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  • 1.  
  • 2. Giuseppe Cardillo, MD, FETCS Indications and Results of Surgical Pleurodesis for Spontaneous Pneumothorax Unit of Thoracic Surgery Glenfield Hospital Leicester - UK Unit of Thoracic Surgery C. Forlanini Hospital ,Rome - Italy
  • 3. EDUCATIONAL AIM
    • To understand when there is a need to treat a spontaneous pneumothorax
    • To understand which procedure should be preferred
    • To understand the risk and benefit of its procedure
    • To understand how to counsel a patient who has been treated for spontaneous pneumothorax
    • To understand the need for follow-up
  • 4. SPONTANEOUS PNEUMOTHORAX
    • Spontaneous pneumothorax (SP) occurs in more than 20,000 patients annually in the United States *
    • Cost nearly $130,000,000 per year **
    * Melton LJ et al. Am Rev Respir Dis 1979, 120:1379–1382. ** Bense L et al. Chest 1991, 99:260–261. ** Baumann MH et al. Chest 1997, 112:789–804.
  • 5. SPONTANEOUS PNEUMOTHORAX
    • Primary
    • Rupture of small bullae or blebs in the absence of clinically apparent lung disorder (80% - 90%)
    • Secondary
    • Underlying lung disease (10%-20%)
    • (m ost commonly chronic obstructive pulmonary disease)
    • Catamenial
    • Associated with endometriosis
    • (within 24-72 hours after the onset of menstruation)
    * Bertrand PC, Ann Thorac Surg 1996, 61:1641-5.
  • 6. PRIMARY SPONTANEOUS PNEUMOTHORAX (PSP) Epidemiology
    • Aged-adjusted incidence:
    • 7.4 to 18 cases per 100.000 person-year (men) *
    • 1.2 to 6 cases per 100.000 person-year (women)*
    • Male predominance 3:1 *
    • Age: 20-40 years old *
    • Bilateral in 10% of cases *
    • Smoking increases the likelihood of PSP up to 20 times, (depending on the number of cigarettes smoked daily **)
    *Bertrand PC, Ann Thorac Surg 1996, 61:1641-5. ** Bense L et al. Chest 1987, 92:1009–1012.
  • 7. SECONDARY SPONTANEOUS PNEUMOTHORAX (SPP) Epidemiology
    • Age-adjusted incidence
    • 6.3 cases per 100,000 persons per year (men) *
    • 2 cases per 100,000 persons per year (women) *
    • Older patients
    • It can be life threatening, depending on the severity of the underlying disease and the size of the pnx
    • Mortality in pts with COPD and SP vary from 1-17%.
    *Bertrand PC, Ann Thorac Surg 1996, 61:1641-5.
  • 8. PRIMARY SPONTANEOUS PNEUMOTHORAX Physiopathology
    • BULLAE
    • BLEBS have no epithelial lining and arise from rupture of the alveolar wall (so-called emphysema-like changes, ELC) *
    * Donahue DM, et al. Chest 1993;104:1767–9. * Lesur O, et al. Chest 1990;98:341–7.
    • ELC are present in the majority of PSP patients, but they are not always the actual site of the air leak
    • Air leakage can occur elsewhere at the visceral pleura whether or not ELC are present (‘ PLEURAL POROSITY’ )
  • 9. SECONDARY SPONTANEOUS PNEUMOTHORAX Physiopathology
    • Every lung disease has been reported to be associated with SSP, but COPD is by far the most common underlying disorder
    • CT is sometimes necessary to differentiate pnx from large thin-walled bullae
    Baumann MH. et al. Pneumothorax. Respirology 2004, 9:157-164.
  • 10. SPONTANEOUS PNEUMOTHORAX Diagnosis
    • Erect PA chest x-ray (inspiration)
    • Small pneumothorax
    • rim of < 2 cm between the lung margin and the chest wall
    • Large pneumothorax
    • rim of > 2 cm between the lung margin and the chest wall
    * Wait MA, et al. Am J Surg 1992;164:528–31. * Tanaka F, et al. Ann Thorac Surg 1993;55:372–6. ¹ Engdahl O, et al. Chest 1993;103:26–9. CT scanning ¹ Accurate size
  • 11. SPONTANEOUS PNEUMOTHORAX CT - Chest Imaging
    • Recommended when :
    • planning surgery in pts > 40 years old
    • aberrant tube placement is suspected
    • plain chest radiograph is not clear
    • during management of a persistent air leak
    • differential diagnosis PTX -complex bullous lung disease
    Henry M. et al. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58 (Suppl II):ii39–ii52.
  • 12. SPONTANEOUS PNEUMOTHORAX Recurrences after drainage 1st episode
    • vary from 16–52%, averaging 30% ¹
    • The likelihood of subsequent recurrences seems to increase progressively up to 62% for a second recurrence and 83% for a third recurrence ²
    • Most recurrences occur within 2 years of the initial episode
    ¹ Schramel FM. et al. Eur. Respir. J. 1997; 10: 1372–9. ² Gobbel W. J. Thorac. Cardiovasc. Surg. 1963; 46: 331–45.
  • 13. SPONTANEOUS PNEUMOTHORAX Management 1st episode
    • O2 therapy
    • Bed Rest
    • Thoracocentesis
    Chest tube placement
  • 14. SPONTANEOUS PNEUMOTHORAX
    • • Second ipsilateral pneumothorax
    • • First contralateral pneumothorax
    • • Bilateral spontaneous pneumothorax
    • • Persistent air leak (> 3 - 4 days of tube drainage; air leak or failure to completely re-expand)
    • • Spontaneous haemothorax
    • • Professions at risk (e.g. pilots, divers)
    Henry M. et al. “BTS guidelines for the management of spontaneous pneumothorax”. Thorax 2003;58 (Suppl II):ii39–ii52. Baumann MH. et al. “Pneumothorax”. Respirology 2004, 9:157-164. Indications for SURGERY
  • 15.
    • The great majority of the last reported papers favors the minimally invasive VATS approach even if, comparing randomized trials , VATS can only be associated with shorter length of hospital stay or use of pain medication than thoracotomy with a comparable complication profile and success rate. *
    SPONTANEOUS PNEUMOTHORAX VATS vs AXILLARY THORACOTOMY * Sedrakyan A. et al. “Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomized clinical trials”. BMJ 2004; 329 : 1008. VATS IS OUR APPROACH
  • 16. PRIMARY SPONTANEOUS PNEUMOTHORAX The lung is inspected during gentle ventilation with saline in the pleural cavity to detect blebs/bullae and air leak Blebs/bullae are treated by means of minimal wedge resection with the endoscopic stapler (SCB 45) In cases of minimal air-leak or bleeding along the suture-line fibrin glue is employed Talc poudrage is accomplished by nebulization in the pleural cavity of 2 grams of asbestos-free sterilized talc VATS
  • 17.
    • Overall series 7/1992 – 12/2006
    • 1316 cases *
    • * Out of 5003 (26,3%) VATS performed
    SPONTANEOUS PNEUMOTHORAX VATS treatment of Primary Spontaneous Pneumothorax Thoracic Surgery “ Carlo Forlanini” Hospital, Rome
  • 18. SPONTANEOUS PNEUMOTHORAX
      • TREATMENT OF THE UNDERLYING DEFECT
      • Resection of blebs
      • Suture of apical perforations
      • PLEURODESIS
      • Pleural abrasion
      • Partial pleurectomy
      • Talc poudrage
      • DRAIN AIR AND REEXPAND THE LUNG
      • Large bore chest tube (20- 24 Fr)
    Surgical Options - Key Points
  • 19. SPONTANEOUS PNEUMOTHORAX
      • TALC POUDRAGE SHOWS A HIGHER
      • SUCCESS RATE AND LOWER MORBIDITY THAN PLEURECTOMY
      • (98.21% vs 90.75% / p: 0.00018 )
      • Cardillo G. Ann Thorac Surg 2000; 69: 357-61
    Pleurectomy vs Talc poudrage
  • 20. VANDERSCHUEREN’S CLASSIFICATION STAGE I No endoscopic abnormalities STAGE II STAGE III STAGE IV Pleuropulmonary adhesions Blebs/bullae < than 2 cm Bullae > than 2 cm
  • 21. SURGICAL PROTOCOL Cardillo G. J Thorac Cardiovasc Surg, 2006; 131:322-8. Cardillo G. Ann Thorac Surg 2000; 69 : 357-61 STAGE I Talc poudrage (TP) only STAGE II STAGE III STAGE IV Lysis of all adhesions + TP Stapling of the blebs/bullae + TP
  • 22. SPONTANEOUS PNEUMOTHORAX Surgical protocol No evidence for blind apical stapling in patients with no bullae/blebs Cardillo G. J Thorac Cardiovasc Surg, 2006; 131:322-8. Cardillo G. Ann Thorac Surg 2000; 69 : 357-61
  • 23.
    • Concern
    • Risk of malignancy
    • Respiratory Insufficiency
    • ARDS
    • Sepsis
    SPONTANEOUS PNEUMOTHORAX TALC POUDRAGE
  • 24. VATS TALC POUDRAGE  No increased risk of mesothelioma Asbestos-free talc RISK OF MALIGNANCY Cardillo G. Ann Thorac Surg 2000; 69 : 357-61 Lange P. Thorax 1988; 43: 559-561
  • 25. TALC POUDRAGE
    • RESPIRATORY INSUFFICIENCY
    • In a review of 4030 cases respiratory failure after administration of talc was described in 41(1%)
    • (old, sick and with neoplasm !)
    Sahn S.A. : “Is talc indicated for pleurodesis? Pro : talc should be used for pleurodesis”. J Bronchology 2002
  • 26. TALC POUDRAGE
    • RISK OF ARDS
    • Kennedy L. Chest 1994;
    • Campos J.R. Lancet 1997;
    • Rehse D.H. Am J Surg 1999;
    • Rinaldo J.E. J Bronchology 2002;
    • Weissberg D. J Thorac Cardiovasc Surg 1993;
    • Cardillo G. Eur J Cardio-thoracic Surg 2002;
    • Viallat J.R. Chest 1996
    ARDS YES (USA/Brazil) NO (EU/Israel)
  • 27. TALC POUDRAGE
    • TALC DEPOSITION IN ORGANS
    • 100% studies from (Brazil)
    • 2% studies from (EU) *
    • * Contamination during storage of organs
    Experimental studies in animals
  • 28.
    • Talc preparation used for pleurodesis varied markedly from one preparation to another
    TALC POUDRAGE Ferrer J. Et al. “Talc preparation used for pleurodesis vary markedly from one preparation to another” Chest 2001 The Role of Talc Particle Size
  • 29.
    • In rabbits damage to lung parenchyma occurred when small size particles were used and not with large size.
    • Ferrer J. “Influence of particles size on extrapleural talc dissemination after talc slurry pleurodesis.” Chest 2002
    TALC POUDRAGE The Role of Talc Particle Size
  • 30.
    • In humans Maskel and al. demonstrated that pleurodesis with mixed talc including small size particles worsened gas exchange and induced more systemic inflammation than graded talc from which most of the particles
    • < 10 mmc were removed.
    • Maskell N.A. et al.: “Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size.” Am J Resp Crit Care Med 2004
    TALC POUDRAGE The Role of Talc Particle Size
  • 31. SPONTANEOUS PNEUMOTHORAX
    • TALC
    • 2 grams asbestos-free (according to EU standards)
    • All particles < 50 µm
    • Median particle size 25.6 µm
    • Small particles (< 5 µm ): 11%
  • 32. VATS TALC POUDRAGE Rationale Asbestos-free talc European/ Italian Pharmacopeia 4-5% 5 μ m 25% 10 μ m 78% 20 μ m PERCENTAGE OF PARTICLES SIZE UNDER
  • 33. TALC POUDRAGE
    • No risk with standard techniques
    • According to EU standards Talc must be sterilized with gamma / β rays
    SEPSIS
  • 34. TALC
    • No oncological risk (absestos-free talc)
    • No reported case of ARDS (size of fibers)
    • No reported case of empyema (sterilized talc)
    • Dosage schedule ( range: 2-10 g)
    • ► Safety of Talc In Spont.Pnx (ERS ongoing trial)
    2g ASBESTOS-FREE STERILIZED (According to EC Pharmacopeia) Rinaldo JE: J Thorac Cardiovasc Surg 1983;85:523 Sedrakyan A: BMJ 2004; 329:1008 West : Curr Opin Pulm Med 2004
  • 35. SPONTANEOUS PNEUMOTHORAX J Thorac Cardiovasc Surg, 2006; 131:322-8. VIDEOTHORACOSCOPIC TALC POUDRAGE The rationale
  • 36. POSTOPERATIVE MORBIDITY Postoperative Complications Rate was 3.36% 29/861 patients Postoperative paresthesia presented in 114 patients at discharge, spontaneously resolved in all patients within 6 months from surgery Localized pleural effusion 15 Prolonged air leaks (> than 5 days) 9 Subcutaneous emphysema 3 Pneumonia 1 Transient Bernard Horner syndrome 1 #
  • 37. RESULTS No postoperative (30 days) death No intraoperative complications Mean operative time: 14 ± 8 min Conversion rate: 0.46% (4/861)
  • 38. RESULTS Mean time to removal of chest tubes: 4.7 days (4-10 days) Mean hospital stay: 5.6 days (4-12 days) Return to occupational activity Within 21 days 65.5% of patients Within 30 days 91.3% of patients Overall recurrence rate: 1.73% (14/805 pts with follow-up)
  • 39. FACTORS INFLUENCING RECURRENCE RATE (7/290) 2.41% (7/515) 1.35% 12/471 (2.54%) 2/334 (0.59%) 28.12 years 29.71 years 9/541 (1.66%) 5/264 (1.89%) Pts with recurrence/Total Pts (%) Surgical treatment Group A (talc poud.only) Group B (stapl+talc poud) Smoke Smokers No smokers Mean age (yrs) Pts without recurrence Pts with recurrence Gender Male Female Factors 0.27 0.037 0.75 0.81 p
  • 40. RECURRENCES RATE IN STUDIES OF VATS TREATMENT OF PSP pleurectomy / talc poudrage 4.4 38 432 2000 Cardillo talc poudrage 5 60 59 2002 Tschopp cautery + talc poudrage 0 62 156 2003 Margolis pleural abrasion 3 84 167 2003 Lang-Lazdunski pleural abrasion 3.6 36.5 111 2003 Gossot pleurectomy 2 48 100 2003 Ayed talc poudrage 1.73 52.5 805 2006 Cardillo Pleurodesis Recurrence (%) Follow-up (months) # Year Author
  • 41. Follow up
    • Still under evaluation in the light of cost-effectiveness.
    • Important to evaluate even minimal recurrences with minor symptoms.
    • Follow-up protocol of our Institution:
    • chest x-ray every at 1 month, 3 month, 6 month and every year for 5 years
  • 42. TALC PLEURODESIS Lung Function and Videothoracoscopic Talc Poudrage LONG-TERM LUNG FUNCTION FOLLOWING VIDEOTHORACOSCOPIC TALC POUDRAGE FOR PRIMARY SPONTANEOUS RECURRENT PNEUMOTHORAX. Cardillo G, Carleo F, Carbone L, Di Martino M, Salvadori L, Ricci A, Petrella L, Martelli M. Eur J CardioThorac Surg. 2007; 31:803-6
  • 43. TALC PLEURODESIS Lung Function From September 1, 1995 to January 31, 2006 we consecutively enrolled 50 patients with no recurrence GROUP A 50 patients after simple drainage for recurrent PSP GROUP B We evaluated lung function with measurement of static and dynamic volumes (FEV1, FVC, TLC, RV) and DLCO at 60 months after surgery Cardillo G. et al. Long-term lung function following videothoracoscopic talc poudrage for primary spontaneous recurrent pneumothorax. Europ J CardioThorac Surg 2007; 31:803-6
  • 44. TALC PLEURODESIS Lung Function The overall functional status was excellent in all patients: no single patient showed FEV1 less than 80%, and the mean values were over 90% in all tests Pulmonary function tests showed no statistical significant difference between group A and group B (p-value): FEV1 (p: 0.07) , FVC (p:0.1), TLC (p:0.06), RV (p:0.07), and DLCO (p: 0.4). Cardillo G. et al. Long-term lung function following videothoracoscopic talc poudrage for primary spontaneous recurrent pneumothorax. Eur J CardioThorac Surg, in press 80,0 90,0 100,0 110,0 A B GROUP FEV1
  • 45. SPONTANEOUS PNEUMOTHORAX VATS Has been shown to be the gold standard for recurrent and complicated Primary Spontaneous Pneumothorax as it allows for shorter hospital stay, less pain, and quicker return to the activities of daily life compared to open thoracotomy, which is important in this young, otherwise healthy, patient population. TALC PLEURODESIS has been shown to be a safe procedure which preserve lung function in the long term and do not restrict chest wall mobility. CONCLUSIONS
  • 46. QUESTIONNAIRE 1) Which is the best treatment for a small primary spontaneous pneumothorax (PSP) ? and for a small secondary spontaneous pneumothorax (SSP) ? 2)In PSP when there is a need for surgery ? For a small PSP bed rest is a good option; pleural drainage being the standard treatment . For SSP pleural drainage is almost always indicated . In recurrent PSP or when there is a failure of primary standard treatment (pleural drainage) 3)What do you suggest for Haemopneumothorax ? Surgery
  • 47. QUESTIONNAIRE 4)Which is the favoured treatment for SP ? 5)which is the aim of thoracoscopy ? Videothoracoscopy, even if randomized study have only showed that VATS can only be associated with shorter length of hospital stay or use of pain medication than thoracotomy with a comparable complication profile and success rate, and obvious better cosmetic result. To treat the bullae if present and to perform a pleurodesis 6)Which are the option for pleurodesis ? Pleurectomy, Pleural abrasion , and Talc poudrage
  • 48. QUESTIONNAIRE 7)Which are the drawbacks of each technique ? 8)Which technique seems to be more useful in the light of the recent data ? Pleurectomy and pleural abrasion: bleeding Talc poudrage: no well defined complication Talc poudrage 9)What’s about the concern for the use of talc poudrage in young patients? The published data do not support any concern for the use of talc poudrage . 10)Is there any relationship between smoking and recurrence ? Yes