Un factor todavía controvertido en la realidad de la Cirugía Torácica es el momento apropiado para tomar una decisión quirúrgica en el tratamiento del derrame pleural complicado. Por ello hemos planteado un seguimiento de larga evolución realizando un estudio comparativo entre la decorticación pulmonar y el uso de agentes fibrinolíticos. El modelo del estudio se planteó con dos grupos de pacientes con un tamaño muestral superior a n= 65- cada uno de ellos- para poder ser estadísticamente significativo. El grupo A correspondería al desbridamiento pleuropulmonar como alternativa quirúrgica frente al uso de uroquinasa en el grupo B. Elaboramos para ello un protocolo de actuación que creemos que puede ser de utilidad debido a la amplitud de la serie y al seguimiento de la misma. El éxito - 95,8 % de resolución - debe ser atribuido a la correcta ubicación guiada de los catéteres de drenaje pleural percutáneo, y la instilación de uroquinasa a su través (que favorece la lisis de los tabiques de fibrina y facilita la salida del líquido pleural por un único catéter). A la vista de nuestros resultados, consideramos que ésta es una técnica sencilla, eficaz, muy bien tolerada por los pacientes, no excesivamente cara, y que puede disminuir la estancia hospitalaria y evitar alguna intervención quirúrgica, con la influencia sobre la economía y la calidad asistencial que ello supone. / STUDY OBJECTIVES: To determine the optimal treatment of complicated pleural effusion comparing pleural drainage and fibrinolytic therapy ( urokinase ) versus videoassisted thoracoscopic surgery (VATS), with regard to efficacy and duration of hospitalization. DESIGN: 186 patients with confirmed complicated pleural effusion were controlled to chest tube pleural drainage plus urokinase (UK) vs VATS. PATIENTS AND METHODS: Equivalent groups of patients with complicated pleural effusion were choosed to receive either of two therapies: UK (n = 113) or VATS (n = 73). The two groups of patients had similar characteristics. Mean age was 60,2 years (range:19-82 years). Outcomes analysis with respect to treatment efficacy, hospital duration, chest tube duration, hospital costs, and need for subsequent procedures was performed. RESULTS: When compared with the VATS group, the UK group had a significantly higher primary treatment success, lower chest tube duration, and lower number of total hospital days ( p < 0.05). Clinically relevant and statistically significant differences in hospital costs also favored the UK group. CONCLUSIONS: In patients with complicated pleural effusion, a primary treatment strategy of UK is associated with a higher efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes surgery

No description available.

Introdução: A pleurodese com talco é o método mais popular para controle sintomático do derrame pleural maligno recidivante. A administração intrapleural do talco pode ser por videotoracoscopia ou dreno de tórax e qual o melhor método é uma questão controversa. Ainda que a expansão pulmonar seja um dos principais critérios de sucesso do procedimento, suas características pós-pleurodese ainda são pouco estudadas. Objetivo: Avaliar a expansão pulmonar após dois diferentes métodos de pleurodese com talco (dreno de tórax ou videotoracoscopia) em pacientes com derrame pleural maligno recidivante, considerando a evolução radiológica, diferença entre os métodos e correlação com desfecho clínico. O objetivo secundário foi comparar ambos os métodos quanto a: efetividade clínica, segurança, qualidade de vida e sobrevivência. Método: Estudo prospectivo randomizado que incluiu 60 pacientes (45 Mulheres, 15 Homens, idade média: 55,2 anos) com derrame pleural maligno recidivante entre janeiro de 2005 e janeiro de 2008. Os pacientes foram alocados em dois grupos: videotoracoscopia com insuflação de talco (VT) ou instilação de talco por dreno de tórax (DT). A expansão pulmonar imediata e a evolução da expansão pulmonar foram avaliadas através de tomografias de tórax obtidas nos primeiros 7 dias, 1, 3 e 6 meses após a pleurodese, as quais foram analisadas por dois observadores independentes. Efetividade clínica (considerada como ausência de necessidade de novos procedimentos pleurais durante o seguimento), complicações, tempo de drenagem e de internação hospitalar e qualidade de vida (questionários gerais e específicos) foram também analisados. A análise estatística foi realizada através dos testes de Qui-quadrado e Fisher para as variáveis categóricas e Mann-Whitney para variáveis contínuas não paramétricas. A sobrevivência foi analisada através do método de Kaplan- Meier e o teste de log-Rank para foi usado para identificar fatores que interferissem na sobrevida. Os resultados dos questionários de qualidade de vida foram avaliados através de ANOVA de duplo-fator. Resultados: Não houve diferença significativa entre os grupos nas variáveis clínicas préoperatórias. A expansão imediata total (>90%) foi observada em 27 (45%) pacientes e foi mais freqüente no grupo VT (60 vs. 30%, p=0.027). Durante o seguimento, 71% dos pacientes estudados tiveram melhora ou ao menos mantiveram a expansão pulmonar observada na 1ª tomografia, fato que ocorreu de forma semelhante entre os grupos (p=0,58). Novos procedimentos pleurais foram necessários em 9(15%) pacientes (5 recidivas no grupo VT e 4 no grupo DT, p=0.999). Não foram encontradas diferenças entre os grupos quanto a: complicações, tempo e de internação. A análise dos questionários de qualidade de vida revelou resultados semelhantes para ambos os grupos. A expansão pulmonar imediata não se correlacionou com recidiva radiológica, recidiva clínica ou complicações (p= 0.60, 0.15 e 0.20, respectivamente). A sobrevida após ambos os procedimentos foi semelhante, porém a ocorrência de recidivas foi um fator relacionado a sobrevida mais curta (p=0,02). Conclusão: Expansão pulmonar imediata parcial foi freqüente, particularmente no grupo DT. Contudo, manutenção do quadro radiológico e até melhora radiológica ocorreram na maioria dos casos. Não foi encontrada correlação entre expansão pulmonar imediata e desfecho clínico neste estudo. / Introduction: Talc pleurodesis is the most popular method to control recurrent malignant pleural effusion symptoms. Two methods may be used to deliver talc into the pleural space: videothoracoscopy or talc slurry through a chest tube ; which is the best method is still controversial. Although lung expansion is the most accepted pleurodesis outcome variable, its features are poorly studied. Objective: To analyze and compare radiological lung expansion after talc pleurodesis performed either by videothoracoscopy or chest tube and correlate it with clinical outcome. Secondary endpoints evaluated were: clinical efficacy, safety, quality of life and survival. Methods: Prospective randomized study that included 60 patients (45 Female, 15 Male, mean age: 55,2 years) with recurrent malignant pleural effusion, between January, 2005 and January, 2008. They were enrolled into two groups: videothoracoscopic talc poudrage (VT) and talc slurry through a chest tube (TS). Lung expansion was evaluated through chest CT scans obtained in the first 7 days and 1, 3 and 6 months after pleurodesis. All examinations were revised by two independent observers. Clinical efficacy (considered as lack of new procedures during follow up), complications, drainage duration, hospital stay and quality of life (general and specific questionnaires) were also analyzed. Categorical variables were compared with the Chi-Square test or Fisher´s exact test for small samples. Mann-Whitney test was used to compare continuous non parametric variables. Survival curves were calculated according to the Kaplan-Meier method and Log-rank test was used to identify factors that could interfere with survival. Double factor ANOVA was used to compare quality of life questionnaires results. Results: No significant difference in pre-procedure clinical variables was observed between groups. Postoperative lung expansion was total (>90%) in 27 (45%) patients and was more frequent in VT group (60% vs. 30%, p=0.027). During follow-up 71% of the patients showed unaltered or improved lung expansion and lung expansion evolution was similar in both groups (p=0.58). Nine (15%) patients needed new pleural procedures (5 recurrences in VT group and 4 in DT group, p=0.999). No statistical difference was found between groups regarding complications, drainage time and hospital stay. Quality of life questionnaires were evaluated but no difference between study arms was observed. There was no correlation between initial lung expansion and clinical recurrence, radiological recurrence or complications (p = 0.60, 0.15 and 0.20, respectively). No difference in survival between study arms was observed, but a shorter survival was observed in patients that developed clinical recurrence (p=0.02). Conclusion: Immediate partial lung expansion was a frequent finding and was more frequent in TS group. However, maintenance of the radiological image and even radiological improvement occurred in most cases. No correlation between immediate lung expansion and clinical outcome was found in this study

BACKGROUND: Malignant and paramalignant pleural effusions are important complications of many malignancies. The two main management options debated in the literature are: 1) insertion of an indwelling pleural catheter (IPC) to achieve chronic drainage of the effusion, or 2) hospitalization with tube thoracostomy and subsequent chemical pleurodesis (CP) with talc or doxycycline to prevent fluid reaccumulation. We aimed to describe a large series of patients with malignant pleural effusions managed with an IPC, identify and validate factors identified in the literature as predictors of spontaneous pleurodesis in the IPC group and compare the group managed with IPC to patients managed with CP. METHODS: We designed a retrospective cohort study comparing patients with malignant and paramalignant pleural effusions managed either with CP between March 1, 2003 and February 28, 2006 or IPC insertion between May 1, 2006 and April 1, 2009. The CP group was identified through the prescription of talc or doxycycline and the IPC group from the IPC clinic database. Data were collected from paper and electronic records and from the Government of Ontario. RESULTS: We identified 193 consecutive patients with an ECOG performance status of less than 4 (ECOG less than 4 means that the patient is not completely disabled and confined to bed or chair) having undergone IPC insertion and 168 who were managed with CP. None of the variables we tested were significant predictors of spontaneous pleurodesis in the IPC group. Pleural effusion control rates at 6 months were higher in the IPC group than in the CP group (52.7% vs 34.0%, p<0.01) but the rate of freedom from pleural effusion at 180 days and catheter removal at 90 days was not significantly different (25.8% in the IPC group and 34.0% in the CP group p=0.14). Patients in the IPC group had a significantly longer median survival (148 days measured from the date of catheter insertion vs 133 days in the CP group, log-rank p<0.05). CONCLUSION: We found an intriguing possible survival benefit favouring management of malignant or paramalignant effusions with an IPC. Given possible biases due to the design of this study and uncertain explanatory mechanism, this needs to be confirmed in a randomized controlled trial. Quality of life, an important measure of success for these palliative procedures, should also be measured.

BACKGROUND: Malignant and paramalignant pleural effusions are important complications of many malignancies. The two main management options debated in the literature are: 1) insertion of an indwelling pleural catheter (IPC) to achieve chronic drainage of the effusion, or 2) hospitalization with tube thoracostomy and subsequent chemical pleurodesis (CP) with talc or doxycycline to prevent fluid reaccumulation. We aimed to describe a large series of patients with malignant pleural effusions managed with an IPC, identify and validate factors identified in the literature as predictors of spontaneous pleurodesis in the IPC group and compare the group managed with IPC to patients managed with CP. METHODS: We designed a retrospective cohort study comparing patients with malignant and paramalignant pleural effusions managed either with CP between March 1, 2003 and February 28, 2006 or IPC insertion between May 1, 2006 and April 1, 2009. The CP group was identified through the prescription of talc or doxycycline and the IPC group from the IPC clinic database. Data were collected from paper and electronic records and from the Government of Ontario. RESULTS: We identified 193 consecutive patients with an ECOG performance status of less than 4 (ECOG less than 4 means that the patient is not completely disabled and confined to bed or chair) having undergone IPC insertion and 168 who were managed with CP. None of the variables we tested were significant predictors of spontaneous pleurodesis in the IPC group. Pleural effusion control rates at 6 months were higher in the IPC group than in the CP group (52.7% vs 34.0%, p<0.01) but the rate of freedom from pleural effusion at 180 days and catheter removal at 90 days was not significantly different (25.8% in the IPC group and 34.0% in the CP group p=0.14). Patients in the IPC group had a significantly longer median survival (148 days measured from the date of catheter insertion vs 133 days in the CP group, log-rank p<0.05). CONCLUSION: We found an intriguing possible survival benefit favouring management of malignant or paramalignant effusions with an IPC. Given possible biases due to the design of this study and uncertain explanatory mechanism, this needs to be confirmed in a randomized controlled trial. Quality of life, an important measure of success for these palliative procedures, should also be measured.

BACKGROUND: Malignant and paramalignant pleural effusions are important complications of many malignancies. The two main management options debated in the literature are: 1) insertion of an indwelling pleural catheter (IPC) to achieve chronic drainage of the effusion, or 2) hospitalization with tube thoracostomy and subsequent chemical pleurodesis (CP) with talc or doxycycline to prevent fluid reaccumulation. We aimed to describe a large series of patients with malignant pleural effusions managed with an IPC, identify and validate factors identified in the literature as predictors of spontaneous pleurodesis in the IPC group and compare the group managed with IPC to patients managed with CP. METHODS: We designed a retrospective cohort study comparing patients with malignant and paramalignant pleural effusions managed either with CP between March 1, 2003 and February 28, 2006 or IPC insertion between May 1, 2006 and April 1, 2009. The CP group was identified through the prescription of talc or doxycycline and the IPC group from the IPC clinic database. Data were collected from paper and electronic records and from the Government of Ontario. RESULTS: We identified 193 consecutive patients with an ECOG performance status of less than 4 (ECOG less than 4 means that the patient is not completely disabled and confined to bed or chair) having undergone IPC insertion and 168 who were managed with CP. None of the variables we tested were significant predictors of spontaneous pleurodesis in the IPC group. Pleural effusion control rates at 6 months were higher in the IPC group than in the CP group (52.7% vs 34.0%, p<0.01) but the rate of freedom from pleural effusion at 180 days and catheter removal at 90 days was not significantly different (25.8% in the IPC group and 34.0% in the CP group p=0.14). Patients in the IPC group had a significantly longer median survival (148 days measured from the date of catheter insertion vs 133 days in the CP group, log-rank p<0.05). CONCLUSION: We found an intriguing possible survival benefit favouring management of malignant or paramalignant effusions with an IPC. Given possible biases due to the design of this study and uncertain explanatory mechanism, this needs to be confirmed in a randomized controlled trial. Quality of life, an important measure of success for these palliative procedures, should also be measured.

Diss. (sammanfattning) Stockholm : Karol. inst., 2004. / Härtill 5 uppsatser.

The pleurodesis is a treatment method for patients suffered from the symptomatic malignant pleural effusion. The goal of the pleurodesis is to close a pleural area by connection of visceral and parietal pleura in order to reduce or terminate production of pleural effusion. The sterile talc powder is the world's most used agens within a practice. After a parental analgesic is the powder (as a sllury) either applicated into a pleural cavity through the chest drainage or surgically dispersed over the treated (via abrasion, decortication) pleural space during the thoracoscopy/thoracotomy. This diploma thesis focuses on the treatment technique of bedside talc-pleurodesis through the chest drainage. The nurse has an irreplaceable role in the whole process from a preparation of patient to assistance by intrapreural application, to care of patient after the operation or serves as a physical support during potential complications. The aim of the presented work is to detect priorities in nursing care and find out whether patients need increased care after intrapleural therapy. The qualitative research method was chosen for the analysis where semi-structural interview with open questions were used. We created case reports analysed with the adaptive model of Callista Roy as well. The research sample contained patients chosen with respect to specialization of researched problem. We set two basic focal stimuli according to the analysis of respondents´ reactions. These stimuli serve as a basis for determination of priority parts of the nursing care by patients after bedside pleurodesis. We defined the need to be without pain and the need to ensure safety and certainty as a central focus of the nursing care. Among secondary fields of nursing care were identified sleep disturbances and limited mobility, which leads to reduction of self-care in getting dress, hygiene as well as in defection and miction. We found out within the second goal identical intensity of the nursing care before and after bedside talc-pleurodesis. This statement is based on comparison of interventions before and after aplication analysed via adaptive model by Roy. Nevertheless, causes of interventions were modified to a certain extent. The main goal of diploma thesis was to map requirements for high-quality nursing care related to bedside talc-pleurodesis via chest drainage. The work should extend theoretical basis not only for nurses in clinical practice.

Introdução: A pleurodese com talco é o método mais popular para controle sintomático do derrame pleural maligno recidivante. A administração intrapleural do talco pode ser por videotoracoscopia ou dreno de tórax e qual o melhor método é uma questão controversa. Ainda que a expansão pulmonar seja um dos principais critérios de sucesso do procedimento, suas características pós-pleurodese ainda são pouco estudadas. Objetivo: Avaliar a expansão pulmonar após dois diferentes métodos de pleurodese com talco (dreno de tórax ou videotoracoscopia) em pacientes com derrame pleural maligno recidivante, considerando a evolução radiológica, diferença entre os métodos e correlação com desfecho clínico. O objetivo secundário foi comparar ambos os métodos quanto a: efetividade clínica, segurança, qualidade de vida e sobrevivência. Método: Estudo prospectivo randomizado que incluiu 60 pacientes (45 Mulheres, 15 Homens, idade média: 55,2 anos) com derrame pleural maligno recidivante entre janeiro de 2005 e janeiro de 2008. Os pacientes foram alocados em dois grupos: videotoracoscopia com insuflação de talco (VT) ou instilação de talco por dreno de tórax (DT). A expansão pulmonar imediata e a evolução da expansão pulmonar foram avaliadas através de tomografias de tórax obtidas nos primeiros 7 dias, 1, 3 e 6 meses após a pleurodese, as quais foram analisadas por dois observadores independentes. Efetividade clínica (considerada como ausência de necessidade de novos procedimentos pleurais durante o seguimento), complicações, tempo de drenagem e de internação hospitalar e qualidade de vida (questionários gerais e específicos) foram também analisados. A análise estatística foi realizada através dos testes de Qui-quadrado e Fisher para as variáveis categóricas e Mann-Whitney para variáveis contínuas não paramétricas. A sobrevivência foi analisada através do método de Kaplan- Meier e o teste de log-Rank para foi usado para identificar fatores que interferissem na sobrevida. Os resultados dos questionários de qualidade de vida foram avaliados através de ANOVA de duplo-fator. Resultados: Não houve diferença significativa entre os grupos nas variáveis clínicas préoperatórias. A expansão imediata total (>90%) foi observada em 27 (45%) pacientes e foi mais freqüente no grupo VT (60 vs. 30%, p=0.027). Durante o seguimento, 71% dos pacientes estudados tiveram melhora ou ao menos mantiveram a expansão pulmonar observada na 1ª tomografia, fato que ocorreu de forma semelhante entre os grupos (p=0,58). Novos procedimentos pleurais foram necessários em 9(15%) pacientes (5 recidivas no grupo VT e 4 no grupo DT, p=0.999). Não foram encontradas diferenças entre os grupos quanto a: complicações, tempo e de internação. A análise dos questionários de qualidade de vida revelou resultados semelhantes para ambos os grupos. A expansão pulmonar imediata não se correlacionou com recidiva radiológica, recidiva clínica ou complicações (p= 0.60, 0.15 e 0.20, respectivamente). A sobrevida após ambos os procedimentos foi semelhante, porém a ocorrência de recidivas foi um fator relacionado a sobrevida mais curta (p=0,02). Conclusão: Expansão pulmonar imediata parcial foi freqüente, particularmente no grupo DT. Contudo, manutenção do quadro radiológico e até melhora radiológica ocorreram na maioria dos casos. Não foi encontrada correlação entre expansão pulmonar imediata e desfecho clínico neste estudo. / Introduction: Talc pleurodesis is the most popular method to control recurrent malignant pleural effusion symptoms. Two methods may be used to deliver talc into the pleural space: videothoracoscopy or talc slurry through a chest tube ; which is the best method is still controversial. Although lung expansion is the most accepted pleurodesis outcome variable, its features are poorly studied. Objective: To analyze and compare radiological lung expansion after talc pleurodesis performed either by videothoracoscopy or chest tube and correlate it with clinical outcome. Secondary endpoints evaluated were: clinical efficacy, safety, quality of life and survival. Methods: Prospective randomized study that included 60 patients (45 Female, 15 Male, mean age: 55,2 years) with recurrent malignant pleural effusion, between January, 2005 and January, 2008. They were enrolled into two groups: videothoracoscopic talc poudrage (VT) and talc slurry through a chest tube (TS). Lung expansion was evaluated through chest CT scans obtained in the first 7 days and 1, 3 and 6 months after pleurodesis. All examinations were revised by two independent observers. Clinical efficacy (considered as lack of new procedures during follow up), complications, drainage duration, hospital stay and quality of life (general and specific questionnaires) were also analyzed. Categorical variables were compared with the Chi-Square test or Fisher´s exact test for small samples. Mann-Whitney test was used to compare continuous non parametric variables. Survival curves were calculated according to the Kaplan-Meier method and Log-rank test was used to identify factors that could interfere with survival. Double factor ANOVA was used to compare quality of life questionnaires results. Results: No significant difference in pre-procedure clinical variables was observed between groups. Postoperative lung expansion was total (>90%) in 27 (45%) patients and was more frequent in VT group (60% vs. 30%, p=0.027). During follow-up 71% of the patients showed unaltered or improved lung expansion and lung expansion evolution was similar in both groups (p=0.58). Nine (15%) patients needed new pleural procedures (5 recurrences in VT group and 4 in DT group, p=0.999). No statistical difference was found between groups regarding complications, drainage time and hospital stay. Quality of life questionnaires were evaluated but no difference between study arms was observed. There was no correlation between initial lung expansion and clinical recurrence, radiological recurrence or complications (p = 0.60, 0.15 and 0.20, respectively). No difference in survival between study arms was observed, but a shorter survival was observed in patients that developed clinical recurrence (p=0.02). Conclusion: Immediate partial lung expansion was a frequent finding and was more frequent in TS group. However, maintenance of the radiological image and even radiological improvement occurred in most cases. No correlation between immediate lung expansion and clinical outcome was found in this study

BACKGROUND: Malignant and paramalignant pleural effusions are important complications of many malignancies. The two main management options debated in the literature are: 1) insertion of an indwelling pleural catheter (IPC) to achieve chronic drainage of the effusion, or 2) hospitalization with tube thoracostomy and subsequent chemical pleurodesis (CP) with talc or doxycycline to prevent fluid reaccumulation. We aimed to describe a large series of patients with malignant pleural effusions managed with an IPC, identify and validate factors identified in the literature as predictors of spontaneous pleurodesis in the IPC group and compare the group managed with IPC to patients managed with CP. METHODS: We designed a retrospective cohort study comparing patients with malignant and paramalignant pleural effusions managed either with CP between March 1, 2003 and February 28, 2006 or IPC insertion between May 1, 2006 and April 1, 2009. The CP group was identified through the prescription of talc or doxycycline and the IPC group from the IPC clinic database. Data were collected from paper and electronic records and from the Government of Ontario. RESULTS: We identified 193 consecutive patients with an ECOG performance status of less than 4 (ECOG less than 4 means that the patient is not completely disabled and confined to bed or chair) having undergone IPC insertion and 168 who were managed with CP. None of the variables we tested were significant predictors of spontaneous pleurodesis in the IPC group. Pleural effusion control rates at 6 months were higher in the IPC group than in the CP group (52.7% vs 34.0%, p<0.01) but the rate of freedom from pleural effusion at 180 days and catheter removal at 90 days was not significantly different (25.8% in the IPC group and 34.0% in the CP group p=0.14). Patients in the IPC group had a significantly longer median survival (148 days measured from the date of catheter insertion vs 133 days in the CP group, log-rank p<0.05). CONCLUSION: We found an intriguing possible survival benefit favouring management of malignant or paramalignant effusions with an IPC. Given possible biases due to the design of this study and uncertain explanatory mechanism, this needs to be confirmed in a randomized controlled trial. Quality of life, an important measure of success for these palliative procedures, should also be measured.