She was hemodynamically stable with SpO2 97% on room air. CT chest revealed a very large loculated right pneumothorax with left mediastinal shift and extensive pleural thickening. Initially she underwent a pigtail catheter placement in the largest pocket. Despite the pigtail drainage, patient continued to have air leak and mediastinal shift. Thus, a decision was made to perform VATS again. Pleural biopsy and VATS pleurodesis were performed with placement of 12F, 19F, 28F chest tubes. Mediastinal shift resolved but she continued to have small pneumothorax. On day 16, she was discharged with a chest tube and outpatient follow-up. Chest tube was removed on one week follow up in the clinic. She continued to have small loculated right sided pneumothorax. Pleural biopsy obtained during VATS, showed positive paired-box gene8 (PAX8) in epithelial lining compatible with presence of endometrial tissue in pleura. She is currently on progesterone only mini pill and is closely followed up in clinic. DISCUSSION: Thoracic endometriosis is the most common site for extra pelvic endometriosis with CP being a common presentation. It mostly affects right side (85-90%) like in our case. Characteristic findings associated with CP include defects of diaphragm like perforation, stomata, pores and fenestrations, which can vary in size, shape and numbers (2). With this case, we emphasize that the physicians should be aware of this relatively uncommon clinical entity when encountering young female with recurrent pneumothorax. Even after confirmed diagnosis, CP poses a treatment challenge as it can continue to cause recurrent large pneumothoraces despite VATS and hormonal therapy. Patients can develop pleural thickening and loculations which makes management of future pneumothoarcses even more difficult. No clear guidelines exist on management of CP. With the disease affecting young population and having a significant effect on lifestyle, it is prudent that more research should be done for CP management. CONCLUSIONS: CP is an uncommon cause of recurrent pneumothorax. Histologic finding of endometrial tissue on pleural biopsy is often required to confirm the diagnosis. CP is usually managed with hormonal therapy and VATS but needs further investigation. Reference #1: Bagan P, et al. Catamenial pneumothorax: retrospective study of surgical treatment. Ann Thorac Surg 2003;75:378-81. Reference #2: Visouli AN, et al. Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature. J Thorac Dis. 2012 Nov;4(Suppl 1):17–31. DISCLOSURES: No relevant relationships by Nidhi Aggarwal, source=Web Response No relevant relationships by Vivek Kumar, source=Web Response No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Jignesh Patel, source=Web Response No relevant relationships by Anand Rai, source=Web Response No relevant relationships by Arjun Saradna, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response No relevant relationships by Parita Soni, source=Web Response

Comparison of Efficiency of Pleurodesis Between Video Assisted Thoracoscopic Surgery (VATS) and Standard Thoracostomy.

Background:Chemical pleurodesis is generally accepted palliative dyspnea therapy and preventive of re-accumulation of pleural fluid in patients with malignant pleural effusions.Aim:Comparative analyses of efficiency of chemical pleurodesis between Video Assisted Thoracoscopic Surgery (VATS) and standard thoracostomy.Methods:From 01.01.2016-01.01.2017 at the Clinic for Thoracic Surgery of University Clinical Center (UCC) Sarajevo retrospective analysis was performed. Studied patients underwent VATS pleurodesis (G1) and standard thoracostomy pleurodesis (G2), with 60 in each group, respecting defined inclusion and exclusion criteria. Pleurodesis success was examined radiologically over the next three months.Results:Average age of all patients was 63.97±8.75 years. Gender related, 45% were men and 55% were women (F/M=1.47:1). Average hospitalization was 7.22±1.37 (G1: 6.68±1.16; G2: 7.44±1.40; Mann-Whitney U-test: p=0.0016) days. Average thoracic drainage duration was 5.45±1.69, (G1: 4.28±1.15,G2: 6.05±1.58; Mann-Whitney U-test p<0.0001) days. Pleurodesis success after first month was 98.30% in G1, 91.60% in G2 (G1 vs. G2; p=0.2089); after second month was 98.30% in G1, 78.30% in G2 (G1 vs. G2; p=0.0011) and after three months was 91.60% in G1, 63.30% in G2(G1 vs. G2; p=0.0006). Average dyspnea degree (0-5) after the pleurodesis was 0.050±0.22 in G1 and 0.62±0.76 in G2 (Mann-Whitney U-test; p=0.0001). Complication were noticed in 9.2% patients, in G1 3.3%, 15.0% in G2.Conclusion:Difference in pleurodesis efficiency between the G1 and G2 was established after second month and was even more evident after third month in favor of G1. Results show the significant statistical improvement of the degree of dyspnea in G1 as opposite to the G2.

Paralysis of the rectus abdominis muscle after video-assisted thoracoscopic surgery for recurrent spontaneous pneumothorax

Clinically apparent injury to an intercostal nerve associated with paralysis of the upper rectus abdominis is a rare complication of video-assisted thoracoscopic surgery (VATS), with no reports available in the pediatric literature. We present the case of a 16-year-old boy who underwent VATS blebectomy and pleurodesis followed by tube thoracostomy for recurrent spontaneous pneumothorax. Definitive reexpansion of the lung was achieved with no immediate complications, but the child complained of abnormal sensation and motor dysfunction of the left upper rectus at his first follow-up visit 2 weeks after the operation. Isolated muscular paralysis persisted at 2-month follow-up, although there was no associated activity limitation. Video-assisted thoracoscopic surgery is now a common practice and recognized as less morbid than open thoracotomy, but there exists scant literature regarding intercostal nerve injury and associated rectus abdominis paralysis. This report reviews the relevant published literature, with emphasis on the mechanism of nerve injury and avoidance of this complication.

Recurrent Bilateral Pneumothoraces: A Rare Complication of Miliary Tuberculosis

Pneumothorax as a complication of adult cavitary pulmonary tuberculosis is well known and not at all rare, but its occurrence as a complication of miliary tuberculosis is extremely rare. We report a 22-year-old woman who had nonproductive cough and fever for 3 days. Chest radiography showed diffuse, symmetrical miliary nodulation throughout both lung fields. The patient was treated for a presumed diagnosis of miliary tuberculosis with standard antituberculous regimen. Bilateral pneumothorax occurred simultaneously during hospitalization and chest tube thoracostomy was performed. Three days later, recurrent right pneumothorax developed. Video-assisted thoracoscopic surgery (VATS) lung biopsy of the right lung was performed and pathology showed granulomatous interstitial pneumonia with acid-fast positive bacilli. Lung tissue culture was positive for Mycobacterium tuberculosis. In the following 2 months, bilateral pneumothorax recurred twice and chemical pleurodesis with minocycline was performed on both sides, but air leakage persisted. VATS pleurodesis was performed on both sides successfully without recurrence of pneumothorax on either side. Our experience highlights the fact that pneumothorax should be suspected in an adult with miliary tuberculosis who suddenly develops acute respiratory distress. Recurrent pneumothorax can be managed, apart from medical therapy of miliary tuberculosis, with surgical intervention.

Transient Diaphragmatic Paralysis by Continuous Para-Phrenic Infusion of Bupivacaine: A Novel Technique for the Management of Residual Spaces

Space problems are a common complication after thoracic surgery. Different procedures have been used to manage them. We describe a novel technique using transient diaphragmatic paralysis by continuous para-phrenic infusion of bupivacaine.

Video-Assisted Thoracoscopic (VATS) Pleurodesis for Malignant Effusion: An Australian Teaching Hospital's Experience

Video-assisted thoracoscopic surgery (VATS) is commonly employed to achieve pleurodesis in patients suffering malignant pleural effusion (MPE). AIMS.: To evaluate the utility and outcome of VATS pleurodesis in management of MPE. Two hundred and two consecutive VATS pleurodesis for MPE were evaluated. Data was derived from a prospectively maintained database and hospital records. Pleurodesis was deemed unsuccessful if a significant effusion occurred within 30 days of surgery. VATS pleurodesis was successful in 88% of patients (failure 12%) while recurrence of effusion occurred in 18%. Post-operative air space, air leak, empyema and prolonged intercostal catheter drainage (>14 days) were all significantly associated with a failed procedure. Mean length of stay was 10.4 days and 42% of patients were discharged within 7 days of surgery. Morbidity was 20% with no operative deaths and median survival was 94 days. Inpatient mortality was 5%. High ASA (>or=4) was significantly associated with increased risk of inpatient death (p<0.001) and poorer long-term survival (43 days versus 133 days, p=0.05). VATS pleurodesis offers reasonable palliation of MPE with low morbidity and rapid recovery. Patients with an ASA score of >or=4 have a poor overall outcome and warrant less invasive palliative measures.

Spontaneous pneumothorax in children.

Sixteen consecutive children diagnosed with spontaneous pneumothorax (SP) and admitted to Chang Gung Children's Hospital between July 1994 and June 1999 were retrospectively studied. The presenting features, radiographic abnormalities, and indications of surgery were reviewed. All patients were exclusively adolescents and were aged between 12 and 17 years. Six patients received chest tube drainage only. Nine patients underwent ablation of blebs or bullae using video-assisted thoracoscopic surgery (VATS) with good results. One patient had a bullous emphysema removed by wedge resection. One patient with spontaneous hemopneumothorax required a blood transfusion and emergent thoracotomy for stabilization. Computed tomographic (CT) scans of the chest detected all seven (100%) cases with apical bulla formations. First episodes of spontaneous pneumothorax were treated conservatively using closed-tube thoracostomy if the plain chest radiographs and CT scans were negative for apical bleb or bulla formations. In summary, SP occurred exclusively in adolescents in this study, commonly they had no underlying pulmonary abnormalities except for bulla or bleb formations. SP can be safely and effectively managed using VATS and abrasive pleurodesis in children without recurrence at follow-up. SP may be treated surgically even in the first event of pneumothorax when subpleural blebs are demonstrated by high-resolution computed tomographic scans.

Thoracoscopic Surgery: Indications and Outcome

Video-assisted thoracoscopic surgery (VATS) has become an established technique in both diagnostic and therapeutic thoracic surgery procedures. In an attempt to evaluate the current indications and outcome of this technique, 143 VATS procedures, which were performed over a three-year period, were retrospectively evaluated. Indications included lung biopsy in 46, recurrent or persistent pneumothorax in 42, and pleural disease in 16 patients. Other indications included sympathectomy in eight, mediastinal mass in three, pericardial window in three, metastasectomy in three, and staging of lung cancer in two patients. There was one postoperative death (0.7%), a patient with massive pleural effusion and end-stage renal and hepatic failure. Conversion to formal thoracotomy was necessary in six patients (4.2%), and was the result of adhesions in four, bleeding in one, and failure to identify the lesion in one patient. Diagnostic procedures were considered successful in 44 out of 46 lung biopsies (95.7%), 15 out of 16 pleural disease cases (93.8%), and two lung cancer staging cases. The other 79 therapeutic VATS procedures were all effective, both in the long and short term, apart from two cases of prolonged air leak after VATS for pneumothorax, one of which was considered a failure (2.4%). VATS should be available in each thoracic surgery unit. It is both safe and effective in a variety of diagnostic and therapeutic procedures.