Pulmonology throws down the gauntlet..

Evaluation and discussion of a new article by Davies et. al. (2011) which calls many of the current practices in thoracic surgery into question. Is this a legitimate assessment of evolving treatment strategies or another attempt for pulmonology to encroach on the thoracic surgery specialty? In this multi-part series, we will address the major points debated in this article.

In a recent article by several pulmonologists in Australia (Helen E. Davies, Andrew Rosenstengel and Y.C. Gary Lee) the authors contend the recent developments in pulmonology have largely made the thoracic surgery specialty obsolete – particularly in the treatment of pleural disease. Are there merits to their claims?  or is this just another example of an expanding turf war, reminiscent of recent battles between cardiology and cardiac surgery?

We will re-post the article here, and discuss their findings at length in a multi-part series.

From Current Opinion in Pulmonary Medicine, “The Diminishing Role of Surgery in Pleural Disease”

Helen E. Davies; Andrew Rosenstengel; Y.C. Gary Lee

 Curr Opin Pulm Med. 2011;17(4):247-254.

Abstract and Introduction


Purpose of review Pleural disease is common. Traditionally, many patients were subjected to surgery for diagnosis and treatment. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal and their use is based on anecdotal series with selection bias. The evidence (or the lack) of benefits of surgery in common pleural conditions is reviewed.
Recent findings Recent studies do not support the routine therapeutic use of surgery in patients with malignant pleural effusions, empyema or mesothelioma. Four randomized studies have failed to show significant benefits of thoracoscopic poudrage over bedside pleurodesis. Surgery as first-line therapy for empyema was studied in four randomized studies with mixed results and no consistent benefits. Cumulative evidence suggests that radical surgery in mesothelioma, especially extrapleural pneumonectomy, is not justified. Advances in imaging modalities and histopathological tools have minimized the need for surgery in the workup of pleural effusions. Complications associated with surgery are increasingly recognized.
Summary Surgery has associated perioperative risks and costs, and residual pain is not uncommon. Many conventional pleural surgeries have not been assessed in randomized studies. Pulmonologists should be aware of the evidence that supports surgical interventions, or the lack of it, in order to make informed clinical decisions and optimize patient care.


Pleural diseases are common; over 1 500 000 patients develop a new pleural effusion annually in the USA alone.[1] Pleural effusion can arise from more than 60 causes, and establishing the cause and effective treatment can be challenging.

Thoracic surgery traditionally plays a major role in the workup and management of pleural effusions, from pleural biopsies to pleurodesis and from empyema to pneumothorax. Various aggressive pleural surgeries have been developed over the years: from the description of Clagett procedure in 1963[2] – a three-stage radical procedure with chest wall resection to create a permanent open window for pleural empyema – to modern day extrapleural pneumonectomy (EPP) for mesothelioma, which involves resection of lung, chest wall, hemidiaphragm, pericardium and regional lymph nodes. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal (let alone randomized studies) and their use is based largely on anecdotal series often flawed with selection bias.

The aim of management of pleural diseases is to deliver the diagnosis and best management with the least invasive procedure(s), shortest hospitalization period and lowest procedural morbidity and cost. Realization of the lack of evidence for many pleural surgeries, and the growing documentation of their procedure-related complications, has prompted the pleural community to examine ‘conventionally accepted’ pleural surgical approaches using randomized trials. Not surprisingly, many (e.g. thoracoscopic poudrage) have failed to demonstrate any significant benefits. Advances in imaging techniques, histopathology methods and therapeutic protocols further contribute to a reduction in need for invasive surgeries. Worldwide, in recent decades, the role of surgical intervention for the diagnosis and management of pleural disease has diminished significantly.

Clinicians must be critically aware of the evidence (or lack of evidence) supporting a specific surgical intervention before subjecting their patient to an operation. Progress can only be made if clinicians continue to challenge the truthfulness of ‘conventional wisdom’ and work toward less invasive means to achieve better patient care.

In this review, we discuss the role of surgery in commonly encountered pleural diseases and highlight the deficit in evidence that supports many ‘accepted’ surgical interventions, and the advances in pleural research which suggest parity or superiority of noninvasive approaches.

Surgery for Diagnosis of Pleural Effusions

A significant shift in the choice of diagnostic procedure for undiagnosed pleural effusion has been seen in recent years. Open thoracotomy, once the gold standard, has given way to less invasive video-assisted thoracoscopic surgery (VATS). In turn, VATS is giving way to the less invasive pleuroscopy (or medical thoracoscopy). VATS requires general anesthesia and is performed usually through two to four portals of entry. Pleuroscopy is performed usually by pulmonologists under conscious sedation with a single or double port of entry, often as a day case.

In the UK, the number of centers offering pleuroscopy has jumped from 11 to 37 in the past decade, significantly reducing the need for VATS or open pleural biopsies.[3] Flexi-rigid pleuroscopy further increases the ease of the procedure over traditional rigid thoracoscopy and is gaining popularity.

This march toward less invasive procedures is in part driven by the realization that surgery carries a risk of chronic complications. Furrer et al.[4] reported that chronic intercostal neuralgia (persistent pain) occurred in up to 44% of patients at 6 months postthoracotomy. In another series (n = 56), 9% of patients suffered from chronic postthoracotomy pain severe enough to require daily analgesia, nerve blocks, acupuncture or specialist pain clinic visits.[5] It is not surprising that a systematic review favored VATS over thoracotomy, reporting lower analgesia requirements and a shorter length of hospital stay. However, VATS is still associated with persistent pain or discomfort at the operation site in over a third of patients after 3–18 months.[4]

No studies directly compare VATS with pleuroscopy, but several large case series have suggested similar diagnostic efficacy for malignancy. Pooled results from case series evaluating pleuroscopy show a diagnostic sensitivity for malignant pleural disease of 92.6% (95% confidence interval 91.0%–93.9%),[6–25] comparable to those achieved following VATS pleural biopsy.[26,27] Pleuroscopy is a well-tolerated, cost-effective procedure. Mortality rates are low (<0.01%) and, in a series of over 6000 cases, surgical intervention was never required for hemostasis.[28] Pleuroscopy is preferable over VATS if initial fluid analyses were uninformative, especially in suspected cases of malignant or tuberculous pleural effusions.

Furthermore, technological improvements in diagnostic imaging modalities have reduced the need for thoracoscopic biopsies. Computed tomography with pleural phase enhancement provides closer definition of the pleural surfaces and circumferential, nodular or mediastinal thickening, and a parietal pleural thickness of more than 1 cm provides diagnostic specificities of 100%, 94%, 88% and 94%, respectively, for malignant disease.[29] Similar results were recently demonstrated by Qureshi et al.[30] using pleural ultrasound.

In patients with radiological evidence of pleural thickening, the diagnostic sensitivity of imaging-guided and thoracoscopically obtained pleural biopsy samples is comparable (approaching 90%).[3]

Advances in laboratory tests and biomarkers for pleural diseases also significantly reduce the need for pleural tissue biopsies. In many endemic countries, adenosine deaminase is used in the diagnosis of tuberculous effusion especially in patients with a compatible clinical picture and a lymphocyte-predominant effusion, negating thoracoscopic biopsies.[27,31] Other examples include flow cytometry for diagnosing lymphoma from pleural fluids, amylase for pancreatic effusions or ruptured esophagus and beta-2 transferrin for duropleural fistulae.

In patients with suspected mesothelioma, the use of a rapidly growing number of biomarkers has been proposed to aid the diagnosis through serum or pleural fluid analyses (reviewed elsewhere[32,33]). Although none can substitute a histocytological diagnosis, a high mesothelin level in cases with suspicious cytology of mesothelioma can add confidence to diagnostic certainty and may obviate the need for surgery.[34] In a study of 167 prospective patients presenting with undiagnosed pleural effusion, a negative mesothelin level together with negative pleural fluid cytology for malignancy yield a negative predictive value of 94%[34] – highly comparable to the false negative rate for pleuroscopy in three large series.[13,35,36] It is anticipated that within the next decade, these biomarkers will have an established place in the diagnostic algorithms for common pleural conditions, further minimizing the need for thoracoscopy.

Surgery for Pleural Infection

Pleural infection is a centuries’ old problem, but its incidence continues to rise despite better medical care and antimicrobials. The principle of therapy is control of sepsis (antibiotics) and drainage of the infected pleural fluid collection by thoracentesis, and if this fails, surgical evacuation.

Empyema is still considered in many centers as a ‘surgical’ disease, where surgeons will insert large bore chest tubes and have a low threshold of performing thoracoscopy for fluid evacuation if there are residual radiographic opacities. The conventional belief of the benefits of surgery stemmed from many anecdotal series, flawed by selection bias. The magnitude of that bias has recently been quantified in a retrospective series of 4424 empyema patients in the USA over 20 years.[37] Empyema patients selected for surgery were significantly younger by almost 10 years (52.9 vs. 61.5 years, P < 0.001) and had a significantly lower comorbidity index (0.8 vs. 1.4, P < 0.001).[37] VATS procedures often (up to 17%[38]) require conversion to open thoracotomy, thus increasing postoperative morbidity (see above). Many aspects of these ‘conventional practices’ are now shown to be overaggressive and unnecessary. There are several factors to consider.

First, the majority of patients with pleural infection can be adequately treated with antibiotics and chest tube drainage, without needing surgery. In the Multicentre Intrapleural Sepsis Trial (MIST) (n = 454), only 18% (n = 74) failed the above approach and required surgical treatment.[39•] [This is akin to pneumothorax management, where a 20% recurrence risk after the first episode does not warrant automatic surgery.[40] Routinely, subjecting all empyema patients to surgery is, therefore, unnecessary.

Four randomized clinical trials (RCTs) have now compared first-line VATS with conservative treatment (antibiotics and chest tube drainage with/without fibrinolytics). No major advantage (e.g. on mortality) has been documented with early surgical approach in all the trials. Two RCTs of pediatric empyema, comparing primary VATS intervention with chest drain and intrapleural fibrinolytic, both showed no advantages of early surgery. On the contrary, Sonnappa et al.[41] showed that surgery was more expensive ($11 379 vs. $9127) but did not alter outcome over conservative management in 60 children with pleural infection. Higher hospital charges were observed in the study by St Peter et al.[42] and similarly no significant differences in length of stay, oxygen requirement, days until afebrile or analgesia needed (n = 36). The two trials on adult empyema were small (n = 19 and 70, respectively) and difficult to interpret. Clear criteria to guide the need for surgical decortication, following the initial treatment administered postrandomization, are lacking in both studies.[43,44] Bilgin et al.[43] and Wait et al.[44] both randomized patients for immediate VATS or chest drain and antibiotics +/− intrapleural fibrinolytic. Neither study showed a major benefit other than shorter hospital stays (8.7 vs. 12.8 and 8.3 vs. 12.8 days, respectively). Hence, a recent Cochrane review concluded that further studies are needed to determine best practice.[45]

Supplementing improvements in antimicrobial therapies, imaging guidance of chest tube drainage is now increasingly used in place of surgical evacuation of pleural collections. This practice has reduced the amount of patients subjected to surgery, though the exact magnitude of the reduction is difficult to quantify.

Intrapleural therapy to aid the drainage also can negate the need for surgical evacuation. A large randomized study (n = 454) and subsequent meta-analysis have shown no benefit from intrapleural streptokinase therapy alone.[39•,46] However, the combined intrapleural use of tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) to breakdown adhesions and thin pus has synergistic benefits in preclinical models.[47,48] This has led to a factorial trial of intrapleural tPA and DNase in patients with pleural infection. Preliminary results from the MIST-2 study (presented at the British Thoracic Society 2009 scientific meeting[49]) appear promising: tPA and DNase improved radiological clearance of pleural abnormalities and reduced hospital stay. Only 5% of patients treated with this combination required surgical debridement.

Second, surgical decortication postempyema is grossly overemployed. Many centers submit patients to surgical decortication because of residual radiologic changes, even when sepsis had subsided. This practice is not supported by current clinical practice guidelines, which recommend surgery only in patients with persistent sepsis and a residual pleural collection despite appropriate drainage and antimicrobial therapy.[50] Longitudinal follow-up data from large clinical studies showed that residual pleural opacities will resolve with time, as the inflammatory changes settle.[39•,51] This is akin to radiographic parenchymal changes in patients with pneumonia.

Third, conventional teaching advocates large bore chest tube drainage for empyema and, in many centers, large drains are inserted only by thoracic surgeons. Traditionally, the main arguments for large catheters have been a better drainage rate, especially in draining pus, and a lower blockage rate. However, no evidence-based data concur with this supposition.[52•] The difference in drainage rate for pus is not significant once the size of internal diameter of the catheter reaches at least 8F or above (~12–14F external diameter). Rates of drain blockage in empyema, another conventional concern, are similar in published literature between large and small bore drains; and regular flushing of small bore catheters often overcomes the problem of blockage.[53]

Empyema fails to drain most commonly because of multiple septations, a hurdle which large drains will not overcome; increasing numbers of studies now show that larger drain size does not increase efficacy, even in empyema. In their study, analysing data on 405 patients with empyema, Rahman et al.[52•] showed no significant difference in mortality, need for subsequent thoracic surgery, length of hospital stay, lung function or radiographic resolution in patients with chest tubes of varying sizes (<10F, 10–14F, 15–20F or >20F).

The main drawback of the large bore catheters is pain secondary to the larger incision and subcutaneous/transpleural tract required, as reported in several series.[52•,54] Others have shown higher rates of infection with large tubes.[55,56]

Surgery for Malignant Pleural Effusions

As many as 100 000 patients in Europe develop a malignant pleural effusion from lung cancer alone[57] and 150 000 cancer patients in USA have a malignant pleural effusion each year.[58] Little evidence suggests thoracic surgery has a salient therapeutic role in malignant effusion management, even though it is often employed worldwide.

Pleurodesis is considered the best therapy wherever suitable and, in head-on comparisons, talc has been shown to be superior to bleomycin, tetracycline or doxycycline.[59–65] The optimal route for delivery of talc is controversial.

Talc poudrage administered by VATS is traditionally thought to be more effective than bedside slurry instilled via a chest tube. However, talc induces pleural mesothelial damage with subsequent pleural inflammation and symphysis, rather than acting as a glue;[66–69] therefore, the supposed even distribution which results from insufflation is not essential for successful pleurodesis. Radioactive isotope studies have shown that talc can distribute around the pleural cavity by respiratory motions even if administered as slurry.[70]

All randomized trials to date have failed to show a benefit of thoracoscopic talc poudrage over bedside chemical pleurodesis; three recent studies have compared talc poudrage with talc slurry,[71•,73,74] and one, by Mohsen et al.,[72] with povidone iodine. These are outlined in Table 1.[71•,72–74]

Table 1. Recent trials comparing talc slurry and bedside chemical pleurodesis

Reference; study design Patient number Primary cancer (TP/TS) Length of follow up Outcome measures Result
Dresler et al. [71•]; TP=251 Lung: 89/93 Until death Recurrence rate at 30 days: No significant difference
RCT TS=250 Breast: 59/56 TP: 145/251 Similar success rates at 30 days (75%) and efficacy at 6 months (50%)
TS: 126/250 (P=NS)
Yim et al. [74]; TP=28 Lung: 18/15 Until death Recurrence rate: No significant difference
RCT TS=29 Breast: 6/9 TP: 1/28
GIT/other: 4/5 TS:3/29
Terra et al. [73]; TP=30 Breast: 15/19 6 months Postpleurodesis lung expansion No significant difference in Clinical outcome complications or quality of life
RCT TC=30 Lung: 11/6 Radiological recurrence
Lymphoma: 2/1 Clinical recurrence (requiring intervention):
Unknown: 1/1 TP: 5/30
Other: 1/3 TS: 4/30
Mohsen et al. [72]; TP=22 All breast 4 years Recurrence requiring intervention: No significant difference
RCT PI=20 TP: 2/22
PI: 3/20

GIT, gastrointestinal; NS, not significant; PI, povidone iodine; RCT, randomized controlled trial; TP, talc poudrage; TS, talc slurry

The largest trial by Dresler et al.[71•] showed that talc poudrage at thoracoscopy induced significantly more complications than talc slurry pleurodesis. Rates of pneumonia requiring antibiotics, respiratory failure, bronchopleural fistulae, requirement for blood transfusion, atelectasis requiring more than two bronchoscopies, dysrhythmia, deep vein thrombosis, pulmonary embolism and postoperative death rates were all increased in the talc poudrage compared with the bedside talc slurry group.[71•] Success rates of both techniques were similar (~75%) at 30 days after procedure. Efficacy reduced with time to approximately 50% at 6 months and a suggestion of a trend toward talc slurry being more effective.[71•]

Indwelling Pleural Catheters

One major recent advance has been the increased utility of indwelling pleural catheters (IPC). These may be inserted as a day-case procedure, with local anesthesia and conscious sedation, thus reducing hospital time and avoiding the risks inherent to a general anaesthetic. It is now the preferred treatment method for patients with an underlying trapped lung and those who fail initial pleurodesis.[75] Extending the use of IPC as a first-line treatment for patients with malignant pleural effusion is the subject of randomized trials in Europe. Recent series suggest that bedside insertion of IPC by pulmonologists or interventional radiologists is as well tolerated as surgical placement in the operating rooms.[76]

Surgery for Malignant Pleural Mesothelioma

Perhaps the most aggressive pleural surgery performed nowadays is EPP. EPP is usually part of trimodality treatment in combination with chemotherapy and hemithoracic radiotherapy. Little high-quality evidence supports its use.

Even in the most experienced centers and despite surgical advances, the perioperative mortality rate remains approximately 4%.[77] Other centers have observed similar findings; e.g. Rice et al.[78] had 8% mortality in 100 cases of EPP; Stewart et al.[79] had 7% mortality in 74 patients and Hasani et al.[80] had 11% mortality in a series of 18 patients. There is also significant associated morbidity: Sugarbaker et al.[77] report a complication rate in excess of 60%, a finding echoed by Schipper et al.[81] (who also report a 3-year survival rate of only 14%). Life-threatening complications affect 25% of patients, including surgical complications requiring re-exploration (7%), cardiac arrest/myocardial infarction (5%), prolonged intubation (8%), deep vein thrombosis and renal failure.[77] Late mortality (days 30–180) is significant, killing as many patients as in the first 30 days in one report. Additional morbidity arises from the chemotherapy and radiotherapy arms of the trimodality regime.

Despite this unacceptable safety profile, the trimodality approach does not cure mesothelioma. Alarmingly, though not surprisingly, Weder et al.[82] reported worsening of quality of life in patients who underwent EPP, especially in physical, psychological and activity scores for at least up to 6 months after surgery. Although improved long-term survival has been claimed, the data are almost certainly a result of selection bias.

The Mesothelioma and Radical Surgery (MARS) trial was designed to address the role of EPP as a component of trimodality treatment in malignant mesothelioma.[83] Even in the 300 patients believed to be potentially suitable and referred, only 50 were ultimately eligible after screening and were randomized; further confirming that EPP, even if useful, is applicable only to a minority of patients and will not make an impact on the global burden of mesothelioma.[84]

Increasing data confirmed that EPP has a worse outcome than less radical surgery, for example pleurectomy/decortication. Flores et al.[85] showed in a large but nonrandomized series that patients who underwent pleurectomy had improved survival compared with those who underwent EPP. Nakas et al.[86] reported significant improvements in pain and dyspnea with VATS pleurectomy/decortication (n = 67) compared with EPP (n = 112), with improved 30 day mortality (VATS group 7.1% vs. EPP 23%), reduced hospital stay (14.3 days vs. 36.6 days) and overall mean survival (14.0 months vs. 11.5 months) in patients aged more than 65 years.

The most striking data to show the lack of surgical benefits came from Flores et al.,[87] who in a large retrospective series showed a median survival of 14.3 months in patients undergoing EPP (n = 208) compared with 15.8 months (n = 176) following pleurectomy/decortication. Both were only marginally better than the median survival for patients (n = 174) who underwent explorative thoracotomy and were found to have extensive and inoperable disease (12.7 months).

Mesothelioma is not a solitary tumor but spreads along serosal surfaces. Surgery is not likely therefore to provide cure, as has been the observation to date. Because of the lag time between exposure and disease onset, the patients are often elderly with significant comorbidity, and current data do not support aggressive operations.

Surgery for Chylothorax

Although dietary manipulation may reduce chyle flow, patients with refractory chylothoraces often require surgical ligation of the thoracic duct if this fails, necessitating either VATS or thoracotomy. Increasing reports suggest that percutaneous thoracic duct embolization using fluoroscopic guidance may be effective and can obviate the need for invasive surgery.[88,89]

Surgery for Pneumothorax

The majority of pneumothoraces can be managed without surgery. Patients with small primary spontaneous pneumothoraces (PSP) or with no symptoms, regardless of the size of the pneumothorax, may be safely treated with observation alone. Guidelines recommend initial pleural aspiration for patients with PSP and significant symptoms, and that any patient with a secondary spontaneous pneumothorax (SSP) has an intercostal chest drain inserted.[41]

No evidence exists on which to base timing of referral for surgical intervention in patients with an ongoing air leak. International guidelines recommend that an opinion is sought within 2–5 days; however, this timeline is largely arbitrary.[41,90]

Several retrospective studies argue against early surgical treatment. One retrospective review (n = 115) reported spontaneous resolution rates of 74% and 100% for those with PSP at 7 and 15 days, respectively; and 61% and 79% (at 7 and 14 days, respectively) for patients with SSP. Only five patients required surgical intervention.[91] Two further studies of PSP showed that only 37% had an air leak at presentation, resolving in two thirds of cases within 1 week without intervention.

Ferraro et al.[92] compared conservative (including tube thoracostomy) to surgical intervention (apical resection with either pleurectomy of pleural abrasion) for 366 patients with 508 episodes of spontaneous pneumothorax (239 patients with PSP, 127 with SSP). No significant difference was noted between the two groups in terms of recurrence rates.

Other nonsurgical approaches under exploration include ambulatory management with chest tube and one-way valve, and pleuroscopy. For patients with SSP, who are more likely to have a prolonged air leak and less likely to tolerate surgical intervention, prolonged observation, intercostal catheter drainage and use of flutter valves may preclude the need for surgery. Medical thoracoscopy as an alternative to VATS has increasingly been used for the management of spontaneous pneumothorax. Tschopp et al.[93] in a RCT compared the efficacy of VATS pleurodesis (via abrasion or talc poudrage) to poudrage via medical thoracoscopy, showing no difference in long-term recurrence rate (approximately 5%).


For centuries, different surgical procedures have been used for various pleural diseases, without any quality data to prove their benefits over conservative alternatives. Surgery has associated perioperative risks and costs; and residual pain is not uncommon. To date, the randomized studies on surgical approaches have not shown a significant advantage in the settings of pleural infection, malignant effusions and mesothelioma. Pulmonologists should be aware of the evidence that supports surgical interventions, or the lack of it, in order to make well-informed clinical decisions and optimize patient care.


Key Points

  • The overall aim of medical practice is to diagnose and treat with the least invasive methods.
  • There is a paucity of randomized evidence to support surgical intervention for many pleural diseases and physicians need to be aware of this in order to make well-informed clinical decisions to optimize patient care.
  • Radical surgery, especially extrapleural pneumonectomy, is not justified for patients with mesothelioma.
  • Advances in pleural research suggest parity or improved outcomes with less interventional approaches for patients with empyema.


  1. Light RW. Pleural diseases. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.
  2. Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema. J Thorac Cardiovasc Surg 1963; 45:141–145.
  3. Rahman NM, Ali NJ, Brown G, et al. Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii54–ii60.
  4. Furrer M, Rechsteiner R, Eigenmann V, et al. Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and chest wall complaints. Eur J Cardiothorac Surg 1997; 12:82–87.
  5. Dajczman E, Gordon A, Kreisman H, Wolkove N. Long-term postthoracotomy pain. Chest 1991; 99:270–274.
  6. Blanc FX, Atassi K, Bignon J, Housset B. Diagnostic value of medical thoracoscopy in pleural disease: a 6-year retrospective study. Chest 2002; 121:1677–1683.
  7. Boutin C, Rey F. Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 consecutive patients. Part 1: Diagnosis. Cancer 1993; 72:389–393.
  8. Davidson AC, George RJ, Sheldon CD, et al. Thoracoscopy: assessment of a physician service and comparison of a flexible bronchoscope used as a thoracoscope with a rigid thoracoscope. Thorax 1988; 43:327–332.
  9. Debeljak A, Kecelj P. Medical thoracoscopy: experience with 212 patients. J Buon 2000; 5:169–172.
  10. Fielding D, Hopkins P, Serisier D. Frozen section of pleural biopsies at medical thoracoscopy assists in correctly identifying benign disease. Respirology 2005; 10:636–642.
  11. Fletcher SV, Clark RJ. The Portsmouth thoracoscopy experience: an evaluation of service by retrospective case note analysis. Respir Med 2007; 101:1021–1025.
  12. Hansen M, Faurschou P, Clementsen P. Medical thoracoscopy, results and complications in 146 patients: a retrospective study. Respir Med 1998; 92:228–232.
  13. Janssen JP, Ramlal S, Mravunac M. The long-term follow up of exudative pleural effusion after nondiagnostic thoracoscopy. J Bronchol 2004; 11:169–174.
  14. Lee P, Hsu A, Lo C, Colt HG. Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome. Respirology 2007; 12:881–886.
  15. Macha HN, Reichle G, von Zwehl D, et al. The role of ultrasound assisted thoracoscopy in the diagnosis of pleural disease. Clinical experience in 687 cases. Eur J Cardiothorac Surg 1993; 7:19–22.
  16. McLean AN, Bicknell SR, McAlpine LG, Peacock AJ. Investigation of pleural effusion: an evaluation of the new Olympus LTF semiflexible thoracofiberscope and comparison with Abram’s needle biopsy. Chest 1998; 114:150–153.
  17. Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med 1991; 114:271–276.
  18. Munavvar M, Khan MA, Edwards J, et al. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J 2007; 29:571–574.
  19. Oldenburg FA Jr, Newhouse MT. Thoracoscopy. A safe, accurate diagnostic procedure using the rigid thoracoscope and local anesthesia. Chest 1979; 75:45–50.
  20. Sakuraba M, Masuda K, Hebisawa A, et al. Diagnostic value of thoracoscopic pleural biopsy for pleurisy under local anaesthesia. ANZ J Surg 2006; 76:722–724.
  21. Schwarz C, Lubbert H, Rahn W, et al. Medical thoracoscopy: hormone receptor content in pleural metastases due to breast cancer. Eur Respir J 2004; 24:728–730.
  22. Simpson G. Medical thoracoscopy in an Australian regional hospital. Intern Med J 2007; 37:267–269.
  23. Smit HJ, Schramel FM, Sutedja TG, et al. Video-assisted thoracoscopy is feasible under local anesthesia. Diagn Ther Endosc 1998; 4:177–182.
  24. Tassi G, Marchetti G. Minithoracoscopy: a less invasive approach to thoracoscopy. Chest 2003; 124:1975–1977.
  25. Wilsher ML, Veale AG. Medical thoracoscopy in the diagnosis of unexplained pleural effusion. Respirology 1998; 3:77–80.
  26. Waller DA, Hasan A, Forty J, Morritt GN. Videothoracoscopy in the diagnosis of intrathoracic pathology: early experience. Ann R Coll Surg Engl 1994; 76:123–126.
  27. Hooper C, Lee YC, Maskell N. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii4–ii17.
  28. Loddenkemper R. Thoracoscopy: state of the art. Eur Respir J 1998; 11:213–221.
  29. Leung AN, Muller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR Am J Roentgenol 1990; 154:487–492.
  30. Qureshi NR, Rahman NM, Gleeson FV. Thoracic ultrasound in the diagnosis of malignant pleural effusion. Thorax 2009; 64:139–143.
  31. Liang QL, Shi HZ, Wang K, et al. Diagnostic accuracy of adenosine deaminase in tuberculous pleurisy: a meta-analysis. Respir Med 2008; 102:744–754.
  32. Scherpereel A, Lee YC. Biomarkers for mesothelioma. Curr Opin Pulm Med 2007; 13:339–443.
  33. Tung A, Porcel JM, Bilaceroglu S, et al. Biomarkers in pleural disease. US Respiratory Diseases 2011 (in press).
  34. Davies HE, Sadler RS, Bielsa S, et al. Clinical impact and reliability of pleural fluid mesothelin in undiagnosed pleural effusions. Am J Respir Crit Care Med 2009; 180:437–444.
  35. Davies HE, Nicholson JE, Rahman NM, et al. Outcome of patients with nonspecific pleuritis/fibrosis on thoracoscopic pleural biopsies. Eur J Cardiothorac Surg 2010; 38:472–477.
  36. Venekamp LN, Velkeniers B, Noppen M. Does ‘idiopathic pleuritis’ exist? Natural history of nonspecific pleuritis diagnosed after thoracoscopy. Respiration 2005; 72:74–78.
  37. Farjah F, Symons RG, Krishnadasan B, et al. Management of pleural space infections: a population-based analysis. J Thorac Cardiovasc Surg 2007; 133:346–351.
  38. Landreneau RJ, Keenan RJ, Hazelrigg SR, et al. Thoracoscopy for empyema and hemothorax. Chest 1996; 109:18–24.
  39. Maskell NA, Davies CW, Nunn AJ, et al. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005; 352:865–874.
    • In this double-blind randomized placebo-controlled trial of 454 patients, no improvement in mortality, rate of surgery or length of hospital stay was shown with the intrapleural administration of streptokinase among patients with pleural infection.
  40. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii18–ii31.
  41. Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 2006; 174:221–227.
  42. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009; 44:106–111.
  43. Bilgin M, Akcali Y, Oguzkaya F. Benefits of early aggressive management of empyema thoracis. ANZ J Surg 2006; 76:120–122.
  44. Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. Chest 1997; 111:1548–1551.
  45. Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema. Cochrane Database Syst Rev 2004:CD002312.
  46. Tokuda Y, Matsushima D, Stein GH, Miyagi S. Intrapleural fibrinolytic agents for empyema and complicated parapneumonic effusions: a meta-analysis. Chest 2006; 129:783–790.
  47. Light RW, Nguyen T, Mulligan ME, Sasse SA. The in vitro efficacy of varidase versus streptokinase or urokinase for liquefying thick purulent exudative material from loculated empyema. Lung 2000; 178:13–18.
  48. Simpson G, Roomes D, Heron M. Effects of streptokinase and deoxyribonuclease on viscosity of human surgical and empyema pus. Chest 2000; 117:1728–1733.
  49. Rahman NM, Maskell NA, Davies CWH, et al. Primary result of the second multicentre intrapleural sepsis (MIST2) trial; randomised trial of intrapleural tPA and DNase in pleural infection [abstract]. Thorax 2009; 64: A1.
  50. Davies HE, Davies RJ, Davies CW. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii41–ii53.
  51. Diacon AH, Theron J, Schuurmans MM, et al. Intrapleural streptokinase for empyema and complicated parapneumonic effusions. Am J Respir Crit Care Med 2004; 170:49–53.
  52. Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest 2010; 137:536–543.
    • This analysis of patients with pleural infection shows that smaller bore chest tubes cause less pain than larger tubes, inserted using blunt dissection, with no impairment of clinical outcome.
  53. Davies HE, Merchant S, McGown A. A study of the complications of small bore ‘Seldinger’ intercostal chest drains. Respirology 2008; 13:603–607.
  54. Clementsen P, Evald T, Grode G, et al. Treatment of malignant pleural effusion: pleurodesis using a small percutaneous catheter. A prospective randomized study. Respir Med 1998; 92:593–596.
  55. Benton IJ, Benfield GF. Comparison of a large and small-calibre tube drain for managing spontaneous pneumothoraces. Respir Med 2009; 103:1436–1440.
  56. Parulekar W, Di Primio G, Matzinger F, et al. Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions. Chest 2001; 120:19–25.
  57. Ferlay J, Autier P, Boniol M, et al. Estimates of the cancer incidence and mortality in Europe in 2006. Ann Oncol 2007; 18:581–592.
  58. Marel M, Zrustova M, Stasny B, Light RW. The incidence of pleural effusion in a well defined region. Epidemiologic study in central Bohemia. Chest 1993; 104:1486–1489.
  59. Diacon AH, Wyser C, Bolliger CT, et al. Prospective randomized comparison of thoracoscopic talc poudrage under local anesthesia versus bleomycin instillation for pleurodesis in malignant pleural effusions. Am J Respir Crit Care Med 2000; 162(4 Pt 1):1445–1449.
  60. Fentiman IS, Rubens RD, Hayward JL. A comparison of intracavitary talc and tetracycline for the control of pleural effusions secondary to breast cancer. Eur J Cancer Clin Oncol 1986; 22:1079–1081.
  61. Haddad FJ, Younes RN, Gross JL, Deheinzelin D. Pleurodesis in patients with malignant pleural effusions: talc slurry or bleomycin? Results of a prospective randomized trial. World J Surg 2004; 28:749–753.
  62. Hamed H, Fentiman IS, Chaudary MA, Rubens RD. Comparison of intracavitary bleomycin and talc for control of pleural effusions secondary to carcinoma of the breast. Br J Surg 1989; 76:1266–1267.
  63. Noppen M, Degreve J, Mignolet M, Vincken W. A prospective, randomised study comparing the efficacy of talc slurry and bleomycin in the treatment of malignant pleural effusions. Acta Clin Belg 1997; 52:258–262.
  64. Ong KC, Indumathi V, Raghuram J, Ong YY. A comparative study of pleurodesis using talc slurry and bleomycin in the management of malignant pleural effusions. Respirology 2000; 5:99–103.
  65. Zimmer PW, Hill M, Casey K, et al. Prospective randomized trial of talc slurry vs bleomycin in pleurodesis for symptomatic malignant pleural effusions. Chest 1997; 112:430–434.
  66. Genofre EH, Vargas FS, Antonangelo L, et al. Ultrastructural acute features of active remodeling after chemical pleurodesis induced by silver nitrate or talc. Lung 2005; 183:197–207.
  67. Idell S, Pendurthi U, Pueblitz S, et al. Tissue factor pathway inhibitor in tetracycline-induced pleuritis in rabbits. Thromb Haemost 1998; 79:649–655.
  68. Kennedy L, Harley RA, Sahn SA, Strange C. Talc slurry pleurodesis. Pleural fluid and histologic analysis. Chest 1995; 107:1707–1712.
  69. Marchi E, Vargas FS, Acencio MM, et al. Evidence that mesothelial cells regulate the acute inflammatory response in talc pleurodesis. Eur Respir J 2006; 28:929–932.
  70. Mager HJ, Maesen B, Verzijlbergen F, Schramel F. Distribution of talc suspension during treatment of malignant pleural effusion with talc pleurodesis. Lung Cancer 2002; 36:77–81.
  71. Dresler CM, Olak J, Herndon JE, et al. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Chest 2005; 127:909–915.
    • In this phase III study of 501 patients, no difference was seen in pleurodesis efficacy between thoracoscopic talc poudrage and talc slurry tube pleurodesis.
  72. Mohsen TA, Zeid AA, Meshref M, et al. Local iodine pleurodesis versus thoracoscopic talc insufflation in recurrent malignant pleural effusion: a prospective randomized control trial. Eur J Cardiothorac Surg 2010 [Epub ahead of print].
  73. Terra RM, Junqueira JJ, Teixeira LR, et al. Is full postpleurodesis lung expansion a determinant of a successful outcome after talc pleurodesis? Chest 2009; 136:361–368.
  74. Yim AP, Chan AT, Lee TW, et al. Thoracoscopic talc insufflation versus talc slurry for symptomatic malignant pleural effusion. Ann Thorac Surg 1996; 62:1655–1658.
  75. Roberts ME, Neville E, Berrisford RG, et al. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65(Suppl 2):ii32–ii40.
  76. Suzuki K, Servais EL, Rizk NP, et al. Palliation and pleurodesis in malignant pleural effusion: the role for tunnelled pleural catheters. J Thorac Oncol 2011 (in press).
  77. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg 2004; 128:138–146.
  78. Rice DC, Stevens CW, Correa AM, et al. Outcomes after extrapleural pneumonectomy and intensity-modulated radiation therapy for malignant pleural mesothelioma. Ann Thorac Surg 2007; 84:1685–1692.
  79. Stewart DJ, Martin-Ucar AE, Edwards JG, et al. Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risks of induction chemotherapy, right-sided procedures and prolonged operations. Eur J Cardiothorac Surg 2005; 27:373–378.
  80. Hasani A, Alvarez JM, Wyatt JM, et al. Outcome for patients with malignant pleural mesothelioma referred for trimodality therapy in Western Australia. J Thorac Oncol 2009; 4:1010–1016.
  81. Schipper PH, Nichols FC, Thomse KM, et al. Malignant pleural mesothelioma: surgical management in 285 patients. Ann Thorac Surg 2008; 85:257–264.
  82. Weder W, Stahel RA, Bernhard J, et al. Multicenter trial of neo-adjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma. Ann Oncol 2007; 18:1196–1202.
  83. Treasure T, Tan C, Lang-Lazdunski L, Waller D. The MARS trial: mesothelioma and radical surgery. Interact Cardiovasc Thorac Surg 2006; 5:58–59.
  84. Treasure T, Waller D, Tan C, et al. The mesothelioma and radical surgery randomized controlled trial: the Mars feasibility study. J Thorac Oncol 2009; 4:1254–1258.
  85. Flores RM, Pass HI, Seshan VE, et al. Extrapleural pneumonectomy versus pleurectomy/decortication in the surgical management of malignant pleural mesothelioma: results in 663 patients. J Thorac Cardiovasc Surg 2008; 135:620–626.
  86. Nakas A, Martin Ucar AE, Edwards JG, Waller DA. The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma. Eur J Cardiothorac Surg 2008; 33:83–88.
  87. Flores RM, Zakowski M, Venkatraman E, et al. Prognostic factors in the treatment of malignant pleural mesothelioma at a large tertiary referral center. J Thorac Oncol 2007; 2:957–965.
  88. Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002; 13:1139–1148.
  89. Cope C. Management of chylothorax via percutaneous embolization. Curr Opin Pulm Med 2004; 10:311–314.
  90. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119:590–602.
  91. Chee CB, Abisheganaden J, Yeo JK, et al. Persistent air-leak in spontaneous pneumothorax: clinical course and outcome. Respir Med 1998; 92:757–761.
  92. Ferraro P, Beauchamp G, Lord F, et al. Spontaneous primary and secondary pneumothorax: a 10-year study of management alternatives. Can J Surg 1994; 37:197–202.
  93. Tschopp JM, Brutsche M, Frey JG. Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia. Thorax 1997; 52:329–332.Papers of particular interest, published within the annual period of review, have been highlighted as:
    • of special interest
    •• of outstanding interest
    Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 293).

Professor Y.C.G.L. receives research grants from the Western Australian Health Department (State Health Research Advisory Council), Sir Charles Gairdner Research Funds, Raine Medical Research Foundation and the Cancer Council of Western Australia.

Curr Opin Pulm Med. 2011;17(4):247-254. © 2011 Lippincott Williams & Wilkins

We’ll be talking about each of these concepts/ treatments in turn in future posts with related research, and published literature.  However, it is immediately apparent in reviewing this work that the authors selectively chose their references to reflect their pre-existing viewpoints – and that much of data on which their conclusions are based is considerable outdated.  While we respectfully appreciate the historical perspectives inherent in thoracic surgery – this type of ‘data culling’ is a deceptive practice.

Author: K Eckland

World of Thoracic Surgery is a blog about the work, research, and practices of thoracic surgeons around the world. It includes case studies, [sometimes] dry research, interviews with thoracic surgeons along with patient perspectives, and feedback.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: