236.ppt

Giuseppe Cardillo, MD, FETCSGiuseppe Cardillo, MD, FETCSGiuseppe Cardillo, MD, FETCSGiuseppe Cardillo, MD, FETCS

Indications and Results of Surgical Indications and Results of Surgical

Pleurodesis for Spontaneous Pleurodesis for Spontaneous

PneumothoraxPneumothorax

Indications and Results of Surgical Indications and Results of Surgical

Pleurodesis for Spontaneous Pleurodesis for Spontaneous

PneumothoraxPneumothorax

Unit of Thoracic Surgery Glenfield Hospital Leicester -

UK

Unit of Thoracic Surgery C. Forlanini Hospital ,Rome -

Italy

EDUCATIONAL AIM

To understand when there is a need to treat a spontaneous pneumothorax

To understand which procedure should be preferred

To understand the risk and benefit of its procedure

To understand how to counsel a patient who has been treated for spontaneous pneumothorax

To understand the need for follow-up

SPONTANEOUS SPONTANEOUS PNEUMOTHORAXPNEUMOTHORAXSPONTANEOUS SPONTANEOUS

PNEUMOTHORAXPNEUMOTHORAX

• Spontaneous pneumothorax (SP) Spontaneous pneumothorax (SP) occurs in more than 20,000 patients occurs in more than 20,000 patients annually in the United States annually in the United States **

• Cost nearly $130,000,000 per year Cost nearly $130,000,000 per year ****

**Melton LJ et al. Am Rev Respir Dis 1979, 120:1379–1382.Melton LJ et al. Am Rev Respir Dis 1979, 120:1379–1382.****Bense L et al. Chest 1991, 99:260–261.Bense L et al. Chest 1991, 99:260–261.****Baumann MH et al. Chest 1997, 112:789–804.Baumann MH et al. Chest 1997, 112:789–804.



Primary Primary Rupture of small bullae or blebs in the absence of Rupture of small bullae or blebs in the absence of

clinically apparent lung disorder (80% - 90%)clinically apparent lung disorder (80% - 90%)

SecondarySecondary Underlying lung disease (10%-20%)Underlying lung disease (10%-20%) (m(most commonly chronic obstructive pulmonary ost commonly chronic obstructive pulmonary

disease)disease)

CatamenialCatamenial Associated with endometriosisAssociated with endometriosis (within 24-72 hours after the onset of (within 24-72 hours after the onset of

menstruation)menstruation)

* Bertrand PC, Ann Thorac Surg 1996, 61:1641-5.* Bertrand PC, Ann Thorac Surg 1996, 61:1641-5.

PRIMARY SPONTANEOUS PRIMARY SPONTANEOUS PNEUMOTHORAX (PSP)PNEUMOTHORAX (PSP)

EpidemiologyEpidemiology

PRIMARY SPONTANEOUS PRIMARY SPONTANEOUS PNEUMOTHORAX (PSP)PNEUMOTHORAX (PSP)

EpidemiologyEpidemiology Aged-adjusted incidence:Aged-adjusted incidence:

7.4 to 18 cases per 100.000 person-year (men)7.4 to 18 cases per 100.000 person-year (men)**

1.2 to 6 cases per 100.000 person-year1.2 to 6 cases per 100.000 person-year (women)*(women)*

Male predominance 3:1Male predominance 3:1** Age: 20-40 years oldAge: 20-40 years old** Bilateral in 10% of casesBilateral in 10% of cases** Smoking increases the likelihood of PSP up to Smoking increases the likelihood of PSP up to

20 times, (depending on the number of 20 times, (depending on the number of cigarettes smoked dailycigarettes smoked daily**)**)

*Bertrand PC, Ann Thorac Surg 1996, 61:1641-5.*Bertrand PC, Ann Thorac Surg 1996, 61:1641-5.****Bense L et al. Chest 1987, 92:1009–1012.Bense L et al. Chest 1987, 92:1009–1012.

SECONDARY SPONTANEOUS SECONDARY SPONTANEOUS PNEUMOTHORAX (SPP)PNEUMOTHORAX (SPP)

Epidemiology Epidemiology

SECONDARY SPONTANEOUS SECONDARY SPONTANEOUS PNEUMOTHORAX (SPP)PNEUMOTHORAX (SPP)

Epidemiology Epidemiology Age-adjusted incidence Age-adjusted incidence 6.3 cases per 100,000 persons per year (men)6.3 cases per 100,000 persons per year (men)** 2 cases per 100,000 persons per year (women)2 cases per 100,000 persons per year (women)** Older patientsOlder patients It can be life threatening, depending on the It can be life threatening, depending on the

severity of the underlying disease and the size severity of the underlying disease and the size of the pnxof the pnx

Mortality in pts with COPD and SP vary from 1-Mortality in pts with COPD and SP vary from 1-17%.17%.

*Bertrand PC, Ann Thorac Surg 1996, 61:1641-5.*Bertrand PC, Ann Thorac Surg 1996, 61:1641-5.

PRIMARY SPONTANEOUS PRIMARY SPONTANEOUS PNEUMOTHORAXPNEUMOTHORAX

PhysiopathologyPhysiopathology


PhysiopathologyPhysiopathology

BULLAE BULLAE BLEBS have no epithelial lining and arise from BLEBS have no epithelial lining and arise from

rupture of the alveolar wall rupture of the alveolar wall (so-called (so-called emphysema-like changes, ELC)emphysema-like changes, ELC)**

**Donahue DM, et al. Chest 1993;104:1767–9.Donahue DM, et al. Chest 1993;104:1767–9.**Lesur O, et al. Chest 1990;98:341–7.Lesur O, et al. Chest 1990;98:341–7.

ELC are present in the majority of PSP ELC are present in the majority of PSP patients, but they are not always the actual patients, but they are not always the actual site of the air leaksite of the air leak

Air leakage can occur elsewhere at the Air leakage can occur elsewhere at the visceral pleura whether or not ELC are visceral pleura whether or not ELC are present (‘present (‘PLEURAL POROSITY’PLEURAL POROSITY’))

SECONDARY SPONTANEOUS SECONDARY SPONTANEOUS PNEUMOTHORAXPNEUMOTHORAXPhysiopathologyPhysiopathology

SECONDARY SPONTANEOUS SECONDARY SPONTANEOUS PNEUMOTHORAXPNEUMOTHORAXPhysiopathologyPhysiopathology

Every lung disease has been reported to Every lung disease has been reported to be associated with SSP, but COPD is by be associated with SSP, but COPD is by far the most common underlying disorderfar the most common underlying disorder

CT is sometimes necessary to CT is sometimes necessary to differentiate pnx from large thin-walled differentiate pnx from large thin-walled bullaebullae

Baumann MH. et al. Pneumothorax. Respirology 2004, 9:157-164.Baumann MH. et al. Pneumothorax. Respirology 2004, 9:157-164.

SPONTANEOUS SPONTANEOUS PNEUMOTHORAXPNEUMOTHORAX

DiagnosisDiagnosis


DiagnosisDiagnosisErect PA chest x-rayErect PA chest x-ray (inspiration)(inspiration)

Small pneumothoraxSmall pneumothoraxrim of < 2 cm between the lung margin and the chest rim of < 2 cm between the lung margin and the chest wallwall

Large pneumothoraxLarge pneumothoraxrim of rim of >> 2 cm between the lung margin and the chest 2 cm between the lung margin and the chest wallwall

**Wait MA, et al. Am J Surg Wait MA, et al. Am J Surg 1992;164:528–31. 1992;164:528–31. **Tanaka F, et al. Ann Thorac Surg Tanaka F, et al. Ann Thorac Surg 1993;55:372–6.1993;55:372–6.¹¹Engdahl O, et al. Chest Engdahl O, et al. Chest 1993;103:26–9.1993;103:26–9.

CT CT scanning scanning ¹¹

Accurate sizeAccurate size


CT - Chest ImagingCT - Chest Imaging


CT - Chest ImagingCT - Chest ImagingRecommended when :Recommended when :• planning surgery in pts > 40 years oldplanning surgery in pts > 40 years old• aberrant tube placement is suspectedaberrant tube placement is suspected• plain chest radiograph is not clearplain chest radiograph is not clear• during management of a persistent air leakduring management of a persistent air leak• differential diagnosis PTX -complex bullous differential diagnosis PTX -complex bullous

lung diseaselung disease

Henry M. et al. BTS guidelines for the management of Henry M. et al. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58 (Suppl II):ii39–ii52.spontaneous pneumothorax. Thorax 2003;58 (Suppl II):ii39–ii52.


Recurrences after drainage Recurrences after drainage 1st episode1st episode


Recurrences after drainage Recurrences after drainage 1st episode1st episode

• vary from 16–52%, vary from 16–52%, averaging 30%averaging 30%¹¹

• The likelihood of subsequent recurrences seems to The likelihood of subsequent recurrences seems to increase progressively up to 62% for a second increase progressively up to 62% for a second recurrence and 83% for a third recurrencerecurrence and 83% for a third recurrence²²

• Most recurrences occur within 2 years of the initial Most recurrences occur within 2 years of the initial episode episode

¹¹Schramel FM. et al. Eur. Respir. J. 1997; 10: 1372–9.Schramel FM. et al. Eur. Respir. J. 1997; 10: 1372–9.²²Gobbel W. J. Thorac. Cardiovasc. Surg. 1963; 46: 331–Gobbel W. J. Thorac. Cardiovasc. Surg. 1963; 46: 331–45.45.


Management Management 1st episode


Management Management 1st episode• O2 therapy• Bed Rest• Thoracocentesi

s

Chest tube placementChest tube placement



• • Second ipsilateral pneumothoraxSecond ipsilateral pneumothorax• • First contralateral pneumothoraxFirst contralateral pneumothorax• • Bilateral spontaneous pneumothoraxBilateral spontaneous pneumothorax• • Persistent air leak (> 3 - 4 days of tube Persistent air leak (> 3 - 4 days of tube

drainage; air leak or failure to completely re-drainage; air leak or failure to completely re-expand)expand)

• • Spontaneous haemothoraxSpontaneous haemothorax• • Professions at risk (e.g. pilots, divers)Professions at risk (e.g. pilots, divers)

Henry M. et al. Henry M. et al. “BTS guidelines for the management of spontaneous “BTS guidelines for the management of spontaneous pneumothorax”.pneumothorax”. Thorax 2003;58 Thorax 2003;58(Suppl II):ii39–ii52.(Suppl II):ii39–ii52.Baumann MH. et al. Baumann MH. et al. “Pneumothorax”.“Pneumothorax”. Respirology 2004, 9:157-164. Respirology 2004, 9:157-164.

Indications for SURGERYIndications for SURGERY

The great majority of the last reported papers The great majority of the last reported papers favors the minimally invasive VATS approach favors the minimally invasive VATS approach even if, comparing even if, comparing randomized trialsrandomized trials, VATS can , VATS can only be associated with shorter length of only be associated with shorter length of hospital stay or use of pain medication than hospital stay or use of pain medication than thoracotomy with a comparable complication thoracotomy with a comparable complication profile and success rate.profile and success rate.**


VATS vs AXILLARY THORACOTOMYVATS vs AXILLARY THORACOTOMY


VATS vs AXILLARY THORACOTOMYVATS vs AXILLARY THORACOTOMY

* * Sedrakyan A. et al. Sedrakyan A. et al. “Video assisted thoracic surgery for “Video assisted thoracic surgery for treatment of pneumothorax and lung resections: treatment of pneumothorax and lung resections: systematic review of randomized clinical trials”.systematic review of randomized clinical trials”. BMJ BMJ 2004; 329 : 1008.2004; 329 : 1008.

VATS IS OUR APPROACHVATS IS OUR APPROACH



The lung is inspected during gentle The lung is inspected during gentle ventilation with saline in the pleural cavity ventilation with saline in the pleural cavity to detect blebs/bullae and air leakto detect blebs/bullae and air leak

Blebs/bullae are treated by means of Blebs/bullae are treated by means of minimal wedge resection with the minimal wedge resection with the endoscopic stapler (SCB 45)endoscopic stapler (SCB 45)

In cases of minimal air-leak or bleeding In cases of minimal air-leak or bleeding along the suture-line fibrin glue is along the suture-line fibrin glue is employed employed

Talc poudrage is accomplished by Talc poudrage is accomplished by nebulization in the pleural cavity of 2 nebulization in the pleural cavity of 2 grams of asbestos-free sterilized talcgrams of asbestos-free sterilized talc

Overall series 7/1992 – 12/2006Overall series 7/1992 – 12/2006

1316 cases1316 cases**

* * Out of 5003 (26,3%) VATS performedOut of 5003 (26,3%) VATS performed

SPONTANEOUSSPONTANEOUS PNEUMOTHORAX PNEUMOTHORAXSPONTANEOUSSPONTANEOUS PNEUMOTHORAX PNEUMOTHORAX

VATS treatment of Primary Spontaneous PneumothoraxThoracic Surgery

“Carlo Forlanini” Hospital, Rome



TREATMENT OF THE UNDERLYING TREATMENT OF THE UNDERLYING DEFECTDEFECT

– Resection of blebsResection of blebs– Suture of apical perforationsSuture of apical perforations

PLEURODESISPLEURODESIS– Pleural abrasion Pleural abrasion – Partial pleurectomy Partial pleurectomy – Talc poudrageTalc poudrage

DRAIN AIR AND REEXPAND THE LUNGDRAIN AIR AND REEXPAND THE LUNG– Large bore chest tube (20- 24 Fr)Large bore chest tube (20- 24 Fr)

Surgical Options - Key PointsSurgical Options - Key Points



TALC POUDRAGE SHOWS A HIGHERTALC POUDRAGE SHOWS A HIGHER

SUCCESS RATE AND LOWER SUCCESS RATE AND LOWER

MORBIDITY THAN PLEURECTOMYMORBIDITY THAN PLEURECTOMY

(98.21% vs 90.75% / (98.21% vs 90.75% / p: 0.00018p: 0.00018))

Cardillo G. Cardillo G. Ann Thorac Surg 2000; 69: 357-61Ann Thorac Surg 2000; 69: 357-61

Pleurectomy vs Talc poudragePleurectomy vs Talc poudrage

VANDERSCHUEREN’S VANDERSCHUEREN’S CLASSIFICATIONCLASSIFICATION

VANDERSCHUEREN’S VANDERSCHUEREN’S CLASSIFICATIONCLASSIFICATION

STAGE ISTAGE INo endoscopic abnormalitiesNo endoscopic abnormalities

STAGE IISTAGE II

STAGE IIISTAGE III

STAGE IVSTAGE IV

Pleuropulmonary adhesionsPleuropulmonary adhesions

Blebs/bullae < than 2 cmBlebs/bullae < than 2 cm

Bullae > than 2 cmBullae > than 2 cm

SURGICAL PROTOCOLSURGICAL PROTOCOLSURGICAL PROTOCOLSURGICAL PROTOCOL

STAGE ISTAGE I Talc poudrage (TP) onlyTalc poudrage (TP) only

STAGE IISTAGE II

STAGE IIISTAGE III

STAGE IVSTAGE IV

Lysis of all adhesions + TPLysis of all adhesions + TP

Stapling of the blebs/bullae + Stapling of the blebs/bullae + TPTP

Cardillo G.Cardillo G. J Thorac Cardiovasc Surg, 2006; 131:322-8. J Thorac Cardiovasc Surg, 2006; 131:322-8.Cardillo G.Cardillo G. Ann Thorac Surg 2000; 69 : 357-61 Ann Thorac Surg 2000; 69 : 357-61



Surgical protocolSurgical protocol

No evidence for blind No evidence for blind apical stapling in patients apical stapling in patients with no bullae/blebswith no bullae/blebs

Cardillo G. Cardillo G. J Thorac Cardiovasc Surg, 2006; 131:322-8.J Thorac Cardiovasc Surg, 2006; 131:322-8.Cardillo G. Cardillo G. Ann Thorac Surg 2000; 69 : 357-61Ann Thorac Surg 2000; 69 : 357-61

ConcernConcern

Risk of malignancyRisk of malignancy

Respiratory InsufficiencyRespiratory Insufficiency

ARDSARDS

SepsisSepsis

ConcernConcern

Risk of malignancyRisk of malignancy

Respiratory InsufficiencyRespiratory Insufficiency

ARDSARDS

SepsisSepsis

TALC TALC POUDRAGEPOUDRAGE

TALC TALC POUDRAGEPOUDRAGE

SPONTANEOUS PNEUMOTHORAXSPONTANEOUS PNEUMOTHORAXSPONTANEOUS PNEUMOTHORAXSPONTANEOUS PNEUMOTHORAX

VATS TALC POUDRAGEVATS TALC POUDRAGEVATS TALC POUDRAGEVATS TALC POUDRAGE

No increased risk of mesotheliomaNo increased risk of mesothelioma No increased risk of mesotheliomaNo increased risk of mesothelioma

Asbestos-free talcAsbestos-free talcAsbestos-free talcAsbestos-free talc

RISK OF MALIGNANCYRISK OF MALIGNANCY

Cardillo G. Cardillo G. Ann Thorac Surg 2000; Ann Thorac Surg 2000; 69 : 357-6169 : 357-61

Lange P.Lange P. Thorax 1988; 43: 559-561 Thorax 1988; 43: 559-561

TALC POUDRAGETALC POUDRAGETALC POUDRAGETALC POUDRAGE

RESPIRATORY INSUFFICIENCYRESPIRATORY INSUFFICIENCY

In a review of 4030 cases respiratory failure after administration of talc was described in

41(1%)(old, sick and with neoplasm !)

RESPIRATORY INSUFFICIENCYRESPIRATORY INSUFFICIENCY

In a review of 4030 cases respiratory failure after administration of talc was described in

41(1%)(old, sick and with neoplasm !)

Sahn S.A. : “Is talc indicated for pleurodesis? Pro : talc should be used for pleurodesis”.Sahn S.A. : “Is talc indicated for pleurodesis? Pro : talc should be used for pleurodesis”.J Bronchology 2002J Bronchology 2002

Sahn S.A. : “Is talc indicated for pleurodesis? Pro : talc should be used for pleurodesis”.Sahn S.A. : “Is talc indicated for pleurodesis? Pro : talc should be used for pleurodesis”.J Bronchology 2002J Bronchology 2002


RISK OF ARDSRISK OF ARDSRISK OF ARDSRISK OF ARDS

Kennedy L. Chest 1994; Kennedy L. Chest 1994; Campos J.R. Lancet 1997; Campos J.R. Lancet 1997; Rehse D.H. Am J Surg 1999;Rehse D.H. Am J Surg 1999; Rinaldo J.E. J Bronchology 2002; Rinaldo J.E. J Bronchology 2002;

Kennedy L. Chest 1994; Kennedy L. Chest 1994; Campos J.R. Lancet 1997; Campos J.R. Lancet 1997; Rehse D.H. Am J Surg 1999;Rehse D.H. Am J Surg 1999; Rinaldo J.E. J Bronchology 2002; Rinaldo J.E. J Bronchology 2002;

Weissberg D. J Thorac Cardiovasc Surg 1993;Weissberg D. J Thorac Cardiovasc Surg 1993; Cardillo G. Eur J Cardio-thoracic Surg 2002;Cardillo G. Eur J Cardio-thoracic Surg 2002; Viallat J.R. Chest 1996Viallat J.R. Chest 1996

Weissberg D. J Thorac Cardiovasc Surg 1993;Weissberg D. J Thorac Cardiovasc Surg 1993; Cardillo G. Eur J Cardio-thoracic Surg 2002;Cardillo G. Eur J Cardio-thoracic Surg 2002; Viallat J.R. Chest 1996Viallat J.R. Chest 1996

YES (USA/Brazil)YES (USA/Brazil)YES (USA/Brazil)YES (USA/Brazil) NO (EU/Israel)NO (EU/Israel)NO (EU/Israel)NO (EU/Israel)

ARDSARDSARDSARDS


TALC DEPOSITION IN ORGANSTALC DEPOSITION IN ORGANS

• 100% studies from (Brazil)100% studies from (Brazil)• 2% studies from (EU) *2% studies from (EU) *

**Contamination during storage of organsContamination during storage of organs

TALC DEPOSITION IN ORGANSTALC DEPOSITION IN ORGANS

• 100% studies from (Brazil)100% studies from (Brazil)• 2% studies from (EU) *2% studies from (EU) *

**Contamination during storage of organsContamination during storage of organs

Experimental studies in animalsExperimental studies in animalsExperimental studies in animalsExperimental studies in animals

Talc preparation used for pleurodesis varied Talc preparation used for pleurodesis varied markedly from one preparation to anothermarkedly from one preparation to another

Talc preparation used for pleurodesis varied Talc preparation used for pleurodesis varied markedly from one preparation to anothermarkedly from one preparation to another

Ferrer J. Et al.Ferrer J. Et al. “Talc preparation used for pleurodesis “Talc preparation used for pleurodesis vary markedly from one preparation to another” vary markedly from one preparation to another” Chest Chest 20012001

Ferrer J. Et al.Ferrer J. Et al. “Talc preparation used for pleurodesis “Talc preparation used for pleurodesis vary markedly from one preparation to another” vary markedly from one preparation to another” Chest Chest 20012001


The Role of Talc Particle SizeThe Role of Talc Particle SizeThe Role of Talc Particle SizeThe Role of Talc Particle Size

In In rabbitsrabbits damage to lung damage to lung parenchyma occurred when small parenchyma occurred when small size particles were used and not size particles were used and not with large size.with large size.

Ferrer J.Ferrer J. “Influence of particles size on extrapleural talc “Influence of particles size on extrapleural talc dissemination after talc slurry pleurodesis.” dissemination after talc slurry pleurodesis.” Chest 2002Chest 2002

In In rabbitsrabbits damage to lung damage to lung parenchyma occurred when small parenchyma occurred when small size particles were used and not size particles were used and not with large size.with large size.

Ferrer J.Ferrer J. “Influence of particles size on extrapleural talc “Influence of particles size on extrapleural talc dissemination after talc slurry pleurodesis.” dissemination after talc slurry pleurodesis.” Chest 2002Chest 2002

TALC POUDRAGETALC POUDRAGETALC POUDRAGETALC POUDRAGEThe Role of Talc Particle SizeThe Role of Talc Particle SizeThe Role of Talc Particle SizeThe Role of Talc Particle Size

In In humanshumans Maskel and al. demonstrated Maskel and al. demonstrated that pleurodesis with mixed talc that pleurodesis with mixed talc including small size particles worsened including small size particles worsened gas exchange and induced more gas exchange and induced more systemic inflammation than graded talc systemic inflammation than graded talc from which most of the particles from which most of the particles

< 10 mmc were removed.< 10 mmc were removed.

Maskell N.A. et al.:Maskell N.A. et al.: “Randomized trials describing lung inflammation “Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size.”after pleurodesis with talc of varying particle size.” Am J Resp Crit Am J Resp Crit Care Med 2004Care Med 2004

In In humanshumans Maskel and al. demonstrated Maskel and al. demonstrated that pleurodesis with mixed talc that pleurodesis with mixed talc including small size particles worsened including small size particles worsened gas exchange and induced more gas exchange and induced more systemic inflammation than graded talc systemic inflammation than graded talc from which most of the particles from which most of the particles

< 10 mmc were removed.< 10 mmc were removed.

Maskell N.A. et al.:Maskell N.A. et al.: “Randomized trials describing lung inflammation “Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size.”after pleurodesis with talc of varying particle size.” Am J Resp Crit Am J Resp Crit Care Med 2004Care Med 2004

TALC POUDRAGETALC POUDRAGETALC POUDRAGETALC POUDRAGEThe Role of Talc Particle SizeThe Role of Talc Particle SizeThe Role of Talc Particle SizeThe Role of Talc Particle Size


PNEUMOTHORAXPNEUMOTHORAXTALCTALC

2 grams asbestos-free (according to 2 grams asbestos-free (according to EU standards)EU standards)

All particles < 50 All particles < 50 µmµmMedian particle size 25.6 Median particle size 25.6 µmµmSmall particles (< 5 Small particles (< 5 µmµm): 11%): 11%

TALCTALC

2 grams asbestos-free (according to 2 grams asbestos-free (according to EU standards)EU standards)

All particles < 50 All particles < 50 µmµmMedian particle size 25.6 Median particle size 25.6 µmµmSmall particles (< 5 Small particles (< 5 µmµm): 11%): 11%

VATS TALC VATS TALC POUDRAGEPOUDRAGE

Rationale Rationale

VATS TALC VATS TALC POUDRAGEPOUDRAGE

Rationale Rationale Asbestos-free talc European/ Italian Asbestos-free talc European/ Italian PharmacopeiaPharmacopeiaAsbestos-free talc European/ Italian Asbestos-free talc European/ Italian PharmacopeiaPharmacopeia

SIZE UNDERSIZE UNDER PERCENTAGE OF PARTICLESPERCENTAGE OF PARTICLES

20 20 μμmm 78%78%

10 10 μμmm 25%25%

5 5 μμmm 4-5%4-5%


• No risk with standard techniquesNo risk with standard techniques

• According to EU standards Talc must According to EU standards Talc must be sterilized with gamma / be sterilized with gamma / ββ rays rays

• No risk with standard techniquesNo risk with standard techniques

• According to EU standards Talc must According to EU standards Talc must be sterilized with gamma / be sterilized with gamma / ββ rays rays

SEPSISSEPSISSEPSISSEPSIS

TALCTALC

• No oncological risk No oncological risk (absestos-free talc)(absestos-free talc)

• No reported case of ARDS No reported case of ARDS (size of fibers)(size of fibers)

• No reported case of empyema No reported case of empyema (sterilized talc)(sterilized talc)

• Dosage schedule Dosage schedule ((range: 2-10 g)range: 2-10 g)

► ► Safety of Talc In Spont.PnxSafety of Talc In Spont.Pnx (ERS ongoing (ERS ongoing trial)trial)

2g ASBESTOS-FREE STERILIZED

(According to EC Pharmacopeia)

Rinaldo JE: J Thorac Cardiovasc Surg 1983;85:523 Sedrakyan A: BMJ 2004; 329:1008Rinaldo JE: J Thorac Cardiovasc Surg 1983;85:523 Sedrakyan A: BMJ 2004; 329:1008West :West : Curr Opin Pulm Med 2004Curr Opin Pulm Med 2004



J Thorac Cardiovasc Surg, 2006; 131:322-8.J Thorac Cardiovasc Surg, 2006; 131:322-8.

VIDEOTHORACOSCOPIC TALC VIDEOTHORACOSCOPIC TALC POUDRAGEPOUDRAGE

The rationaleThe rationale

VIDEOTHORACOSCOPIC TALC VIDEOTHORACOSCOPIC TALC POUDRAGEPOUDRAGE

The rationaleThe rationale

POSTOPERATIVE POSTOPERATIVE MORBIDITYMORBIDITY

POSTOPERATIVE POSTOPERATIVE MORBIDITYMORBIDITYPostoperative Complications Rate was 3.36%Postoperative Complications Rate was 3.36%

29/861 patients29/861 patients

Localized pleural effusionLocalized pleural effusion 15 15Prolonged air leaks (> than 5 days)Prolonged air leaks (> than 5 days) 9 9Subcutaneous emphysemaSubcutaneous emphysema 33PneumoniaPneumonia 11Transient Bernard Horner syndrome Transient Bernard Horner syndrome 11

#

Postoperative paresthesiaPostoperative paresthesia presented in 114 patients at discharge, presented in 114 patients at discharge,

spontaneously resolved in all patients within 6 spontaneously resolved in all patients within 6 months from surgerymonths from surgery

RESULTSRESULTSRESULTSRESULTS

No postoperative (30 days) deathNo postoperative (30 days) death

No intraoperative complicationsNo intraoperative complications

Mean operative time: Mean operative time: 14 14 ± 8 min± 8 min

Conversion rate: Conversion rate: 0.46% (4/861)0.46% (4/861)

RESULTSRESULTSRESULTSRESULTSMean time to removal of chest tubes: Mean time to removal of chest tubes:

4.7 days (4-10 days)4.7 days (4-10 days)

Mean hospital stay: Mean hospital stay: 5.6 days (4-12 days)5.6 days (4-12 days)

Return Return to occupational to occupational

activityactivity

Within 21 days Within 21 days 65.5% of patients65.5% of patients

Within 30 days Within 30 days 91.3% of patients91.3% of patients

Overall recurrence rate: Overall recurrence rate: 1.73% 1.73% (14/805 pts with follow-up)(14/805 pts with follow-up)

FACTORS INFLUENCING FACTORS INFLUENCING RECURRENCE RATERECURRENCE RATE

FactorsFactors Pts with Pts with recurrence/Total Pts recurrence/Total Pts

(%)(%)

pp

GenderGender MaleMale FemaleFemale

9/541 (1.66%)9/541 (1.66%)5/264 (1.89%)5/264 (1.89%)

0.810.81

Mean age (yrs)Mean age (yrs) Pts without Pts without recurrencerecurrence Pts with recurrencePts with recurrence

28.12 years 28.12 years 29.71 years29.71 years 0.750.75

SmokeSmoke SmokersSmokers No smokersNo smokers

12/471 (2.54%)12/471 (2.54%)2/334 (0.59%)2/334 (0.59%)

0.0370.037

Surgical treatmentSurgical treatment Group A (talc Group A (talc poud.only)poud.only) Group B (stapl+talc Group B (stapl+talc poud)poud)

(7/290) 2.41% (7/290) 2.41% (7/515) 1.35% (7/515) 1.35% 0.270.27

RECURRENCES RATE IN RECURRENCES RATE IN STUDIES OF VATS STUDIES OF VATS

TREATMENT OF PSPTREATMENT OF PSP AuthorAuthor YeaYea

rr## Follow-Follow-

upup(months(months

))

RecurrenRecurrencece

(%)(%)

PleurodesisPleurodesis

CardilloCardillo 20020066

808055

52.552.5 1.731.73 talc talc poudragepoudrage

Ayed Ayed 20020033

101000

4848 22 pleurectomypleurectomy

Gossot Gossot 20020033

111111

36.536.5 3.63.6 pleural pleural abrasionabrasion

Lang-Lang-Lazdunski Lazdunski

20020033

161677

8484 33 pleural pleural abrasionabrasion

Margolis Margolis 20020033

151566

6262 00 cautery + cautery + talc talc

poudragepoudrage

TschoppTschopp 20020022

5959 6060 55 talc talc poudragepoudrage

Cardillo Cardillo 20020000

434322

3838 4.44.4 pleurectomy pleurectomy / talc / talc

poudragepoudrage

Follow up

• Still under evaluation in the light of cost-effectiveness.

• Important to evaluate even minimal recurrences with minor symptoms.

• Follow-up protocol of our Institution:chest x-ray every at 1 month, 3 month, 6 month and every year for 5 years

TALC PLEURODESISTALC PLEURODESIS

Lung Function and Lung Function and Videothoracoscopic Talc Videothoracoscopic Talc

PoudragePoudrageLONG-TERM LUNG FUNCTION FOLLOWING LONG-TERM LUNG FUNCTION FOLLOWING VIDEOTHORACOSCOPIC TALC POUDRAGE VIDEOTHORACOSCOPIC TALC POUDRAGE

FOR PRIMARY SPONTANEOUS RECURRENT FOR PRIMARY SPONTANEOUS RECURRENT PNEUMOTHORAX. PNEUMOTHORAX.

Cardillo G, Carleo F, Carbone L, Di Martino M, Salvadori L, Ricci Cardillo G, Carleo F, Carbone L, Di Martino M, Salvadori L, Ricci A, Petrella L, Martelli M.A, Petrella L, Martelli M.

Eur J CardioThorac Surg. 2007; 31:803-6Eur J CardioThorac Surg. 2007; 31:803-6

From September 1, 1995 to January 31, 2006From September 1, 1995 to January 31, 2006we consecutively enrolled we consecutively enrolled

50 patients with no recurrence50 patients with no recurrenceGROUP AGROUP A

50 patients after simple drainage50 patients after simple drainagefor recurrent PSP for recurrent PSP

GROUP BGROUP B

We evaluated lung function with measurement of We evaluated lung function with measurement of static and dynamic volumes (FEV1, FVC, TLC, RV) andstatic and dynamic volumes (FEV1, FVC, TLC, RV) and

DLCO at 60 months after surgeryDLCO at 60 months after surgery

TALC PLEURODESISTALC PLEURODESIS

Lung FunctionLung Function

Cardillo G. et al. Long-term lung function following Cardillo G. et al. Long-term lung function following videothoracoscopic talc poudrage for primary spontaneous videothoracoscopic talc poudrage for primary spontaneous recurrent pneumothorax. Europ J CardioThorac Surg 2007; recurrent pneumothorax. Europ J CardioThorac Surg 2007; 31:803-631:803-6

TALC PLEURODESISTALC PLEURODESISLung FunctionLung Function

80,0

90,0

100,0

110,0

A B

GROUP

FE

V1

The overall The overall functional status functional status was excellent in was excellent in all patients: no all patients: no single patient single patient

showed FEV1 less showed FEV1 less than 80%, and than 80%, and

the mean values the mean values were over 90% in were over 90% in

all testsall tests Pulmonary function tests showed no statistical Pulmonary function tests showed no statistical

significant difference between group A and group significant difference between group A and group B (p-value): B (p-value): FEV1 (p: 0.07)FEV1 (p: 0.07), FVC (p:0.1), TLC , FVC (p:0.1), TLC

(p:0.06), RV (p:0.07), and DLCO (p: 0.4). (p:0.06), RV (p:0.07), and DLCO (p: 0.4).

Cardillo G. et al. Long-term lung function following Cardillo G. et al. Long-term lung function following videothoracoscopic talc poudrage for primary spontaneous videothoracoscopic talc poudrage for primary spontaneous recurrent pneumothorax. Eur J CardioThorac Surg, recurrent pneumothorax. Eur J CardioThorac Surg, in pressin press



VATSVATS Has been shown to be the Has been shown to be the gold standardgold standard for recurrent for recurrent and complicated Primary Spontaneous Pneumothorax and complicated Primary Spontaneous Pneumothorax as it allows for shorter hospital stay, less pain, and as it allows for shorter hospital stay, less pain, and quicker return to the activities of daily life compared quicker return to the activities of daily life compared to open thoracotomy, which is important in this young, to open thoracotomy, which is important in this young, otherwise healthy, patient population.otherwise healthy, patient population.

TALC PLEURODESISTALC PLEURODESIS has been shown to be a safe procedure which has been shown to be a safe procedure which preservepreserve

lung functionlung function in the long term and do not restrict in the long term and do not restrict chest wall mobility.chest wall mobility.

VATSVATS Has been shown to be the Has been shown to be the gold standardgold standard for recurrent for recurrent and complicated Primary Spontaneous Pneumothorax and complicated Primary Spontaneous Pneumothorax as it allows for shorter hospital stay, less pain, and as it allows for shorter hospital stay, less pain, and quicker return to the activities of daily life compared quicker return to the activities of daily life compared to open thoracotomy, which is important in this young, to open thoracotomy, which is important in this young, otherwise healthy, patient population.otherwise healthy, patient population.

TALC PLEURODESISTALC PLEURODESIS has been shown to be a safe procedure which has been shown to be a safe procedure which preservepreserve

lung functionlung function in the long term and do not restrict in the long term and do not restrict chest wall mobility.chest wall mobility.

CONCLUSIONSCONCLUSIONS

QUESTIONNAIREQUESTIONNAIRE QUESTIONNAIREQUESTIONNAIRE 1) Which is the best treatment for a small primary spontaneous pneumothorax (PSP) ? and for a small secondary spontaneous pneumothorax (SSP) ?

2)In PSP when there is a need for surgery ?

For a small PSP bed rest is a good option; pleural drainage being the standard treatment .

For SSP pleural drainage is almost always indicated.

In recurrent PSP or when there is a failure of primary standard treatment

(pleural drainage)3)What do you suggest for Haemopneumothorax ?

Surgery

QUESTIONNAIREQUESTIONNAIRE QUESTIONNAIREQUESTIONNAIRE 4)Which is the favoured treatment for SP ?

5)which is the aim of thoracoscopy ?

Videothoracoscopy, even if randomized study have only showed that VATS can only be

associated with shorter length of hospital stay or use of pain medication than thoracotomy with a

comparable complication profile and success rate, and obvious better cosmetic result.

To treat the bullae if present and to perform a pleurodesis

6)Which are the option for pleurodesis ?

Pleurectomy, Pleural abrasion , and Talc poudrage

QUESTIONNAIREQUESTIONNAIRE QUESTIONNAIREQUESTIONNAIRE 7)Which are the drawbacks of each technique ?

8)Which technique seems to be more useful in the light of the recent data ?

Pleurectomy and pleural abrasion: bleedingTalc poudrage: no well defined complication

Talc poudrage

9)What’s about the concern for the use of talc poudrage in young patients?

The published data do not support any concern for the use of talc poudrage.

10)Is there any relationship between smoking and recurrence ?

Yes

236.ppt

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