ABSTRACT
Pleural effusions are common during the course of malignant disease, with 16% of patients dying of malignancy found at autopsy to have a pleural effusion. Carcinomas of the lung and breast combined account for 60% of all malignant pleural effusions. These effusions can cause significant morbidity, including dyspnea in 96%, chest pain in 57%, and persistent cough in 44% of patients (1). At the same time, the prognosis for patients with malignant pleural effusions is very poor, with reported 1-and 6-month mortality rates of 54% and 85%, respectively (2, 3), so that quality of life is of paramount importance. Since dyspnea in patients with advanced malignancy is often multifactorial, an initial needle aspiration will confirm diagnosis in 65% of patients, but will also help define to what extent the pleural effusion itself is responsible for the symptoms. In frail patients with very short life expectancy of 1-2 months, repeated needle aspiration can be helpful to control symptoms. In the majority of patients with recurrent symptomatic malignant effusions, lasting palliation can be achieved by one of the spectrum of techniques used to achieve chemical pleurodesis, commonly by a tube thoracostomy or video-assisted thoracoscopy under general anaesthesia for the fitter patients. The basic prerequisite for a successful chemical pleurodesis by any technique is that the lung can reexpand following drainage of the pleural effusion, so that the visceral and parietal pleura can remain apposed while adhesions are formed. However, the presence of a malignant restricting cortex on the visceral pleura prevents reexpansion of the lung and apposition to the parietal pleura. The presence of such a trapped lung (Figs. 1-3) means that any attempt at chemical pleurodesis is destined to fail. The treatment options in these circumstances are very few, and most are unattractive. Repeated aspirations require frequent hospitalization and are painful-both detrimental to quality of life of the patients. Furthermore, they carry the risk of the devastating complication of infection of the fluid and empyema formation. This is the major concern, which also limits the popularity of permanent chest drain devices like PleurX®. Thoracotomy and decortication of the lung, combined with chemical pleurodesis or pleurectomy involves major surgery with very significant morbidity and mortality, unacceptable for a palliative procedure (4). In contrast, pleuro-peritoneal shunts provide an elegant, effective, and lasting
solution to this difficult problem and can be used with minimal morbidity and mortality in properly selected patients (Tables 1, 2).
