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AME Case Reports 2024Chylothoraces result from traumatic or non-traumatic insult to the thoracic duct, allowing for lymph to accumulate in the chest. Patients present with increasing dyspnea...
BACKGROUND
Chylothoraces result from traumatic or non-traumatic insult to the thoracic duct, allowing for lymph to accumulate in the chest. Patients present with increasing dyspnea and fatigue, and the diagnosis is made via chest X-ray, computed tomography (CT), and comparative analysis of the pleural fluid and serum. Management largely entails diet modification and drainage with or without adjunct medications, reserving pleurodesis, percutaneous duct embolization, or thoracic duct ligation for recalcitrant cases.
CASE DESCRIPTION
A 72-year-old female presented with a 10-year history of recurrent chylothorax. This was precipitated by a rib biopsy in 2013 for concerns of fibrous dysplasia, which was complicated by pneumothorax requiring chest tube placement and recurrent chylous effusion. The patient remained minimally symptomatic despite its chronicity. The lymphatic leak fistulized into her right breast in 2019 to cause significant swelling and exacerbate discomfort. Upon presentation, she noted incessant dyspnea, right arm and breast lymphedema, and exercise intolerance. Initial treatment involved placement of an indwelling pleural catheter (IPC) and interventional radiology (IR)-guided thoracic duct embolization. When persistent, she proceeded with video-assisted thorascopic surgery (VATS) decortication, talc pleurodesis, and ligation of the chylous leak. She was discharged with a drain that remained for one month until sinograms displayed resolution of the effusion.
CONCLUSIONS
Optimal chylothorax management remains debatable as it is understudied with few high-quality trials guiding treatment. When conservative management is unsuccessful, procedural intervention is often required to minimize morbidity and mortality. A literature review yielded sparse similarities between our case and others, highlighting the irregularity of presentation, challenges faced, and importance of a multidisciplinary approach in management.
PubMed: 38234347
DOI: 10.21037/acr-23-157 -
Interdisciplinary Cardiovascular and... Jan 2024A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'For patients with malignant pleural effusion is...
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'For patients with malignant pleural effusion is chemical pleurodesis with povidone-iodine as effective, safe and well tolerated as talc pleurodesis for prevention of recurrent malignant pleural effusions?'. A total of 124 papers were found during the search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. At present, medical-grade talc is the most commonly used agent for chemical pleurodesis due to its high success rate, extensive history of clinical use and well-known side-effect profile. However, studies using povidone-iodine seek to establish it as a readily available,low-cost alternative to talc that can be easily administered through an intercostal catheter at the bedside. The summation of available evidence suggests that povidone-iodine is a safe, well-tolerated and equally efficacious agent for pleurodesis in the setting of malignant pleural effusion, when compared to talc.
PubMed: 38230708
DOI: 10.1093/icvts/ivad192 -
Cureus Jan 2024, an oral anaerobe and a known gastrointestinal microbiota, has also been found to be enriched in mucosal tissues of the colon. Our patient presented with chest pain,...
, an oral anaerobe and a known gastrointestinal microbiota, has also been found to be enriched in mucosal tissues of the colon. Our patient presented with chest pain, productive cough, and hypoxia. He was diagnosed with COVID-19 pneumonia with a suspected superimposed bacterial infection. After the initiation of treatment, the patient developed a right hydropneumothorax/loculated pleural effusion on X-ray. Bedside drainage was done, and cross-sectional imaging showed findings of pleural empyema. Cultures obtained after bedside drainage grew The patient underwent right posterolateral open thoracotomy, total lung decortication, wedge resection, pneumonolysis, and mechanical pleurodesis. Antimicrobial therapy was adjusted based on culture sensitivities and infectious disease evaluation. Adequate drainage and source control were achieved, COVID-19 infection was resolved, and the patient was discharged on oral antibiotics. This case report highlights a rare and interesting case of pleural empyema caused by a superimposed bacterial infection with in a patient with COVID-19 pneumonia.
PubMed: 38205082
DOI: 10.7759/cureus.51998 -
Journal of Cardiothoracic Surgery Jan 2024Pleurodesis is often performed for air leaks; however, the ideal materials and timing of the procedure remain controversial. We investigated the efficacy of pleurodesis...
BACKGROUND
Pleurodesis is often performed for air leaks; however, the ideal materials and timing of the procedure remain controversial. We investigated the efficacy of pleurodesis using different materials and timing.
METHODS
We retrospectively reviewed 913 consecutive patients who underwent segmentectomy or lobectomy for non-small cell lung cancer between 2014 and 2021. Pleurodesis efficacy was assessed on the day of chest tube removal.
RESULTS
Eighty-six patients (9%) underwent pleurodesis for postoperative air leaks. Pleurodesis was performed on a median of postoperative day (POD) 5. Talc was the most frequently used material (n = 52, 60%), followed by autologous blood patches (n = 20, 23%), OK-432 (n = 12, 14%), and others (n = 2, 2%). No difference existed in the number of days from initial pleurodesis to chest tube removal among the three groups (talc, 3 days; autologous blood patch, 3 days; OK-432, 2 days; P = 0.55). No difference in patient background, except for sex, was observed between patients who underwent pleurodesis within 4 PODs and those who underwent pleurodesis on POD 5 or later. Drainage time was significantly shorter in patients who underwent pleurodesis within 4 PODs (median, 7 vs. 9 days; P = 0.004).
CONCLUSIONS
The efficacies of autologous blood patch, talc, and OK-432 would be considered comparable and early postoperative pleurodesis could shorten drainage time. Prospective studies are required.
Topics: Humans; Carcinoma, Non-Small-Cell Lung; Lung Neoplasms; Talc; Pleurodesis; Picibanil; Retrospective Studies; Pneumonectomy; Lung
PubMed: 38167171
DOI: 10.1186/s13019-023-02444-6 -
Trials Jan 2024The prolonged air leak is probably the most common complication following lung resections. Around 10-20% of the patients who undergo a lung resection will eventually... (Randomized Controlled Trial)
Randomized Controlled Trial
ERASURE: early autologous blood pleurodesis for postoperative air leaks-a randomized, controlled trial comparing prophylactic autologous blood pleurodesis versus standard watch and wait treatment for postoperative air leaks following thoracoscopic anatomic lung resections.
BACKGROUND
The prolonged air leak is probably the most common complication following lung resections. Around 10-20% of the patients who undergo a lung resection will eventually develop a prolonged air leak. The definition of a prolonged air leak varies between an air leak, which is evident after the fifth, seventh or even tenth postoperative day to every air leak that prolongs the hospital stay. However, the postoperative hospital stay following a thoracoscopic lobectomy can be as short as 2 days, making the above definitions sound outdated. The treatment of these air leaks is also very versatile. One of the broadly accepted treatment options is the autologous blood pleurodesis or "blood patch". The purpose of this trial is to investigate the impact of a prophylactic autologous blood pleurodesis on reducing the duration of the postoperative air leak and therefore prevent the air leak from becoming prolonged.
METHODS
Patients undergoing an elective thoracoscopic anatomic lung resection for primary lung cancer or metastatic disease will be eligible for recruitment. Patients with an air leak of > 100 ml/min within 6 h prior to the morning round on the second postoperative day will be eligible for inclusion in the study and randomization. Patients will be randomized to either blood pleurodesis or watchful waiting. The primary endpoint is the time to drain removal measured in full days. The trial ends on the seventh postoperative day.
DISCUSSION
The early autologous blood pleurodesis could lead to a faster cessation of the air leak and therefore to a faster removal of the drain. A faster removal of the drain would relieve the patient from all the well-known drain-associated complications (longer hospital stay, stronger postoperative pain, risk of drain-associated infection, etc.). From the economical point of view, faster drain removal would reduce the hospital costs as well as the costs associated with the care of a patient with a chest drain in an outpatient setting.
TRIAL REGISTRATION
German Clinical Trials Register (DRKS) DRKS00030810. 27 December 2022.
Topics: Humans; Pleurodesis; Postoperative Complications; Drainage; Device Removal; Lung; Pneumonectomy
PubMed: 38166982
DOI: 10.1186/s13063-023-07875-z -
The Medical Journal of Malaysia Dec 2023Fluoroscopic-guided transbronchial lung biopsy (FG-TBLB) is routinely performed via bronchoscopy to diagnose focal peripheral lesions and diffuse lung disease....
INTRODUCTION
Fluoroscopic-guided transbronchial lung biopsy (FG-TBLB) is routinely performed via bronchoscopy to diagnose focal peripheral lesions and diffuse lung disease. Identifying the risk factors of FG-TBLB-related pneumothorax can assist the operator in taking pre-emptive measures to prepare for this potential complication.
MATERIALS AND METHODS
We retrospectively analysed data from 157 patients who underwent FG-TBLB, with the primary outcome being procedure-related pneumothorax. We assessed several risk factors for pneumothorax following FG-TBLB: patient characteristics, location of biopsy, number of biopsies and computed tomography pattern. Univariate and multivariate logistic regression analyses were performed.
RESULTS
One-hundred fifty-seven patients were included [mean (SD) age 57.9 (16.2) years; 60.5% male]. The most common location for FG-TBLB was the right upper lobe (n=45, 28.7%). The mean (SD) number of biopsy samples was 6.7 (2.1). Radiographic evidence of pneumothorax was reported in 12 (7.6%) patients, with 11 of those requiring intercostal chest tube intervention (mean air leak time: 5.7 days and 1 had persistent air leak requiring autologous blood patch pleurodesis. None experienced pneumothorax recurrence. Female gender and upper lobe location of the biopsy were identified as predisposing factors for pneumothorax. In the multivariable analysis, upper lobe biopsies were associated with a higher risk of pneumothorax (OR 0.120; 95% CI 0.015-0.963; p = 0.046).
CONCLUSION
The overall rate of pneumothorax is low. We recognise the increased risk of pneumothorax associated with upper lobe biopsy. These findings suggest that clinicians should exercise caution when performing FGTBLB in this region and consider alternative biopsy locations whenever feasible. We suggest adequate planning and preparation should be implemented to minimise the risk of pneumothorax following FG-TBLB.
Topics: Humans; Male; Female; Middle Aged; Pneumothorax; Retrospective Studies; Biopsy; Lung; Bronchoscopy; Risk Factors
PubMed: 38159925
DOI: No ID Found -
Breathe (Sheffield, England) Dec 2023No pleural intervention in a patient with confirmed malignant pleural effusion (MPE) prolongs life, but even the recommended interventions for diagnosis and palliation... (Review)
Review
UNLABELLED
No pleural intervention in a patient with confirmed malignant pleural effusion (MPE) prolongs life, but even the recommended interventions for diagnosis and palliation can be costly and therefore unavailable in large parts of the world. However, there is good evidence to guide clinicians working in low- and middle-income countries on the most cost-effective and clinically effective strategies for the diagnosis and management of MPE. Transthoracic ultrasound-guided closed pleural biopsy is a safe method of pleural biopsy with a diagnostic yield approaching that of thoracoscopy. With the use of pleural fluid cytology and ultrasound-guided biopsy, ≥90% of cases can be diagnosed. Cases with an associated mass lesion are best suited to an ultrasound-guided fine needle aspiration with/without core needle biopsy. Those with diffuse pleural thickening and/or nodularity should have an Abrams needle (<1 cm thickening) or core needle (≥1 cm thickening) biopsy of the area of interest. Those with insignificant pleural thickening should have an ultrasound-guided Abrams needle biopsy close to the diaphragm. The goals of management are to alleviate dyspnoea, prevent re-accumulation of the pleural effusion and minimise re-admissions to hospital. As the most cost-effective strategy, we suggest early use of indwelling pleural catheters with daily drainage for 14 days, followed by talc pleurodesis if the lung expands. The insertion of an intercostal drain with talc slurry is an alternative strategy which is noninferior to thoracoscopy with talc poudrage.
EDUCATIONAL AIMS
To provide clinicians practising in resource-constrained settings with a practical evidence-based approach to the diagnosis and management of malignant pleural effusions.To explain how to perform an ultrasound-guided closed pleural biopsy.To explain the cost-effective use of indwelling pleural catheters.
PubMed: 38125800
DOI: 10.1183/20734735.0140-2023 -
Cureus Nov 2023Chylothorax, the presence of lymph in the pleural cavity, is a significant post-cardiac surgery complication. Historically linked to left internal mammary artery (LIMA)...
Chylothorax, the presence of lymph in the pleural cavity, is a significant post-cardiac surgery complication. Historically linked to left internal mammary artery (LIMA) harvesting, its occurrence in cases without LIMA usage is uncommon. This paper details a case of chylothorax in an 84-year-old female patient who underwent coronary artery bypass grafting (CABG) without LIMA harvesting. Three months post-surgery, she manifested symptoms of exertional shortness of breath and diminished breath sounds on the left side. Diagnostic measures, including echocardiography and chest X-rays, revealed a pronounced left-sided pleural effusion. Diagnostic thoracocentesis yielded a milky fluid, and laboratory analysis confirmed its chylous nature. Therapeutic interventions comprised chest tube insertion, drainage of the milky fluid, dietary modifications, and the performance of talc pleurodesis after a fatty food-provocation test resulted in increased fluid collection. The patient's journey highlights the challenges of diagnosing and managing post-cardiosurgical chylothorax. The paper emphasizes the importance of early detection and appropriate interventions to prevent complications associated with a heightened mortality risk.
PubMed: 38106785
DOI: 10.7759/cureus.48843 -
Jornal Brasileiro de Pneumologia :... Dec 2023
Topics: Humans; Pleural Effusion, Malignant; Pleura; Catheters, Indwelling; Prognosis; Drainage; Pleurodesis; Pleural Effusion
PubMed: 38055389
DOI: 10.36416/1806-3756/e20230225 -
Cureus Nov 2023A case is presented in which COVID-19 pneumonia led a young male patient to develop a pneumothorax requiring lobectomy and pleurodesis after the resolution of COVID-19...
A case is presented in which COVID-19 pneumonia led a young male patient to develop a pneumothorax requiring lobectomy and pleurodesis after the resolution of COVID-19 pneumonia. The literature review showed a few similar cases with clear evidence suggesting that prior COVID-19 infection may be considered a risk factor for pneumothorax. It is crucial for clinicians to take such risk factors into consideration for better clinical outcomes.
PubMed: 38024030
DOI: 10.7759/cureus.49238