Left uniportal VATS for lung decortication after chemical pleurodesis under spontaneous breathing in patient with lymphangiomyomatosis

Pneumothorax can be the first symptom of lymphangioleiomyomatosis. Patients with lymphangioleiomyomatosis have a higher risk of recurrence of pneumothorax. Chemical pleurodesis is a viable option to treat the recurrence, but in rare cases, it is not the solution. We present the case of a patient with lymphangioleiomyomatosis undergoing a talc poudrage via video-assisted thoracoscopic surgery for pneumothorax that failed to reexpand the lung. We proposed to the patient a surgical approach to debride the lung parenchyma with the patient under deep sedation with spontaneous breathing. The patient was discharged on the 5th postoperative day. The chest computed tomography scan showed complete lung reexpansion. We advocate that video-assisted thoracoscopic surgery in patients who are awake is a feasible surgical option that permits the restoration of physiological lung expansion in selected patients who underwent chemical pleurodesis and minimizes the risk of one-lung ventilation.

The use of transdermal therapeutic systems for chemical pleurodesis in a patient with prolonged air leakage after lung resection for cancer

This clinical observation demonstrates a method of a motivated use of a transdermal therapeutic system (TTS) based on fentanyl for chemical pleurodesis in a patient with prolonged air leakage after lung resection for cancer. The most common complication after elective lung resections is an alveolar-pleural fistula or prolonged air leakage. This clinical phenomenon occurs as a result of communication between the alveoli of the lung parenchyma distal to the segmental bronchus and the pleural cavity. In most cases, air leakage through the drains is eliminated spontaneously, but the frequency of prolonged pneumostasis absence in the postoperative period can reach 25 %, which has a negative effect on the outcomes of surgical interventions due to the development of pneumonia and empyema. Long-term drainage of the pleural cavity does not always end with aerostasis and requires repeated invasive interventions. One of the ways to achieve the tightness of the lung tissue involves various methods of chemical pleurodesis, which is a surgical manipulation – the introduction of a sclerosing chemical substance into the pleural cavity by spraying medical talc through a trocar or a injecting tetracycline solution into the pleural drains. The chemical causes aseptic inflammation and adhesions between the visceral and parietal pleura, followed by obliteration of the pleural cavity. The sclerosant introduction is accompanied by severe pain that can provoke respiratory and/or hemodynamic deficits, up to apnea and life-threatening heart rhythm disturbances. Pain relief during chemical pleurodesis is obviously an important factor in the prevention of a number of complications in patients undergoing surgery for lung cancer. Bolus intravenous injections of narcotic analgesics lead to an analgesic effect, but a short-term one due to the absence of a depot in the body and a sharp drop in the drug concentration in the blood serum. Unfortunately, this method of introducing narcotic drugs can cause various complications in weakened and elderly cancer patients, such as respiratory depression and cardiac arrest. The TTS action is characterized with continuous dosing and the creation of a constant concentration of the narcotic drug over a certain period of time. This method provides a multilevel and systematic approach to pain relief, reduces toxicity and minimizes the inhibition of the central mechanisms of external respiration regulation without causing respiratory and cardiac disorders in patients who underwent lung resection.

Povidon-iodine applied for the treatment of chylothorax in children

Introduction. The aim of this study is to demonstrate the experience of non-surgical treatment of congenital and acquired chylothorax in children using povidone-iodine.Material and methods. The study presents results of treatment of 10 patients with chylothorax who had chemical pleurodesis with povidone-iodine. The study covered a time period from 2016 to 2020. The congenital character of the disease was registered in 2 patients, the acquired one - in 8 patients. The main indication for surgery was ineffective conservative therapy, including the withdrawal of feeding and the administration of preparation Octreotide. The procedure consisted of intrapleural injection of 4% povidone-iodine solution into the pleural cavity with the calculated dose of 1 ml/kg and solution exposure for 4 hours. Results. The interpleural administration of povidone-iodine was effective in all patients. Complications of chemical pleurodesis were observed in 2 patients and were associated with pulmonary edema on the injection side. Lymph outflow was stopped on average in 4 days. There was one adverse episode which developed because of the lung malformation incompatible with life. Conclusions. Intrapleural administration of povidone-iodine is an effective treatment of chylothorax in children.

Comparative Assessment of Inflammatory Reaction in Experimental Animals after Pleurodesis with Solutions of Hydrogen Peroxide and Talc

The aim of our research was to compare the nature and severity of the inflammatory process in the lungs, in the leaves of the visceral and parietal pleura, and in the adjacent subpleural tissues of the chest wall in experimental animals after pleurodesis with solutions of 3% and 6% hydrogen peroxide, and talc. Methods and Results: The experiment was carried out on 200 Wistar rats, weighing 160-180 grams, 10 specimens in a subgroup, depending on the time of the experiment, i.e. 50 specimens in each study group, including the control group. The main criterion by which we determined the comparative characteristics of the effectiveness of talc and 3% and 6% solutions of hydrogen peroxide as preparations used for chemical pleurodesis in the rats was a morphological characteristic of inflammation. This criterion was confirmed by counting free cell populations in lung tissue (lymphocytes, macrophages, neutrophils, histiocytes). All comparison groups were characterized by a gradual increase in the number of lymphocytes, macrophages and histiocytes, ranging from minimum to maximum values, and by a gradual decrease in the number of neutrophils, starting with max and ending with minimum values. The number of lymphocytes, macrophages and histiocytes were increasing faster. But at the same time, for the most part, their number was lower after pleurodesis with 6% hydrogen peroxide. The minimum number of neutrophils and the fastest possible reduction in all cases was observed in pleurodesis with 6% hydrogen peroxide. Conclusion: Pleurodesis with a 6% solution of hydrogen peroxide as a chemical agent significantly affects the quality of the inflammatory response, reducing its duration and severity in the organs and tissues of the rats’ chests, compared with a solution of 3% hydrogen peroxide and talc.

Thoracoscopy for Spontaneous Pneumothorax

Video-assisted thoracic surgery (VATS) is the treatment of choice for recurrence prevention in patients with spontaneous pneumothorax (SP). Although the optimal surgical technique is uncertain, bullous resection using staplers in combination with mechanical pleurodesis, chemical pleurodesis and/or staple line coverage is usually undertaken. Currently, patient satisfaction, postoperative pain and other perioperative parameters have significantly improved with advancements in thoracoscopic technology, which include uniportal, needlescopic and nonintubated VATS variants. Ipsilateral recurrences after VATS occur in less than 5% of patients, in which case a redo-VATS is a feasible therapeutical option. Randomized controlled trials are urgently needed to shed light on the best definitive management of SP.

Left Uniportal VATS for Lung Decortication After Chemical Pleurodesis Under Spontaneous Breathing in Patient with Lymphangiomyomatosis – A Case Report.

Background: Pneumothorax can be the first symptom of lymphangioleiomyomatosis. Patients with lymphangioleiomyomatosis have a higher risk of recurrence of pneumothorax. Chemical pleurodesis is a viable option to treat the recurrence, but in rare cases, it is not the solution. Case Presentation: We present the case of a patient with lymphangioleiomyomatosis undergoing a talc poudrage via video-assisted thoracoscopic surgery for pneumothorax that failed to re-expand the lung. We proposed to the patient a surgical approach to debride the lung parenchyma with the patient under deep sedation with spontaneous breathing. The patient was discharged on the 5th postoperative day. The chest computed tomography scan showed complete lung re-expansion. Conclusion: We advocate that video-assisted thoracoscopic surgery in patients who are awake is a feasible surgical option that permits the restoration of physiological lung expansion in selected patients who underwent chemical pleurodesis and minimizes the risk of one-lung ventilation.

A Multidirectional Two-tube Method for Chemical Pleurodesis could improve distribution of the Sclerosing Agent within the Pleural Cavity

Introduction: Malignant pleural effusion (MPE) affects approximately 200,000 people in the United States per annum. Chemical pleurodesis is a recommended first line treatment in the management of MPE, however, success rates as low as 43% has been reported. A bedside chemical pleurodesis can cost up to $11,224 and an estimated inpatient annual expenditure of more than $5 billion in the US alone. This study aims to assess the distribution of the talc slurry within the pleural space using cadaveric models and to determine the force required to push the talc slurry though a 14 Fr chest tube. Materials and Methods: The force required to administer the talc slurry through a 14 Fr chest tube was tested using a Zwick/Roelle Z005 mechanical tester. Talc slurry distribution within the pleural cavity was assessed by direct visualisation following administration to the cadaveric models using single and multidirectional two-tube methods. Results: Maximum force required to push the talc slurry though a 14 Fr chest tube was 11.36 N +/- 2.79 N. Distribution of the talc slurry within the pleural cavity was found to be poor with a single tube method. Multidirectional two-tube method of administration showed more even distribution. Conclusion: The experimental multidirectional two-tube method results in wider distribution of the talc slurry within the pleural cavity and could further improve success rate of the talc pleurodesis.