Short-term safety of thoracoscopic talc pleurodesis for recurrent primary spontaneous pneumothorax: a prospective European multicentre study.

The safety of talc pleurodesis is under dispute following reports of talc-induced acute respiratory distress syndrome (ARDS) and death. We investigated the safety of large-particle talc for thoracoscopic pleurodesis to prevent recurrence of primary spontaneous pneumothorax (PSP). 418 patients with recurrent PSP were enrolled between 2002 and 2008 in nine centres in Europe and South Africa. The main exclusion criteria were infection, heart disease and coagulation disorders. Serious adverse events (ARDS, death or other) were recorded up to 30 days after the procedure. Oxygen saturation, supplemental oxygen use and temperature were recorded daily at baseline and after thoracoscopic pleurodesis (2 g graded talc). During the 30-day observation period following talc poudrage, no ARDS (95% CI 0.0-0.9%), intensive care unit admission or death were recorded. Seven patients presented with minor complications (1.7%, 95% CI 0.7-3.4%). After pleurodesis, mean body temperature increased by 0.41°C (95% CI 0.33-0.48°C; p<0.001) at day 1 and returned to baseline value at day 5. Pleural drains were removed after day 4 in 80% of patients. Serious adverse events, including ARDS or death, did not occur in this large, multicentre cohort. Thoracoscopic talc poudrage using larger particle talc to prevent recurrence of PSPS can be considered safe.

Why you do or do not need thoracoscopy.

Thoracoscopy is an old but still very valuable technique for the evaluation of pleural pathology and, especially for the further investigation of the aetiology of pleural fluid. It remains of great importance, since it is able to not only provide an exact diagnosis, but also can have therapeutic potential. In this review, the differential diagnostic aspects of transudate versus exudate are further elaborated, and the role of thoracoscopy is compared to closed pleural biopsy and image guided biopsy.

Autofluorescence videothoracoscopy in exudative pleural effusions: preliminary results.

Videothoracoscopy has been proven to be a safe tool to establish the diagnosis in >90% of patients with exudative pleural effusions of unknown origin. In the majority of patients with malignant pleural diseases, the endoscopic appearance of pleural lesions during white light thoracoscopy is suggestive of malignancy, but could be misleading in some cases. The aim of the present study was to estimate whether the combination of thoracoscopy with autofluorescence modalities would be useful to further improve the diagnostic accuracy of the conventional method. The present study displays early results of thoracoscopy performed consecutively with a normal light source and with autofluorescence light in 24 patients with exudative pleural effusion during 2003-2004. In all cases of malignant pleuritis (carcinoma or mesothelioma), the colour of the affected area of the pleura changed from white/pink to red (sensitivity 100%). However, in two cases of chronic pleuritis, a colour change from white/pink to orange/red was recorded (specificity 75%). In conclusion, the calculated positive predictive value of colour change for malignant pleuritis during autofluorescence thoracoscopy in this study was 92%. However, the clinical value of autofluorescence thoracoscopy in daily practice remains to be proven.

Is thoracoscopic talc pleurodesis really safe?

Talc is a mineral defined as hydrated magnesium silicate in its pure form. It is mined in open pits throughout the world. For induction of chemical pleurodesis, talc has been shown to be superior to all other products. The safety of the use of talc for pleurodesis is subject to discussion in the literature. In early days, there was concern about asbestos contamination of talc, which could cause mesothelioma in patients who had undergone talc pleurodesis. The long-term safety of talc was proven in several studies, and today talc for pharmaceutical use is asbestos-free. Today the discussion is concentrated on the early complications of talc; Acute respiratory failure, sometimes with fatal outcome, has been attributed to the intrapleural use of talc particles. In recent animal studies, a relation was demonstrated between the size of talc particles and pulmonary injury as well as dissemination to other organs. Pulmonary injury and dissemination to other organs are related to a talc particle size of less than 10 micro. With certain precautions, talc can be used safely for pleurodesis; Simultaneous bilateral procedures, concomitant pulmonary biopsies and use of more than 5 grams of talc should be avoided. As long as the hypothesis about the influence of particle size on complications has not been confirmed by studies in humans, the use of talc with a large mean particle diameter is to be preferred.

Quantitative analysis of vascular images, in particular of abdominal aorta aneurysms from 3D CTA data sets.

This article presents a combination of well known image processing techniques to automatically segment CTA images of the Abdominal Aortic Aneurysm. Current results are that about 80% of the contours need no manual corrections. The remaining 20% fail due to calcified plaque close to the lumen border. After correction a 3D surface model is created from the 2D contours which is used as input for flow simulations and for parameter extraction of the AAA by clinicians for selecting the proper size and shape endograft, and to plan the placement procedure of this endograft in the patient.

Automated segmentation and analysis of vascular structures in magnetic resonance angiographic images.

The accurate assessment of the presence and extent of vascular disease, and planning of vascular interventions based on MRA requires the determination of vessel dimensions. The current standard is based on measuring vessel diameters on maximum intensity projections (MIPs) using calipers. In order to increase the accuracy and reproducibility of the method, automated analysis of the 3D MR data is required. A novel method for automatically determining the trajectory of the vessel of interest, the luminal boundaries, and subsequent the vessel dimensions is presented. The automated segmentation in 3D uses deformable models, combined with knowledge of the acquisition protocol. The trajectory determination was tested on 20 in vivo studies of the abdomen and legs. In 93% the detected trajectory followed the vessel. The luminal boundary detection was validated on contrast-enhanced (CE) MRA images of five stenotic phantoms. The results from the automated analysis correlated very well with the true diameters of the phantoms used in the in vitro study (r = 0.999, P < 0.001). MRA and x-ray angiography (XA) of the phantoms also correlated well (r = 0.895, P < 0.001). The average unsigned difference between the MRA and XA measurements was 0.08 +/- 0.05 mm. In conclusion, the automated approach allows the accurate assessment of vessel dimensions in MRA images.

Talcage by medical thoracoscopy for primary spontaneous pneumothorax is more cost-effective than drainage: a randomised study.

Simple thoracoscopic talcage (TT) is a safe and effective treatment of primary spontaneous pneumothorax (PSP). However, its efficacy has not previously been estimated in comparison with standard conservative therapy (pleural drainage (PD)). In this prospective randomised comparison of two well-established procedures of treating PSP requiring at least a chest tube, cost-effectiveness, safety and pain control was evaluated in 108 patients with PSP (61 TT and 47 PD). Patients in both groups had comparable clinical characteristics. Drainage and hospitalisation duration were similar in TT and PD patients. There were no complications in either group. The immediate success rate was different: after prolonged drainage (>7 days), 10 out of 47 PD patients, but only 1 out of 61 TT patients required a TT as a second procedure. Total costs of hospitalisation including any treatment procedure were not significantly different between TT and PD patients. Pain, measured daily by visual analogue scales, was statistically higher during the first 3 days in TT patients but not in those patients receiving opiates. One month after leaving hospital, there was no significant difference in residual pain or full working ability: 20 out of 58 (34%) versus 10 out of 47 (21%) and 36 out of 61 (59%) versus 26 out of 39 (67%) in TT versus PD groups, respectively. After 5 yrs of follow-up, there had been only three out of 59 (5%) recurrences of pneumothorax after TT, but 16 out of 47 (34%) after conservative treatment by PD. Cost calculation favoured TT pleurodesis especially with regard to recurrences. In conclusion, thoracoscopic talc pleurodesis under local anaesthesia is superior to conservative treatment by chest tube drainage in cases of primary spontaneous pneumothorax that fail simple aspiration, provided there is efficient control of pain by opioids.

Video assisted thoracoscopic treatment of pleuropericardial cysts.

Question of the Study In this study, safety and feasibility of thoracoscopic fenestration of pleuropericardial cysts under local and general anaesthesia is evaluated. Besides, a rare case of a pleural cyst, causing a superior vena cava syndrome, is described.Materials, Patients and Methods In a retrospective study, the results of thoracoscopic treatment of pleuropericardial cysts in three patients are presented. We performed videothoracoscopic fenestration of pleuropericardial cysts. One of these was performed under local anaesthesia. The two other cases were performed under general anaesthesia. After fenestration, talc poudrage of the inner lining of the cysts was performed in one case.Results Thoracoscopic fenestration appeared to be safe and effective. No recurrence was observed. One patient was lost to follow-up.Answer to the Question Thoracoscopic fenestration of pleuropericardial cysts is safe and effective. This procedure can be performed under local anaesthesia in selected cases. The role of talc poudrage of the cysts is unclear and needs further investigation.

Detection of areas with viable remnant tumor in postchemotherapy patients with Ewing's sarcoma by dynamic contrast-enhanced MRI using pharmacokinetic modeling.

An approach is presented for monitoring the effects of neoadjuvant chemotherapy in patients with Ewing's sarcoma using dynamic contrast-enhanced perfusion magnetic resonance (MR) images. For that purpose, we modify the three-compartment pharmacokinetic permeability model introduced by Tofts et al. (Magn Reson Med 1991;17:357-67) to a two-compartment model. Perfusion MR images acquired using an intravenous injection with Gadolinium (Gd-DTPA) are analyzed with this two-compartment pharmacokinetic model as well as the with an extended pharmacokinetic model that includes the (local) arrival time t(0) of the tracer as an endogenous (estimated) parameter. For each MR section, a wash-in parameter associated with each voxel is estimated twice by fitting each of the two pharmacokinetic models to the dynamic MR signal. A comparison of the two wash-in parametric images (global versus local arrival time) with matched histologic macroslices demonstrates a good correspondence between areas with viable remnant tumor and a high wash-in rate. This can be explained by the high number and permeability of the (leaking) capillaries in viable tumor tissue. The novel pharmacokinetic model based on a local arrival time of tracer results in the best fit of the wash-in rate, the most important factor discerning viable from nonviable tumor components. However, parameter estimates obtained with this model are also more sensitive to noise in the MR signal. The novel pharmacokinetic model resulted in a sensitivity between 0.22 and 0.60 and a specificity between 0.61 and 1. The model based on a global arrival time gave sensitivities between 0.33 and 0.77 and specificities between 0.58 and 0.99. Both statistics are computed as the fraction of correctly labeled voxels (viable or nonviable tumor) within a specified ROI, which delineates the tumor. We conclude that the added value of estimating the local arrival time of tracer first manifests itself for moderate noise levels in the MR signal. The novel pharmacokinetic model should moreover be preferred when pharmacokinetic modeling is applied on the average signal intensity within a ROI, where noise has less effect on the fitted parameters.

Chylothorax.

Chylothorax is defined as an accumulation of chyle in the pleural space caused by disruption of the thoracic duct or one of its major divisions. Chyle has a high content of triglycerides. The odorless fluid is turbid and milky due to the presence of fat containing particles, the chylomicrons. The etiology of chylothorax can be divided into four major categories: tumor, trauma, idiopathic and miscellaneous. Although chylothorax is uncommon, it is a serious and potentially hazardous disorder. Loss of chyle leads to metabolic disturbances, malnutrition and immunodeficiency. Treatment consists of treatment of the underlying disease, conservative treatment (medium chain triglyceride diet, parenteral nutrition) or surgical intervention. Appropriate timing of surgical intervention is essential. Since the ligation of the thoracic duct can be performed during thoracoscopy, this minimal interventional technique is the procedure of choice when conservative treatment fails.

Thoracoscopy in the management of spontaneous pneumothorax.

For many years, treatment of spontaneous pneumothorax (SP) has been a matter of debate. Since the introduction of videothoracoscopy, videothoracoscopic procedures have replaced thoracotomy as the ultimate procedure for treatment of complicated cases of SP in many institutes. However, the place of (video) thoracoscopy in SP has not been fully established yet. Satisfactory results have been published about several different combinations of bullectomy (Stapler resection, endoloop ligation, electrocoagulation, Nd-YAG laser, CO2 laser, argon beam coagulation) and pleurodesis (mechanical, chemical, pleurectomy). Until today, it remains obscure if bullectomy as well as pleurodesis are always necessary to prevent recurrence.

Pulmonary function of patients with spontaneous pneumothorax in relation to the extent of emphysema-like changes.

The aim of the present study was to analyse pulmonary function parameters of patients with spontaneous pneumothorax (SP) in relation to the extent of emphysema-like changes (ELCs). Pulmonary function tests were performed in 85 patients with unilateral SP, 6 weeks after video-assisted thoracoscopy (VAT). In 63 patients, thoracic computer tomography (CT) was obtained. An ELCs score, based on findings of CT and VAT, was used to quantify ELCs, ranging from 0 (expressing no ELCs) to 3 (expressing extensive ELCs). Emphysema-like changes were detected during VAT in 74% of patients, of which 70% were considered larger than 2 cm. An ELCs score > or = 2 was found in 27 patients. Clinical characteristics of the patients grouped according to thoracoscopical findings and ELCs score did not differ, except for age. Patients with large ELCs were significantly older than patients without ELCs or small ELCs (P = 0.0009). In patients with large ELCs and ELCs score > or = 2, increased mean percentages of predicted total lung capacity and decreased diffusing capacity (KCO) were found. None of the patients exhibited all pulmonary function criteria of emphysema, in contrast to 43% of the patients with an ELCs score > or = 2. KCO was the only pulmonary function parameter which was decreased in smokers, especially in patients with large ELCs or ELCs score > or = 2. Static lung compliance (Cstat) was the only pulmonary function parameter which was increased in patients with recurrent SP. The authors concluded that KCO is related to smoking behaviour and ELCs in patients with SP. Cstat is the only parameter which is increased in patients with recurrent SP. The discrepancy between pulmonary function and macroscopical parenchymal changes could be explained by the fact that not all patients with SP are old enough at presentation to show all signs of emphysema with pulmonary function testing. On the other hand, it might be possible that ELCs in SP cause different pulmonary function abnormalities than in centriacinar or panacinar emphysema.

Videothoracoscopic appearance of first and recurrent pneumothorax.

STUDY OBJECTIVE: Comparison of the videothoracoscopic appearance of first and recurrent pneumothorax, and assessment of a relation between endoscopic appearance and recurrence rate. SETTING: University hospital. PATIENTS: Eighty-two patients, 64 men (mean age, 32.7 years) and 18 women (mean age, 31.5 years), were included. Patients with known underlying pulmonary disease at the time of hospital admission were excluded. There were 61 patients (74%) with first pneumothorax, and 21 patients (26%) with recurrent pneumothorax. INTERVENTIONS: All patients underwent videothoracoscopy under general anesthesia, with double-lumen intubation. RESULTS: Blebs or bullae were found in 47 patients (77%) with first pneumothorax, and in 14 patients (67%) with recurrent pneumothorax. Bullae > 2 cm were found in 34 patients (56%) with first pneumothorax and 10 patients (48%) with recurrent pneumothorax. Patients with blebs or bullae were significantly older than patients with normal videothoracoscopic appearance (mean age, 36.5 +/- 15.7 years vs 25.3 +/- 5.8 years, p < 0.05). Adhesions were significantly more frequently found in patients with blebs or bullae compared with patients with normal thoracoscopic appearance of the lung (p < 0.05). Seventeen of 21 patients (81%) with normal thoracoscopic appearance were smokers. Of nonsmoking patients (n = 22), 82% had blebs and bullae. CONCLUSIONS: No significant differences in videothoracoscopic appearance were found between first and recurrent pneumothorax. These results suggest that recurrence after the first event of spontaneous pneumothorax cannot be predicted by thoracoscopic findings. Smoking and blebs or bullae are independent risk factors for development of spontaneous pneumothorax.

Diagnostic thoracoscopy.

Since the introduction of video-imaging and endoscopic surgical interventions, there is a worldwide renewed interest in thoracoscopy. However, thoracoscopy for diagnosis of pleural and pulmonary disease has been performed for more than 30 years. An overview is presented here of the results and experiences in the past 3 decades of thoracoscopy for diagnosis of pulmonary and pleural disease. Thoracoscopy is a simple and safe method to obtain a diagnosis in case of pleural effusion, pleural mass, or interstitial lung disease. In most cases, it can be performed under local anaesthesia.

Prognostic factors in patients with spontaneous pneumothorax treated with video-assisted thoracoscopy.

To analyse the efficacy of video-assisted thoracoscopy (VAT) in patients with spontaneous pneumothorax (SP) and to identify clinical factors associated with outcome after VAT, one hundred and one VATs were performed in 97 patients in this prospective study. Based on thoracoscopic appearance of the visceral pleura three groups were identified, group 1 (n = 23) showing no abnormalities treated with talcage, group 2 (n = 23) showing bullae less than 2 cm treated with talcage and coagulation, and group 3 (n = 51) showing bullae larger than 2 cm treated with bullectomy by staplers, coagulation and pleural scarification. Data were analyzed with regard to clinical factors such as age, smoking behavior, pulmonary function and recurrent pneumothorax at presentation. No perioperative deaths occurred. Overall relapse rate was 4.0% during a follow-up period of 3 to 38 months (median 27.2). Univariate analysis did not show any association of clinical factors with postoperative complications (n = 19). Patients with extensive pulmonary lesions had longer drainage and hospitalization time, probably due to insufficient sealing effects of stapler devices and/or pleural scarification. Using multivariate analysis, none of the clinical factors had any association with complication rate, drainage/hospitalization time or relapses after VAT. Only patients with bullae larger than 2 cm treated with bullectomy by stapler devices were associated with longer drainage and hospitalization time. This study suggests that VAT is effective in the treatment of spontaneous pneumothorax, although the use of stapler devices and/or pleural scarification was associated with longer drainage and hospitalization time, however, none of the clinical factors were associated with the outcome after VAT.

Video-Assisted Thoracoscopy is Superior to Standard Computer Tomography of the Thorax for Selection of Patients With Spontaneous Pneumothorax for Bullectomy.

BACKGROUND: Spontaneous pneumothorax (SP) is a common disease of unknown cause often attributed to rupture of a subpleural bulla or bleb [in this study described as emphysema-like changes (ELC)]. Treatment of SP varies from conservative (rest) to aggressive (surgery). Patients with bullae >2 cm diameter, found either by chest roentgenogram or during thoracoscopy, are often treated surgically (bullectomy and pleurectomy, or abrasion). Thoracoscopy is frequently used as the method of choice to select patients for surgery. With the recent introduction of video-assisted thoracoscopy (VAT), it is now possible to combine a diagnostic and therapeutic procedure. However, to do this general anesthesia and a fully equipped operating theater are needed. Proper selection of patients for this costly and time-consuming procedure is necessary. We evaluated whether standard computed tomography (CT) is appropriate for selection of patients with SP who are candidates for surgical intervention. METHODS: In 43 patients with SP, CT was performed after re-expanding the lung by suction through a chest tube if the lung was completely collapsed. After <48 hours VAT under general anesthesia was performed. All CT scans were scored by two investigators who were not informed about the VAT findings or the outcome of the patient. CT findings and VAT findings were compared. RESULTS: In 16 patients (37%), CT scans of the affected lung were considered normal, while in 13 patients (30%) ELCs >/=2 cm were seen and in 14 patients (33%) ELCs <2 cm were found. VAT showed a normal lung in 11 patients (26%), in 24 patients ELCs >/=2 cm were seen, and in 8 patients ELCs <2 cm were present. Of these 32 patients, in 18 bullous degeneration of the apex of the upper lobe was found. Of the 24 patients with ELCs >/=2 cm detected during VAT, 13 were detected by CT. In no patient were ELCs >/=2 cm seen on CT scans that were not detected during VAT. The sensitivity of CT for ELCs >/=2 cm is 54%, and the specificity is 100%. The positive predictive value is 100%; the negative predictive value is 63%. CONCLUSIONS: CT detects ELCs >/=2 cm in 54% of the patients in whom VAT shows these abnormalities. If interventional therapy is deemed appropriate for first time or recurrent SP, VAT should be used since it is superior to CT in demonstrating the presence, number, and size of ELCs.