Insights in Chest Diseases

Keywords

Pleural disease; Mesotheloma; Pleurodesis; Asbestos

Case Report

Our department is based in a Tertiary Centre with a dedicated Cardiothoracic Unit [1-3]. Talc pleurodesis by far the most common technique we use for managing malignant effusion. Due to legal implications in cases where mesothelioma is the suspected causative agent histological confirmation is required. This usually requires operative pleural biopsy. Most commonly access to the chest cavity is gained by insertion of a VATs port in the anterior auxiliary line, 4^th intercostal space. Following assessment of the lung and pleura under direct vision we perform talc insufflation and chest drain insertion. One size 28 or 30 F drain is placed in the apical position.

Level C evidence states that low pressure and high volume suction may benefit pleural effusion drainage [4]. Therefore, traditionally we would have closed and placed the swinging drain on suction producing significant visible talc loss into the drain. As drains occasionally blocked and such significant volumes of talc were being lost we looked for a cost effective way to address the issue. After trial and error we found elevation of drain lines as an effective way of reducing talc in the drain aspirate. We now elevate all suction drains over a drip stand at approximately one and a half meters for the following 23 h post op before being returning to normal position.

This modification of the standard technique manages potential post op air leak, permits fluid and air drainage, allows lung expansion and avoids excess loss of intrathoracic talc. Following talc pleurodesis we use tube extensions to standard chest drains which allows the elevation over a drip stand (Figure 1) for the first few hours post op to maximize adhesion of talc to the pleura.

Figure 1: HPLC chromatogram of the nine reference compounds in 50% aqueous methanol, measured at 370nm. Retention times for rutin, sutherlandin A, sutherlandin B, kaempferol-3-O-rutinoside, sutherlandin C, sutherlandin D, quercitrin, quercetin and kaempferol were 11.9, 12.7, 13.8, 15.3, 16.2, 17.0, 18.0, 26.2 and 28.1 minutes, respectively.

They are then collected to a standard Sahara drain placed on suction. However, in a handful of cases we have also employed the long line in bedside talc pleurodesis through a standard chest drain set. This is especially effective were patient is too unfit to proceed to theatre for biopsy. We have now been using this technique for the past year in over 50 cases. Usual patient demographic is middle aged to elderly male with mesothelioma secondary to asbestos exposure, though it is equally effective in any malignant effusion. We see such a number of cases due to Belfast's historic shipbuilding past which widely used asbestos right up to the late 1980's.

Discussion

We have noted clinically more full inflation occurring during the first few hours in some cases where the lung did not appear to expand fully intra-operatively. We had no increased length of stay compared to patients in other groups who had standard drainage technique. On average patients were discharged home the second day post-surgery. There is no cost difference in regards to traditional drainage aside from the cost of extra 150 cm of drain piping. As discussed, research is ongoing into the benefits of suction drainage post pleural biopsy. This technique gives the operator the option of employing suction drainage, while reducing risk of drain blockage and talc loss.

By implementing this technique far less talc is visible within the drain aspirate suggesting clinically more talc is retained within the chest cavity. This permits fuller lung expansion and while providing an emergency drain if any sudden air leak develops as the lung expands. Standard risks associated with the technique are as those associated with surgical chest drain insertion. These include bleeding, organ damage and risk of infection. The increased tubing length produces no additional patient risks. As this technique can be used after both bedside talc insufflations via a chest drain or intra-operatively post biopsy we feel that it has a wide range of application in both Cardiothoracic Surgery and Respiratory Medicine (Figure 1).

References

1. Robinson S (1917) Resection of lobes f lbfthe lung. JAMA 69:355.
2. SahnSA (2000) Talc Should Be Used for Pleurodesis. American Journal of Respiratory and Critical Care Medicine 162: 2023-2024.
3. Neragi-MiandoabS (2006) Malignant pleural effusion, current and evolving approaches for its diagnosis and management. Lung Cancer 54: 1-9.
4. Mark ER, Edmund N, Richard GB, George A, Nabeel JA (2010) Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline. Thorax 65: ii32­ii40.