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Interactive Cardiovascular and Thoracic... Nov 2014A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether preservation of the pleura during internal... (Review)
Review
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether preservation of the pleura during internal mammary artery (IMA) harvesting improved clinical outcomes after coronary artery bypass graft surgery. More than 210 papers were found using the reported search, of which 18 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studies, relevant outcomes, results and study weakness of these papers are tabulated. Most studies dealt with investigating the radiographic changes, pulmonary function tests, ventilation time and also clinical consequences, such as bleeding, the need for blood transfusion, pain scores and the length of hospital stay. There is still no meta-analysis and systematic review regarding this surgical problem. Eighteen articles were found, of which 6 were prospective randomized, controlled trials and 12 were cohort studies. In these studies, some beneficial clinical outcomes were reported including: pleural effusion (15 studies), atelectasis (11 studies), pulmonary function tests (9 studies), arterial blood gases (5 studies), postoperative pain (6 studies), tamponade (2 studies), ventilation time (12 studies with), blood loss (9 studies), transfusion (4 studies), intensive care unit stay (5 studies) and hospital stay (12 studies). Based on our findings, preservation of pleural integrity seems to contribute to decreased pulmonary complications and improved clinical outcomes, such as bleeding, pain and length of hospital stay.
Topics: Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Humans; Male; Mammary Arteries; Middle Aged; Pleura; Postoperative Complications; Tissue and Organ Harvesting
PubMed: 25082837
DOI: 10.1093/icvts/ivu254 -
Pleura and Peritoneum Jun 2023Pressurized intraperitoneal aerosol chemotherapy (PIPAC) gives encouraging results in the treatment of peritoneal metastasis (PM). The current recommendations require at... (Review)
Review
OBJECTIVES
Pressurized intraperitoneal aerosol chemotherapy (PIPAC) gives encouraging results in the treatment of peritoneal metastasis (PM). The current recommendations require at least 3 sessions of PIPAC. However, some patients do not complete the full treatment course and stop after only 1 or 2 procedures, hence the limited benefit. A literature review was performed, with search terms including "PIPAC" and "pressurised intraperitoneal aerosol chemotherapy."
CONTENT
Only articles describing the causes for premature termination of the PIPAC treatment were analysed. The systematic search identified 26 published clinical articles related to PIPAC and reporting causes for stopping PIPAC.
SUMMARY
The series range from 11 to 144 patients, with a total of 1352 patients treated with PIPAC for various tumours. A total of 3088 PIPAC treatments were performed. The median number of PIPAC treatments per patient was 2.1, the median PCI score at the time of the first PIPAC was 19 and the number of patients who did not complete the recommended 3 sessions of PIPAC was 714 (52.8%). Disease progression was the main reason for early termination of the PIPAC treatment (49.1%). The other causes were death, patients' wishes, adverse events, conversion to curative cytoreductive surgery and other medical reasons (embolism, pulmonary infection, etc…).
OUTLOOK
Further investigations are necessary to better understand the causes for interrupting PIPAC treatment and also improving the selection of patients who are most likely to benefit from PIPAC.
PubMed: 37304159
DOI: 10.1515/pp-2023-0004 -
Pleura and Peritoneum Mar 2021Malignant pleural effusion (MPE) is a common condition that presents with progressive breathlessness. Long term solutions are often required due to recurrence of... (Review)
Review
Malignant pleural effusion (MPE) is a common condition that presents with progressive breathlessness. Long term solutions are often required due to recurrence of effusion after simple drainage. Pleurodesis is one of the main options resorted to for long term control of MPE. There is data to suggest there may be a survival benefit for patients with MPE who achieve successful pleurodesis. A systematic review was carried out to explore this correlation and results suggest that there could be a survival difference according to pleurodesis outcome in patients with MPE. Fifteen studies (reported in 13 papers) were included; 13 (86.6%) of the studies showed survival difference in favour of pleurodesis success. The median [interquartile range] difference in survival between the two groups among the different studies was five [3.5-5.8] months. Most of the included studies suffered moderate to severe risk of bias and, thus, large prospective studies of patients undergoing pleurodesis are required to ascertain this effect.
PubMed: 34222645
DOI: 10.1515/pp-2020-0147 -
Anticancer Research May 2015Malignant pleural mesothelioma (MPM) is a rare but aggressive malignancy mainly localized to the pleura. Malignant mesothelioma grows highly invasive into surrounding... (Review)
Review
Malignant pleural mesothelioma (MPM) is a rare but aggressive malignancy mainly localized to the pleura. Malignant mesothelioma grows highly invasive into surrounding tissue and has a low tendency to metastasize. The median overall survival (OS) of locally advanced or metastatic disease without treatment is 4-13 months but, during recent years, improvement in survival has been achieved since treatment for patients with mesothelioma has improved with better palliative care, systemic medical treatment, surgery and improved diagnostics methods. The present review aims at describing available data from randomized trials considering systemic medical treatment for this patient category.
Topics: Antineoplastic Combined Chemotherapy Protocols; Combined Modality Therapy; Disease-Free Survival; Humans; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Palliative Care; Pleural Neoplasms; Randomized Controlled Trials as Topic
PubMed: 25964522
DOI: No ID Found -
The Cochrane Database of Systematic... May 2016Malignant pleural effusion (MPE) is a common problem for people with cancer as a result of malignant infiltration of the pleura. It is usually associated with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Malignant pleural effusion (MPE) is a common problem for people with cancer as a result of malignant infiltration of the pleura. It is usually associated with considerable breathlessness. A number of treatment options are available to manage the uncontrolled accumulation of pleural fluid including administration of a pleurodesis agent (either via a chest tube or at thoracoscopy) or indwelling pleural catheter insertion.
OBJECTIVES
To ascertain the optimal management strategy for adults with malignant pleural effusion in terms of pleurodesis success. Additionally, to quantify differences in patient-reported outcomes and adverse effects between management strategies.
SEARCH METHODS
We searched The Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid EMBASE; EBSCO CINAHL; SCI-EXPANDED and SSCI (ISI Web of Science) to April 2015.
SELECTION CRITERIA
We included randomised controlled trials of intrapleural interventions for adults with symptomatic MPE in the review.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data on study design, study characteristics, outcome measures, potential effect modifiers and risk of bias.The primary outcome measure was pleurodesis failure rate. Secondary outcome measures were adverse effects and complications, patient-reported control of breathlessness, quality of life, cost, mortality, duration of inpatient stay and patient acceptability.We performed network meta-analysis with random effects to analyse the primary outcome data and those secondary outcomes with enough data. We also performed pair-wise random-effects meta-analyses of direct comparison data. If interventions were not deemed jointly randomisable, or insufficient data were available, we reported the results by narrative synthesis. We performed sensitivity analyses to explore heterogeneity and to evaluate only those pleurodesis agents administered via a chest tube at the bedside.
MAIN RESULTS
Of the 1888 records identified, 62 randomised trials, including a total of 3428 patients, were eligible for inclusion. All studies were at high or uncertain risk of bias for at least one domain.Network meta-analysis evaluating the rate of pleurodesis failure, suggested talc poudrage to be a highly effective method (ranked second of 16 (95% credible interval (Cr-I) 1 to 5)) and provided evidence that it resulted in fewer pleurodesis failures than eight other methods. The estimated ranks of other commonly used agents were: talc slurry (fourth; 95% Cr-I 2 to 8), mepacrine (fourth; 95% Cr-I 1 to 10), iodine (fifth; 95% Cr-I 1 to 12), bleomycin (eighth; 95% Cr-I 5 to 11) and doxycyline (tenth; 95% Cr-I 4 to 15). The estimates were imprecise as evidenced by the wide credible intervals and both high statistical and clinical heterogeneity.Most of the secondary outcomes, including adverse events, were inconsistently reported by the included studies and the methods used to describe them varied widely. Hence the majority of the secondary outcomes were reported descriptively in this review. We obtained sufficient data to perform network meta-analysis for the most commonly reported adverse events: pain, fever and mortality. The fever network was imprecise and showed substantial heterogeneity, but suggested placebo caused the least fever (ranked first of 11 (95% Cr-I 1 to 7)) and mepacrine and Corynebacterium parvum (C. parvum) appeared to be associated with the most fever (ranked tenth (95% Cr-I 6 to 11) and eleventh (95% Cr-I 7 to 11) respectively). No differences between interventions were revealed by the network meta-analysis of the pain data. The only potential difference in mortality identified in the mortality network was that those receiving tetracycline appeared to have a longer survival than those receiving mitoxantrone (OR 0.16 (95% Confidence Interval (CI) 0.03 to 0.72)). Indwelling pleural catheters were examined in two randomised studies, both of which reported improved breathlessness when compared to talc slurry pleurodesis, despite lower pleurodesis success rates.The risk of bias in a number of the included studies was substantial, for example the vast majority of studies were unblinded, and the methods used for sequence generation and allocation concealment were often unclear. Overall, however, the risk of bias for all studies was moderate. We have not reported the GRADE quality of evidence for the outcomes, as the role of GRADE is not well established in the context of Network Meta-analysis (NMA).
AUTHORS' CONCLUSIONS
Based on the available evidence, talc poudrage is a more effective pleurodesis method in MPE than a number of other frequently used methods, including tetracycline and bleomycin. However further data are required to definitively confirm whether it is more effective than certain other commonly used interventions such as talc slurry and doxycycline, particularly in view of the high statistical and clinical heterogeneity within the network and the high risk of bias of many of the included studies. Based on the strength of the evidence from both direct and indirect comparisons of randomised data of sclerosants administered at the bedside, there is no evidence to suggest large differences between the other highly effective methods (talc slurry, mepacrine, iodine and C. parvum). However, local availability, global experience of these agents and their adverse events, which may not be identified in randomised trials, must also be considered when selecting a sclerosant. Further research is required to delineate the roles of different treatments according to patient characteristics (e.g. according to their prognosis or presence of trapped lung) and to explore patient-centred outcomes, such as breathlessness and quality of life, in more detail. Careful consideration to minimise the risk of bias and standardise outcome measures is essential for future trial design.
Topics: Adult; Bleomycin; Doxycycline; Fever; Humans; Iodine; Pleural Effusion, Malignant; Pleurodesis; Quinacrine; Randomized Controlled Trials as Topic; Talc; Treatment Failure
PubMed: 27155783
DOI: 10.1002/14651858.CD010529.pub2 -
BMC Cancer Feb 2020Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is used in the palliative treatment of peritoneal metastasis. The combination of intraperitoneal and systemic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is used in the palliative treatment of peritoneal metastasis. The combination of intraperitoneal and systemic chemotherapy seems rational, and the aim of this systematic review was to compare PIPAC directed monotherapy with a bidirectional treatment approach (PIPAC in combination with systemic chemotherapy). Main outcomes were survival and quality of life.
METHODS
A systematic literature search in Medline, Embase, Cochrane and the "Pleura and Peritoneum" was conducted and analyzed according to PRISMA guidelines. Studies in English reporting on bidirectional treatment with PIPAC and systemic chemotherapy and published before April 2019 were included.
RESULTS
Twelve studies with a total of 386 patients were included. None were specifically designed to compare mono- versus bidirectional treatment, but 44% of the patients received bidirectional treatment. This was more frequent in women (non-gynecological cancers) and one-third of the bidirectional treated patients had received no prior chemotherapy. Data from the included studies provided no conclusions regarding survival or quality of life.
CONCLUSION
Bidirectional treatment with PIPAC and systemic chemotherapy is practised and feasible, and some patients are enrolled having received no prior systemic chemotherapy for their PM. The difficulty in drawing any conclusions based on this systematic review has highlighted the urgent need to improve and standardize reports on PIPAC directed therapy. We have, therefore, constructed a list of items to be considered when reporting on clinical PIPAC research.
TRIAL REGISTRATION
International Prospective Register of Systematic Reviews, PROSPERO. Registration number: 90352, March 5, 2018.
Topics: Aerosols; Antineoplastic Combined Chemotherapy Protocols; Clinical Trials as Topic; Humans; Infusions, Parenteral; Peritoneal Neoplasms; Prognosis; Quality of Life; Treatment Outcome
PubMed: 32041558
DOI: 10.1186/s12885-020-6572-6 -
General Thoracic and Cardiovascular... May 2021Malignant pleural effusion is a severe and common complication in patients with primary or metastatic malignancies of the pleura. Although talc pleurodesis is widely... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Malignant pleural effusion is a severe and common complication in patients with primary or metastatic malignancies of the pleura. Although talc pleurodesis is widely used for managing malignant pleural effusions, there is still controversy in the literature regarding its superiority compared to other approaches. We conducted this meta-analysis to further investigate its efficacy compared to alternative interventions.
METHODS
We systematically reviewed the PubMed, Cochrane, and Scopus databases to identify studies that fulfilled our inclusion criteria. Study quality was evaluated using validated tools and the pooled Risk Ratio (RR) and confidence interval (CI) were calculated. We performed sensitivity analyses based on the meta-analysis method and type of study.
RESULTS
Twenty-four studies were included in the current systematic review meta-analysis. Talc pleurodesis was associated with statistically significant higher successful pleurodesis rates when compared with all controls [RR (95% CI) 1.15 (1.00, 1.31); P = 0.04], only chemical controls [RR (95% CI) 1.26 (1.13, 1.40); P < 0.0001], and bleomycin [RR (95% CI) 1.22 (1.05, 1.42); P = 0.008]. The comparison between talc pleurodesis and controls at the > 1-month follow-up time point favored talc pleurodesis [RR (95% CI): 1.62 (1.15, 2.27); P = 0.005]. Finally, talc poudrage was associated with a statistically significant higher successful pleurodesis rate when compared with all controls. Sensitivity analyses verified the robustness of our results.
CONCLUSION
Talc pleurodesis is an effective MPE management approach presenting borderline statistically significant superiority compared to control methods especially compared to bleomycin as well as when pleurodesis success is evaluated later than 1 month postoperatively.
Topics: Bleomycin; Humans; Pleural Effusion, Malignant; Pleurodesis; Talc
PubMed: 33222091
DOI: 10.1007/s11748-020-01549-2 -
Pleura and Peritoneum Mar 2019The quest to cure or to contain the disease in cancer patients leads to new strategies and techniques being added to the armamentarium of oncologists. Pressurized... (Review)
Review
BACKGROUND
The quest to cure or to contain the disease in cancer patients leads to new strategies and techniques being added to the armamentarium of oncologists. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a recently described surgical technique which is being evaluated at many centers for the management of peritoneal metastasis (PM). The present study is a systematic review to evaluate the current role of PIPAC in the management of gastric cancer associated PM.
METHODS
A systematic search was conducted in Pubmed and EMBASE database using relevant keywords and confirming to the PRISMA guidelines to identify the articles describing the role of PIPAC in gastric cancer associated PM. All the studies which were published prior to July 1, 2018 in English literature and reported the role of PIPAC in gastric cancer associated PM were included in the systematic review.
RESULTS
The search yielded 79 articles; there were ten published studies which have reported the use of PIPAC in gastric cancer associated PM. A total of 129 patients with gastric cancer associated PM were treated in the studies. Only two studies had an exclusive cohort of gastric cancer patients while eight other studies had a heterogeneous population with a small proportion of gastric cancer patients. There was only one study highlighting the role of PIPAC in neoadjuvant setting to downgrade the peritoneal carcinomatosis index. All the studies revealed that PIPAC is feasible and has minimal perioperative morbidity, even after repeated applications.
CONCLUSION
There is a scarcity of English literature related to the role of PIPAC in gastric cancer associated PM. PIPAC is a safe and well-tolerated procedure which has the potential to contain spreading PM. Further studies are warranted to better define the role of PIPAC in gastric cancer associated PM.
PubMed: 31198852
DOI: 10.1515/pp-2018-0127 -
Clinical Imaging Jan 2020Magnetic resonance imaging (MRI) of the abdomen may include lower chest findings which may be overlooked or misinterpreted due to their location outside the area of main...
Magnetic resonance imaging (MRI) of the abdomen may include lower chest findings which may be overlooked or misinterpreted due to their location outside the area of main exam focus or lack of familiarity with the image appearance of these findings. This article will review the utility of abdominal MRI sequences to diagnose lower chest pathology while providing a systematic pictorial review of imaging findings in the lungs, pleura, mediastinum and chest wall. We will discuss the MRI appearance of lung nodules and masses, lung infiltrates, pulmonary infarction, pulmonary embolism, empyema, pleural effusions and thickening, mediastinal lesions and lymphadenopathy, cardiac thrombus and masses, and breast lesions. The purpose of this article is to increase awareness to the diagnostic advantages of abdominal MRI sequences for lower chest findings and encourage abdominal MRI readers to meticulous scrutinize the lower chest for concomitant pathology.
Topics: Abdomen; Adult; Aged; Female; Humans; Incidental Findings; Lung Diseases; Magnetic Resonance Imaging; Male; Mediastinal Diseases; Middle Aged; Pleural Effusion; Thoracic Wall
PubMed: 31760280
DOI: 10.1016/j.clinimag.2019.10.005 -
Journal of Cardiothoracic Surgery Dec 2021Internal thoracic arteries (ITAs) are the gold standard conduits for coronary revascularization because of their long-term patency and anti-atherosclerotic properties.... (Review)
Review
Internal thoracic arteries (ITAs) are the gold standard conduits for coronary revascularization because of their long-term patency and anti-atherosclerotic properties. Harvesting and preparation of ITAs for revascularization is a technically demanding procedure with multiple challenges. Over the last few decades, various methods and techniques for ITAs harvesting have been introduced by different surgeons and applied in clinical practice with different results. Harvesting of ITAs in pedicled or skeletonized fashion, with electrocautery or harmonic scalpel, with open or intact pleura, with clipping the end or keeping it perfused; papaverine delivery with intraluminal injection, perivascular injection, injecting into endothoracic fascia, and papaverine topical spray are the different techniques introduced by the number of researchers. At the same time, access to the ITAs for harvesting has also been studied. Access and harvesting through median sternotomy, mini anterolateral thoracotomy, thoracoscopic, and robotic-assisted harvesting of ITAs are the different techniques used in clinical practice. However, the single standard method for harvesting and preparation of ITAs has yet to be determined. In this review article, we aimed to discuss and analyze all these techniques of harvesting and preparing ITAs with the help of literature to find the best way for ITAs harvesting and preparation for myocardial revascularization.
Topics: Humans; Mammary Arteries; Myocardial Revascularization; Papaverine; Thoracotomy; Tissue and Organ Harvesting
PubMed: 34961523
DOI: 10.1186/s13019-021-01733-2