VGTT: video-guided tube thoracostomy

Dr. Chin Hao Chen revisits one of the basic procedures in thoracic surgery: Chest tube placement

Even Hippocrates placed chest tubes or the history of tube thoracostomy

Chest tube placement has been performed since ancient Greek times.  Early physicians, including Hippocrates himself, performed (and wrote about) the use of tube thoracostomy for the treatment of lung abscesses and empyema.  Often this procedure is performed using a ‘blind approach’ based entirely on external anatomic features (intercostal spaces) and a fundamental knowledge of internal and chest wall anatomy.  Over the years, surgeons have developed guidelines to this technique using palpation/ and other tactile information but none of these techniques challenged initial insertion technique.

With any blind procedure, there is a risk of inadvertent injury due to the lack of visualization, particularly in patients with previous thoracic procedures or infections (adhesions), or when performed by less experienced staff.

Direct visualization during this procedure (akin to VATS) may lessen this risk.  However, little has been published on alternatives to the traditional technique.

VGTT: video-guided tube thoracostomy

Our latest post comes directly from Dr. Chih-Hao Chen at Mackay Memorial Hospital in Taiwan.

Dr. Chen presents a video clip demonstrating video-guided tube thoracostomy (VGTT), a technique used to avoid tube-related injury during the course of tube thoracostomy (versus blind insertion).  This visualization technique is helpful particularly when performed by inexperienced staff, such as residents or in emergent situations.

A complete description of this technique was recently published in the Annals of Thoracic Surgery.

Chen, et. al (2013). Video-guided tube thoracostomy with use of a nonfiberoptic endoscope. Ann Thorac Surg, 2013;96: 1450-5.  Articles commentary also available.

This paper describes the technique as well as discussing the clinical experience of Dr. Chen and his team in applying this technique to several patients.

Dr. Chin-Hao Chen is a thoracic surgeon at Mackay Memorial Hospital in Taiwan.  Dr. Chen is a frequent and valued contributor here at Cirugia de Torax.  He has provided several case studies as well as articles and videos on surgical techniques.

Outpatient Treatment for Malignant Effusions

Discussion of treatment goals, and patient centered care for Malignant pleural effusions. This is the first in a series of articles on lung cancer, and lung surgery topics. Originally posted at our sister site.

Not all conditions are curable, and not all treatments are curative. Some treatments are based on improving quality of life, and alleviating symptoms. This is a hallmark of patient centered care – doing what we can to make the patient feel better even when we can’t ‘fix’ or cure the underlying disease. No where is this more evident than in the treatment of malignant effusions.

By definition, a Malignant Effusion is the development of fluid in the fluids related to an underlying (and sometimes previously undiagnosed) malignancy. Malignant effusions can be seen with several different kinds of cancers, most commonly lung and breast cancers. The development of a malignant effusion is a poor prognostic sign as it is an indicator of metastasis to the pleural tissue/ space.

The development of a malignant effusion usually presents with symptoms of shortness of breath, and difficulty breathing. While the treatment of the underlying cancer may vary, the primary goal of treatment of an effusion is palliative (or symptom relief). The best way to relieve symptoms is by removing the fluid.

This can be done several ways – but each has its own drawbacks.

Thoracentesis:
The fluid can be drawn out with a needle (thoracentesis) either bedside or under fluroscopy. This procedure is quick, and can be performed on an out-patient basis, in a doctor’s office, or in radiology.

The potential drawbacks with this treatment strategy are two-fold:

1. There is a chance that during the procedure, the needle will ‘poke’ or ‘pop’ the lung, causing a pneumothorax (or collapse of the lung). This then requires a chest tube to be placed so the lung can re-expand while it heals. However, if the procedure is performed uneventfully, (like it usually does) the patient can go home the same day.

2. The other complication – is rapid re – accumulation – since you haven’t treated the underlying cause, but have only removed the fluid. This also happens when the cause of the effusion (nonmalignant) is from congestive heart failure. This means the fluid (and symptoms of shortness of breath) may return quickly, requiring the patient to return to the hospital – which is hard of the patient and their family.

Video- Assisted Thoracoscopy: (VATs)
Malignant effusions can also be treated by VATS – this is a good option if we are uncertain of the etiology (or the reason) for the effusion. While all fluid removed is routinely sent for cytopathology (when removed during surgery, thoracentesis or chest tube placement) – but cytopathology can be notoriously inaccurate with false negative reports, because the diagnosis is dependent on the pathologist actually seeing cancer cells in the fluid.  However, during the VATs procedure – the surgeon can take tissue samples, and photos along with fluid for diagnostic testing.   This is important because I have had cases in the operating room (VATS) where the surgeon actually sees the tumor(s)** with the camera but the fluid comes back as negative.

** in these cases, we send biopsies of the tumor tissue – which is much more accurate and definitive.

But a VATS procedure requires an operation, chest tube placement and several days in the hospital.

Chest tube placement:
Another option is chest tube placement – which also requires several days in the hospital..

During both chest tube placement and VATS, a procedure called pleurodesis can be performed to try to prevent the fluid from re-accumulating.

But what if we know it’s a malignant effusion? What are the other options for treatment?

Catheter based treatments: (aka PleurX style catheter, or Heimlich valve)
(note: catheter means a small tube – a foley catheter is the type used to drain urine, but other types are used for many things – even an IV is a catheter.)
One of the options used in our practice was pleur X (brand) catheter placement. This catheter was a small flexible tube that could be placed under local anesthesia – either in the office or the operating room – as an ambulatory procedure. After some patient teaching, including a short video, most family members felt comfortable emptying the catheter every two or three days at home, to prevent fluid  re -accumulation (and allowing the patient to continue normal activities, at home.)

PleurX catheter placement is preferred in many cases due to ease of use, and patient convenience. The Heimlich valve is messier – as it tends to leak, and harder for patients to hide under clothing.

Sometimes a visiting nurse would go out and empty the catheter, and in several cases, patients would come to the office, where I would do the same thing – it was a nice way to relieve the patient’s symptoms without requiring hospitalization, and several studies have shown that repeated drainage often caused spontaneous pleurodesis (fluid no longer accumulated.) We would then take the catheter out in the office.. Now, like any procedure, there is a chance for problems with this therapy as well, infection, catheter can clog, etc..

But here’s another study, showing that even frail patients benefit from home-based therapy – which is important when we go back and consider our original treatment goals:
-Improving quality of life
-Relieving symptoms

In the article, the authors used talc with the catheters and then applied a Heimlich valve, which is another technique very similar to pleurX catheter placement.  (Sterile talc is used for the pleurodesis procedure – which we will talk about in more detail in the future.)

Another article, this one by Heffner & Klein (2009) published in the Mayo Clinic Proceedings discusses the diagnosis and treatment of malignant effusions.