Novel approach for talc pleurodesis by dedicated catheter through flexi-rigid thoracoscope under local anesthesia☆

Abstract

For pleurodesis, talc administered by poudrage is usually insufflated blindly from a single port of entry using the standard method with a small-diameter rigid thoracoscope. In order to visually perform talc poudrage from a single port, we introduced a catheter technique through a flexi-rigid thoracoscope. Patients with uncontrolled and symptomatic pleural effusion requiring pleurodesis underwent flexi-rigid thoracoscopy under local anesthesia for talc poudrage. A dedicated catheter with 2.1-mm inner diameter was connected to a talc atomizer and inserted through the working channel of the flexi-rigid thoracoscope to insufflate talc into the pleural cavity under visualization. Nine patients were included in this study. Three patients were >75 years old, and two were Karnofsky performance status 50. Three patients received propofol for sedation and six were not sedated. Mean operative time was 30.8 min for all patients, and 21.3 min for cases without sedation. All procedures were performed easily under clear visualization with no major complications or catheter obstructions. This novel approach for talc pleurodesis using a catheter was well-tolerated and seems feasible for patients with uncontrolled pleural effusion. We consider this technique useful even for difficult cases, such as elderly patients or those with relatively low performance status.

1. Introduction

Talc is the most effective pleurodesis agent, and has been used for several pleural diseases, such as malignant pleural effusion [1, 2] and pneumothorax [3]. When talc is administered by poudrage, a rigid thoracoscope is commonly used [4]. This technique is already well-established, and we have utilized a small-diameter rigid thoracoscope for talc poudrage since we commenced the procedure. However, one drawback to that procedure in this situation has been that talc has to be insufflated blindly if there is only a single-port of entry, otherwise talc insufflation with rigid thoracoscope under visualization requires a second port or punc-ture. In order to perform talc poudrage under visual control with a single-port of entry, we developed a catheter technique employing a flexi-rigid thoracoscope.

The flexi-rigid thoracoscope has a rigid shaft and a bidirectional flexible tip developed to examine the pleural cavity, and contains a working channel for suction and biopsy under direct observation [5, 6]. Using it under local anesthesia, we found it useful in the diagnosis of pleural effusion of unknown cause [6, 7]. The catheter technique we introduced for visually controlled talc poudrage with a single-port of entry was using a catheter inserted through the working channel of the flexi-rigid thoracoscope. As a catheter, we first used an endoscopic nasobiliary drainage tube in our preliminary test on goats. However, it was easily obstructed by talc powder because of its small inner diameter. After various attempts to determine the most suitable catheter for talc poudrage, we finally developed a dedicated catheter with a 2.1-mm inner diameter. The catheter has a larger inner diameter with fluorocarbon polymer coating, and there was no tube obstruction by talc.

Based on our preliminary tests, we applied the dedicated catheter for talc poudrage. In this report, we describe the technique and benefit of talc poudrage using a catheter through a flexi-rigid thoracoscope under local anesthesia for patients with pleural effusion.

2. Patients and methods

2.1. Patients

This was a prospective study provided for patients with uncontrolled and symptomatic pleural effusion requiring pleurodesis in a 1.5-year period. We included patients aged >20 years, and excluded those considered unable to tolerate thoracoscopy, such as patients with Karnofsky performance status (KPS) <50, having insufficient lung function parameters, uncontrolled bleeding tendency and severe heart failure. This study was approved by the Ethics Committee of St Marianna University School of Medicine, and prior written informed consent was obtained from all patients.

2.2. Methods

Thoracoscopy was performed under local anesthesia of the chest wall using 10 ml of 1% lidocaine and adding a maximum of 10 ml more, if needed. Then, a flexible trocar (MAJ-1058; Olympus; Tokyo, Japan) was placed, and the flexi-rigid thoracoscope (LTF-240; Olympus), with a 2.8-mm working channel, was inserted into the pleural cavity. Any pleural fluid, if present, was aspirated as much as possible through the working channel of the scope under visual control. If necessary, pleural biopsy was performed. When patients complained of pain, 1% lidocaine was administered into the pleural cavity using a spray catheter through the working channel of the flexi-rigid thoracoscope, as previously described [8]. A dedicated catheter (Olympus) with a 2.55-mm outer diameter and 2.1-mm inner diameter was connected to a talc atomizer (Wolf Company, Knittlingen, Germany), and was inserted through the working channel of the flexi-rigid thoracoscope (Fig. 1a ). Under direct visualization, 4 g of sterile talc (Steritalc^®; Novatech; La Ciotat, France) was then insufflated into the pleural cavity (Fig. 1b). At the end of the procedure, a 20 F chest tube was inserted and attached to an aspiration device. The tube was connected to –10 to –20 cm H₂O suction for at least two days, and removed when <200 ml of fluid was drained per day.

2.3. Data collection and assessment

All data were collected prospectively. The time taken for the procedure, the duration of chest tube drainage after talc poudrage, complications related to the procedure, and efficacy of pleurodesis were recorded. For the procedure time, we measured the time from the beginning of administration of anesthesia to the end of chest tube placement as the total procedure time, and the time using the flexi-rigid thoracoscope including pleural fluid aspiration, examination of the pleural cavity and talc insufflation as the operative time. For complications, chest pain requiring prescription for pain control, temporary fever of 38.5 °C or over, and any other complications requiring additional treatment or procedures were noted. Regarding evaluation of efficacy, cases in which the chest tube was successfully removed when fluid drainage decreased to <200 ml/day, and in which chest radiography one month after the procedure showed no pleural effusion were considered to be complete response cases. Cases in which the chest tube was successfully removed but chest radiography one month after the procedure showed pleural effusion occupying less than one third of the pleural space and without requiring further drainage were considered to be partial response cases. All other cases were recorded as failures.

3. Results

Table 1 shows the patients' characteristics. There were five females and four males with a mean (±S.D.) age of 72.9±7.0 years (range 64–82). There were four patients with KPS 80, one with KPS 70, two with KPS 60, and two with KPS 50. There were five patients with lung cancer, and one each with malignant pleural mesothelioma, ovarian cancer, liposarcoma, and primary systemic amyloidosis. Three patients were given sedation using propofol and six received no sedative drugs. With local anesthesia to the chest wall using 10 ml of 1% lidocaine administered routinely, the pain during the procedure was well controlled for all but except a patient who underwent the procedure without sedation. This patient complained of severe pain and we added 10 ml of 1% lidocaine for chest wall and sprayed 10 ml of 1% lidocaine on the pleura before biopsy. The mean (±S.D.) total procedure time and operative time were 56.1±32.0 min (range 28–119) and 30.8±19.3 min (range 12–74), respectively. For cases receiving sedation, the mean (±S.D.) total procedure time and operative time were 86.0±41.8 min and 49.7±22.4 min, whereas for cases without sedation, they were 41.2±11.7 min and 21.3±8.5 min, respectively. The mean (±S.D.) duration of chest tube drainage after talc pleurodesis was 5.1±3.3 days (range 2–13).

All procedures were performed by pulmonologists, and none of the operators experienced difficulty. The catheter was never obstructed by talc powder. No patient complained of chest pain requiring prescription for pain control. Temporary fever of 38.5 °C or over was observed in two patients, in both of which the temperature decreased to the normal range within 24 h. There were no major complications. Complete response was achieved in eight cases, and one case was evaluated as partial response. No patient resulted in failure.

Fig. 2 shows three cases. The first case (Fig. 2a–d) had increasing bilateral pleural effusion due to primary systemic amyloidosis despite systemic chemotherapy with melphalan and dexamethasone. Although right pleural effusion decreased only with chest tube drainage, as persistent left pleural effusion required frequent thoracentesis, we performed talc poudrage using the catheter technique with the flexi-rigid thoracoscopy under local anesthesia. Chest radiography one month after pleurodesis showed successful symphysis.

The second case (Fig. 2e–h) had right pleural effusion caused by malignant mesothelioma, and the third case (Fig. 2i–l) had left pleural effusion caused by pleural dissemination of lung cancer. Since both pleural effusions were increasing and symptomatic, we performed talc pleurodesis. For both cases, talc poudrage using our catheter technique was successfully and easily performed under clear visualization.

4. Discussion

To the best of our knowledge, this is the first report of talc poudrage using a catheter technique through a flexi-rigid thoracoscope. Talc poudrage using flexi-rigid thoracoscope was once reported by Lee et al. [9] previously, however, it was the procedure performed blindly using a bulb syringe through the trocar. The main advantage of our method is that both pleural fluid aspiration and talc insufflation can be performed under visualization with a single-port of entry, which is assumed more effective and less invasive. Our method for talc poudrage under local anesthesia without sedative drugs shortened the procedure time compared to the procedure with sedation. Many patients with malignant pleural effusion are in poor general condition, therefore, our method performed under local anesthesia without sedation may be helpful in these patients.

For thoracoscopy including diagnostic purposes and talc poudrage, rigid thoracoscopes have commonly been used [4] as they provide excellent vision and allow larger biopsy specimens [10]. On the other hand, the flexi-rigid thoracoscope enables the operator to examine most of the pleural cavity as the tip of the scope bends vertically upwards and downwards [6, 7, 9]. We introduced the catheter technique for talc poudrage using a dedicated catheter, and found it easily performed by pulmonologists. With the technique of catheter and flexi-rigid thoracoscopy, we consider that talc can be easily insufflated even in narrow spaces, such as the pleural cavity with adhesion, or spaces close to the mediastinum.

The dedicated catheter we developed for talc poudrage has a 2.1-mm inner diameter and 2.55-mm outer diameter. Compared to the spray catheter we used for lidocaine administration with a 1.0-mm inner diameter and 1.9-mm outer diameter, the inner diameter of our catheter is much larger. In addition, as the surface of the catheter is coated with fluorocarbon polymers, it is unlikely to be obstructed inside by talc powder. One drawback of the procedure was that the catheter kinked easily at the proximal side of the working channel during the procedure. However, we solved this problem by carefully keeping it straight.

Although the gold standard technique for talc poudrage is still considered to be conventional medical thoracoscopy with a rigid thoracoscope, we were able to perform the procedure safely under local anesthesia, even in elderly patients, and also in patients with relatively poor performance status. We believe that our method is more tolerable for those in poor general condition than conventional thoracoscopic talc poudrage, therefore, the next step will be to compare talc pleurodesis with our method and by slurry for such difficult-to-treat patients especially from the safety point of view.

We are indebted to J. Patrick Barron and Roderick J. Turner of the Department of International Medical Communications of Tokyo Medical University for their review of this English manuscript.

References