The diagnostic significance and the assessment of the value of vascular endothelial growth factor as a marker for success of chemical pleurodesis in malignant pleural effusion

Differential diagnosis of pleural effusion is an important issue, since the treatment modalities and prognosis strictly depend on early and correct diagnosis of the underlying etiology. We assessed the efficacy of vascular endothelial growth factor (VEGF) in the differential diagnosis of patients with malignant and non-malignant pleural diseases. And also is assessed of the VEGF as a marker for success of chemical pleurodesis in malignant pleural effusion. Pleural effusions of 40 patients with a mean age of 55 (range, 26 to 78 years) were examined. A total of 20 patients had malignant pleural effusion;malignant mesothelioma (n=7), lung cancer (n=5) and metastatic malignancies (n=8). Twenty patients had benign pleural effusion;fibrinous pleuritis (n=6), tuberculosis (n=3) empyema (n=5), congestive heart failure (n=3), and acute pancreatitis (n=3). Definitive diagnosis was obtained in all cases with blind or open pleural biopsy, and cytological examination. VEGF levels were determined by enzyme-linked immunosorbent assay. The VEGF level of pleural effusion was comparably higher in the malignant group. The mean level of VEGF in patients with malignant pleural effusions (21.7 ± 1.8 ng/ml) was significantly (P <0.001) higher than that of (13.2 ± 1.5 ng/ml) non-malignant effusions. No significant difference was found regarding the VEGF levels and histological types in malignant pleural effusions. Negative correlation was observed between success rate of pleurodesis and VEGF level of pleural effusion (p= 0.015). The measurement of VEGF levels in pleural effusion may be useful to differentiate malignant from nonmalignant pleural effusions. VEGF level may also be an important prognostic marker for effective treatment of the patients who had malignant pleural effusions with pleurodesis. It is important issue in here whether VEGF could be useful in prognostication of outcome of chemical pleurodesis or not.

Towards an easier pleurodesis: Ultrasound-guided iodopovidone sclerotherapy in cirrhotic patients with hepatic hydrothorax

Background and Aim: Hepatic hydrothorax is one of the complications encountered in end stage liver disease. Pleural drainage carries the risk of massive protein and electrolyte depletion as well as the risk of bleeding and hepatic encephalopathy. Pleurodesis following pleural aspiration decreases the chance of pleural effusion recurrence, and has been a widely used long-standing method of controlling recurrent pleural effusions. The aim of this study is to evaluate the effect of pleurodesis using ultrasound-guided iodopovidone sclerotherapy in hepatic hydrothorax. Patients and Methods: This prospective study included 56 patients with clinical, laboratory and radiological evidence of liver cirrhosis and symptomatic right sided hepatic hydrothorax. All patients were subjected to repeated thoracentesis. Ten ml of lidocaine 2% were injected in the pleural space followed by 20 ml of iodopovidone. The follow-up was done after 3 months. Results: The sclerotherapy procedure was successful in 40 out of 56 cases (71.4%), and the success rate was 66.7% in massive effusion and reached 80% in moderate effusion. Twenty eight patients (50%) had to repeat the procedure for a second time, sixteen of which (28.6%) failed despite the second trial and twelve cases (21.4%) showed no fluid reaccumulation. Conclusion: Ultrasound-guided iodopovidone sclerotherapy is an effective approach for a successful pleurodesis in hepatic hydrothorax.

Management of recurrent malignant pleural effusions with a tunneled indwelling pleural catheter

In this review, we report on the use of indwelling pleural catheters in the treatment of malignant pleural effusions. We describe the most commonly used catheter. Also, treatment with indwelling pleuralcatheters as compared to talc pleurodesis is reviewed. A comparison of efficacy, costs, effects on quality of life, and complications is made. Only one randomized controlled trial comparing the two is available up to date, but several are underway. We conclude that treatment for malignant pleural effusions with indwelling pleural catheters is a save, cost-effective, and patientfriendly method, with low complication rates.

Simultaneous Bilateral Spontaneous Pneumothorax: Report of 6 Adult Patients

Background: Spontaneous pneumothorax (SP) refers to the spontaneous presence of air in the pleural sac(s) without iatrogenic or traumatic factors. The simultaneous bilateral SP (SBSP) is rare yet serious clinical condition which may pose a significant threat to patient’s life. Herein, 6 patients with SBSP managed in Sulaimaniyah Teaching Hospital (STH) over 6-year period (2006-2011) are reported with literature review. Methodology: A prospective clinical study. The diagnosis was made on clinical and radiographic grounds. The initial therapy was a bilateral tube thoracostomy (BTT) followed by chemical pleurodesis. Thoracotomy for excision of subpleural blebs or bullae and pleurectomy was performed for prolonged air leak (lasting >14 days). Results: There were 5 males (83.33%) and 1 female (16.67%) with a mean age of 34.8 years ranging between 20 and 50. All patients had presented with dyspnea and chest pain and were smokers. Three patients (50%) had primary (PSP) whereas the remaining had secondary (SSP) (chronic obstructive pulmonary disease—COPD, n = 2 and pneumonia, n = 1). None of the patients had recurrence. Unilateral thoracotomy was necessary in 5 patients (SSP, n = 3 and PSP, n = 2). Prolonged air leak was observed once postoperatively (16.7%) while mortality was nil. Conclusions: Prompt recognition of this rare yet potentially serious condition is crucial. The clinical diagnosis is straightforward with plain chest radiography being the most helpful workup. The initial therapy is via BTT followed by pleurodesis. Surgery is necessary for prolonged air leak and failure of the lung to expand.

Primary pneumothorax:Should surgery be offered after the first episode?

Surgery is the recommended and most effective means of preventing the recurrence of primary spontaneous pneumothorax(PSP). However, the conventional belief amongst most clinicians is that surgery should not be routinely offered to patients with an uncomplicated first episode of PSP. The view that surgery should be reserved for recurrent episodes of ipsilateral PSP is based on an apprehension regarding traumatic thoracicsurgery combined with a perception that recurrences after a single episode of PSP are unlikely. Modern advances in minimally invasive thoracic surgery have now dramatically reduced the morbidity of PSP surgery. Such surgery is now safe, effective and causes minimal indisposition for patients. On the other hand, modern clinical data suggests that recurrence rate of PSP is perhaps much higher than previously assumed, with more than half of patients experiencing a second episode within several years of the first. With such new appreciations of the current situation, it is appropriate to now consider offering surgery to patients even after the first episode of PSP.

Thoracoscopy for diagnosis and management of refractory hepatic hydrothorax

The prevalence of pleural effusion caused by hepatocirrhosis ranges from 0.4% to 30%. Some patients with hepatic hydrothorax （HH） fail to respond to aggressive medical management such as albumin application, diuretics, and thoracentesis, and remain refractory massive pleural fluid. The repeated suctions to relieve the symptoms such as respiratory distress are associated with significant hyponatremia and hypoalbuminemia caused by the large volumes of fluid loss. Review of the literature has revealed that, to date, no therapy is ideal. This report describes our experiments in treating HH of patients with cirrhosis and ascites by thoracoscopy and talc poudrage, to offer our efforts to approach the pathogenesis of HH and to explore the new therapeutic strategy.

Video-assisted thoracoscopic surgery (VATS) for the treatment of hepatic hydrothorax:report of twelve cases

Background： Hepatic hydrothorax is defined as a significant pleural effusion in patients with liver cirrhosis and without underlying cardiopulmonary diseases. Treatment of hepatic hydrothorax remains a challenge at present. Methods： Herein we share our experiences in the treatment of 12 patients with hepatic hydrothorax by video-assisted thoracoscopic surgery （VATS） Repair of the diaphragmatic defects, or pleurodesis by focal pleurectomy, talc spray, mechanical abrasion, electro-cauterization or injection was administered intraoperatively, and tetracycline intrapleural injection was used postoperatively for patients with prolonged （〉7 d） high-output （〉300 ml/d） pleural effusion. Results： Out of the 12 patients, 8 （67%） had uneventful postoperative course and did not require tube for drainage more than 3 months after discharge. In 4 （33%） patients the pleural effusion still recurred after discharge due to end-stage cirrhosis with massive ascites. Conclusion： We conclude that the repair of the diaphragmatic defect and pleurodesis through VATS could be an alternative of transjugular intrahepatic portal systemic shunt （T1PS） or a bridge to liver transplantation for patients with refractory hepatic hydrothorax. Pleurodesis with electrocauterization can be an alternative therapy if talc is unavailable.