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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 68  |  Issue : 3  |  Page : 383-389

Preparation for minithoracoscopy by percutaneous pigtail catheter insertion for difficult pleural effusion cases


Department of Chest Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission05-Aug-2018
Date of Acceptance26-Sep-2018
Date of Web Publication4-Sep-2019

Correspondence Address:
MD degree of chest diseases Mohamed El- Shabrawy
Department of Chest Medicine, Faculty of Medicine, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejcdt.ejcdt_116_18

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  Abstract 


Background Pigtail catheters are flexible tubes that can be inserted into the body to drain pleural effusions in a less invasive manner. Minithoracoscopy is a part of the general evolution of endoscopy toward mini-invasiveness to fasten the management of small pleural effusions or patients with narrow intercostal spaces.
Objective The aim of this study is to evaluate the ease and safety of the use of a minithoracoscope after the preparation of certain cases by pigtail catheter insertion.
Patients and methods This study was carried out at the Chest Department of Zagazig University Hospitals in the period from March 2017 to July 2018. It included 20 patients with pleural effusion of undiagnosed etiology; all of them signed a written consent to publish the findings of their cases. Some had massive effusion with hypoxemia, some had massive effusion with dyspnea or cough, some had mild effusion with or without loculations, some had poor general health, one was a Kyphoscoliotic patient, and others had platelet counts of 45 000. In the aforementioned patients, an assessment of their medical history was performed and clinical examination, routine laboratory investigations, plain chest radiograph, ultrasonography, computed tomography of the chest, tuberculosis assessment, and a pleural fluid analysis were carried out. If the etiology was still unknown, pigtail catheter insertion by the modified Seldinger technique and minithoracoscopy were carried out.
Results Twenty patients were examined: 12 men and eight women, mean age 58.4±13.1 years. Overall, 55% of these patients were smokers and 80% had comorbidities; the most common comorbidity was diabetes mellitus 60%. Four (20%) patients had massive pleural effusion with hypoxemia, six (30%) patients had massive pleural effusion with dyspnea and or cough, five (25%) patients had mild effusion with loculations, two (10%) patients had poor general health, two (10%) patients had a count of 45 000, and one (5%) patient had Kyphoscoliosis. Dyspnea was the most common symptom encountered among the studied patients, at 70%, followed by chest pain, at 60%, and cough, at 45%. The histopathological results of thoracoscopic pleural biopsies were as follows: six (30%) patients had metastatic adenocarcinoma, seven (35%) patients had mesothelioma, three (15%) patients had tuberculous pleuritis, two (10%) patients had empyema, and the other two (10%) patients had nonspecific pleuritis. The average length of hospital stay was 6.6±7 days, and the duration of drainage after the procedure was 2.8±1.4 days. However, post-thoracoscopic complications occurred in four (20%) patients, surgical emphysema in one (5%) patient, bleeding during the procedure in one (5%) patient, and failure of re-expansion in two (10%) patients.
Conclusion Minithoracoscopes can be considered revolutionary equipment in standard medical thoracoscopy as they can be applied safely after pigtail insertion, making patients’ conditions more stable and ensuring safe introduction in difficult and inaccessible cases of effusions by the standard procedure; furthermore, they are well tolerated by patients with narrow intercostal spaces.

Keywords: medical thoracoscopy, pigtail catheters, pleural effusion


How to cite this article:
El- Shabrawy M, Elhawary A. Preparation for minithoracoscopy by percutaneous pigtail catheter insertion for difficult pleural effusion cases. Egypt J Chest Dis Tuberc 2019;68:383-9

How to cite this URL:
El- Shabrawy M, Elhawary A. Preparation for minithoracoscopy by percutaneous pigtail catheter insertion for difficult pleural effusion cases. Egypt J Chest Dis Tuberc [serial online] 2019 [cited 2019 Oct 15];68:383-9. Available from: http://www.ejcdt.eg.net/text.asp?2019/68/3/383/265970




  Introduction Top


Pleural diseases continue to affect a large population of patients worldwide. Pleural fluid analysis and radiology including chest ultrasonography are among the important steps in the management of pleural effusions. When a diagnosis cannot be made, open thoracotomy and thoracoscopy should be considered. However, the advances in medicine and medical instruments make medical thoracoscopy (MT) a routine procedure in the management of diseases of the pleura [1].

MT is generally a safe and well-tolerated procedure, with rare mortality. There are, however, a few contraindications to MT. Absolute contraindications to thoracoscopy are an inaccessible pleural space with dense adhesions, inability to tolerate partial or complete unilateral collapse of the lung, comatosed or unresponsive patient, shock, respiratory failure or cardiac arrest, and a markedly unstable patient. Other factors that can make the thoracoscopic approach difficult or risky are obesity or increased thickness of the chest wall, uncontrolled cough, narrow rib spaces, unable to lie flat for a minimum of 1 h, a small chest, or underlying conditions associated with increased bleeding [2].

A pigtail catheter is a long, flexible tube that can be inserted easily into the pleural cavity. The design of this catheter includes small holes that enable an effective and safe method of draining pleural fluid. We can also control the amount of drained fluid per time (each time of evacation when needed) [3],[4].

There are relative contraindications and or difficult cases of pleural effusions such as those that are too small for an endoscopic examination with a standard thoracoscope. To overcome these situations, minithpracoscopy can be used as; it is a minimally invasive technique with smaller telescopes designed for laparoscopy. The term minithoracoscopy has been chosen to emphasize the minimally invasive nature of the procedure [5].

Therefore, the aim of this study was to evaluate the ease and safety of the minithoracoscopic procedure after preparation by pigtail catheter insertion in certain cases.


  Patients and methods Top


The current work is a prospective randomized study that was carried out at the Chest Department of Zagazig University Hospitals in the period from March 2017 to July 2018. The number of institutional review board (5017). The study was carried out on 20 patients with pleural effusion of undiagnosed etiology after a definitive diagnosis by thoracocentesis failed.

Patients

Some patients had massive effusion with hypoxemia, some had massive effusion with dyspnea or cough, some had mild effusion with or without loculations, some had poor general health, one was a Kyphoscoliotic patient, and others had a platelet count of 45.000. Any Included patients would undergo thoracoscopy.

The patients who had any of the following criteria were excluded:
  1. No pleural space.
  2. Sonographically complex septated effusion.
  3. Bleeding disorder.
  4. Unstable cardiovascular patients with acute coronary syndrome or uncontrolled arrhythmias.
  5. Patient who were hemodynamically unstable.
  6. Severe chronic obstructive pulmonary disease [hypoxemia (PaO2<60 mmHg) and hypercapnia (PaCo2>50 mmHg)].
  7. Uncontrolled diabetes or hypertension.
  8. Recent history of chest trauma or proved hemothorax [6].


Methods

The patients included were subjected to the following:
  1. Informed signed consent was obtained from all patients eligible to participate in this study.
  2. Detailed assessment of history and a full clinical examination.
  3. Routine laboratory investigations: complete blood picture, erythrocyte sedimentation rate, liver function and kidney function test, prothrombin time and concentration and partial thromboplastin time, fasting, and 2 h postprandial blood glucose.
  4. Tuberculin skin test by Mantoux maneuvers.
  5. Radiology:
    1. Plain chest radiography: posteroanterior and lateral views.
    2. Chest ultrasonography: this should be done in all patients, with identification of septations, localization of site, and assessment of fluid echogenicity and diaphragmatic motility (Samsung Medison Sono Ace R3 Ultrasound System, Pangyoyeok-ro, Bundang-gu,Seongnam-si, Gyeonggi-do, Republic of Korea).
    3. Conventional contrast enhanced computed tomography: this was done in all patients. The pleural fluid was considered small, moderate, or massive according to BTS guidelines for the investigations of pleural effusion [7] .
  6. Pleural fluid aspiration (pleural fluid was aspirated from the patients and sent for full chemical, bacteriological, and repeated cytological analyses).
  7. Pigtail catheter insertion: the modified Seldinger technique was used for percutaneous pigtail insertion (Dawson-Mueller Drainage Catheters; Cook Medical Interventional Radiology, UK) had the size of 8.5–14 Fr (2.8–4.7 mm in diameter). All procedures were performed by ultrasonic guidance under local anesthesia with 3–6 ml of lidocaine 2%. The site of catheter insertion was determined according to ultrasound findings, and was usually in the mid-axillary line.

    The pleura was initially punctured just above the top of the lower rib to avoid injury to the intercostal neurovascular bundle with a hollow needle trocar attached to a syringe; fluid was aspirated to confirm that the distal end of the needle was well inside the pleural space. The syringe was removed and a guide wire was advanced through the needle lumen. A dilator was passed over the guide wire to widen the opening and create adequate tract through which the catheter would be placed. Next, the dilator was removed, the pigtail was uncoiled, and the catheter was threaded over the guide wire and into the pleural space. Finally, the guide wire was removed as the distal end of the catheter curled inside the chest in such a way that the side holes were well within the pleural space [8].
  8. Thoracoscopic examination of the pleural space.


The minithoracoscope used in this study was TEKNO (Tuttlingen, Germany), which consists of a blind tip trocar, an obturator, an optical telescope, a light source, biopsy forceps, and a suction catheter [6]. The length of the thoracoscope was 22 cm, outer diameter 7 mm. The procedures were carried out in the endoscopy unit using completely aseptic techniques by conscious sedation, which was achieved by intravenous midazolam (Midathetic ampoule; Amoun, Egypt, First industrial zone, Elobour city, Qalubia) with a loading dose of 0.01–0.05 mg/kg. All patients received supplemental oxygen through the nasal cannulae. Oxygen saturation, pulse rate, and blood pressure were monitored continuously throughout the procedure. During the thoracoscopic intervention, the patients were kept in the lateral decubitus position with the affected side upwards. Local anesthesia (2% lignocaine) was administered to the skin, subcutaneous tissue, muscle, and parietal pleura. The portal of the entry was determined previously at the site of entry of the pigtail, just enlarging it with a scalpel. Often, there was no need for blunt dissection as the rigid trocar was introduced through the tract of the pigtail with ease. Pleural fluid was then sucked while air was allowed to enter the pleural space. A thorough examination of the pleural cavity was then performed. Four to six pleural biopsies were obtained from the parietal pleura, particularly where it appeared abnormal. A chest tube was introduced through the entry site at the end of the procedure. A follow-up chest radiograph was subsequently asked to check the position of the chest tube and pick up lung expansion.

The end point of the study was either, there was a need for another intervention or the Therefore, the chest tube was removed as soon as full lung expansion was achieved when amount of pleural fluid drained less than 100 ml/day [9].

Statistical analysis

All data were collected, tabulated, for statistical analysis using the statistical package for the social sciences (version 19; SPSS Inc., Chicago, Illinois, USA). The results of this study were analyzed and presented as numbers and percentages or mean±SD [10].


  Results Top


The current work reviewed our experience with 20 patients, 12 men and eight women, mean age 58.4±13.1 years, who had undergone pigtail catheter insertion for special cases of pleural effusion to overcome some difficulties in facilitating a minithoracoscopic intervention over a 16-month period. Overall, 55% of these patients were smokers and 80% had comorbidities; the most common comorbidity was diabetes mellitus, 60% ([Table 1]).
Table 1 Demographic data of the patients studied

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Four (20%) patients had massive pleural effusion with hypoxemia, six (30%) patients had massive pleural effusion with dyspnea and or cough, five (25%) patients had mild effusion with loculations, two (10%) patients had poor general health, two (10%) patients had a platelet count of 45 000, and one (5%) patient had Kyphoscoliosis ([Figure 1]).
Figure 1 Different types of patients studied.

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Dyspnea was the most common symptom encountered among the studied patients, at 70%, followed by chest pain, at 60%, and cough, at 45% ([Figure 2]).
Figure 2 Clinical data among the patients studied.

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The histopathological results of thoracoscopic pleural biopsies were as follows: six (30%) patients had metastatic adenocarcinoma, seven (35%) patients had mesothelioma, three (15%) patients had tuberculous pleuritis, two (10%) patients had empyema, and the other two (10%) patients had nonspecific pleuritis ([Table 2]).
Table 2 Diagnostic yield of procedure

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In the studied group, there were different sonograghic amounts of fluid after pigtail insertion and before the minithoracoscopic procedure. Six (30%) patients had pleural volume fluid less than or equal to 1500 ml, five (25%) had pleural volume fluid 1500–3000 ml, and nine (45%) had pleural volume fluid more than 3000. The average length of hospital stay was 6.6±7 days, and the duration of drainage after the procedure was 2.8±1.4 days. However, post-thoracoscopic complications occurred in four (20%) patients, surgical emphysema in one (5%) patient, bleeding during the procedure in one (5%) patient, and failure of re-expansion in two (10%) patients ([Table 3] and [Figure 3]).
Table 3 Clinical data of patients

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Figure 3 (a) Radiography performed after left pigtail catheter insertion showed the catheter in place, (b) pigtail catheter before its removal in the endoscopy room, and (c) thoracoscopic view showing a parietal pleural nodule.

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  Discussion Top


Minithoracoscopy is part of small-caliber endoscopies that used for mini-invasive procedures to reduce trauma, which is an important advantage that is especially notable in different inaccessible cases such as patients with narrow intercostal spaces or small chests and those with small loculated effusions [11].

Minithoracoscopy is a safe procedure, and most of its complications can be avoided by a proper and careful selection of patients. Cough, fever, hypoxemia, inability to lie flat for a minimum of 1 h, and infection are relative contraindications for thoracoscopy; therefore, medical treatment should be considered before the procedure is scheduled. Also, coagulation defects should be corrected before thoracoscopy [12].

Development of a pigtail catheter is a potentially less traumatic bedside maneuver alternative to the traditional techniques; the catheters are easy to place even in critically ill patients. The pigtail catheters are very effective in draining different types of pleural effusions. Furthermore, they were successful in draining blood, air, or empyema [13].

Therefore, the aim of this study was to evaluate the ease and safety of minithoracoscopic procedure after preparation by pigtail catheter insertion in certain cases.

Twenty patients were examined: 12 men and eight women, mean age 58.4±13.1 years, who had undergone pigtail catheter insertion for special cases of pleural effusion to overcome some difficulties to facilitate a minithoracoscopic intervention. Overall, 55% of these patients were smokers and 80% had comorbidities; the most common comorbidity was diabetes mellitus, 60% ([Table 1]).

Four (20%) patients had massive pleural effusion with hypoxemia, six (30%) patients had massive pleural effusion with dyspnea and or cough, five (25%) patients had mild effusion with loculations, two (10%) patients had poor general health, two (10%) patients had a platelet count of 45 000, and one (5%) patient had Kyphoscoliosis ([Figure 1]).

In agreement with Liang et al. [14], who studied (n=33, 25%) critically ill patients with massive pleural effusion, Light et al. [15] concluded that drainage of pleural effusions may improve hypoxemia by allowing re-expansion of collapsed lung, which proceeds variably over the subsequent 24 h and may continue for many weeks. Also, Talmor et al. [16] reported a significant improvement in oxygenation with thoracentesis by preselecting patients for study who had pleural effusion and hypoxemia.

Estenne et al. [17] concluded, in their study of spontaneously breathing patients, that maximal inspiratory pressure is markedly increased immediately after thoracentesis, suggesting that diaphragmatic function might be impaired in the presence of a pleural effusion. They attributed the significant relief of dyspnea reported by patients after thoracentesis to improved diaphragm mechanics.

In a study by Wang et al. [18], a significantly greater improvement was observed in dyspnea and cough after thoracentesis, which was explained by presence of paradoxical motion of the diaphragm in patients with pleural effusions.

In this study, dyspnea was the most common symptom encountered among the studied patients, at 70%, followed by chest pain, at 60%, and cough, at 45% ([Figure 2]). This was in agreement with the findings of a study by Law et al. [9] and Prabhu and Narasimhan [19], who concluded that dyspnea was the main complaint of the pleural effusion patients that they studied.

In terms of the histopathological results of thoracoscopic, pleural biopsies were as follows: six (30%) patients had metastatic adenocarcinoma, seven (35%) patients had mesothelioma, three (15%) patients had tuberculous pleuritis, two (10%) patients had empyema, and the other two (10%) patients had nonspecific pleuritis ([Table 2]).

These results were close to those obtained in several other studies, in which malignancy was the final diagnosis of most patients with pleural effusion, such as in studies by Mootha et al. [20], Helala et al. [21], Mohamed and Shaban [22], and Ali et al. [23], where malignant pleural effusion was present in 73, 70, 74.4, and 83.9% of patients, respectively.

Among the patients with malignant pleural effusion, mesothelioma (n=7 patients, 35%), followed by metastatic adenocarcinoma was encountered in (n=6 patients, 30%). These results were in agreement with those of Ali et al. [23] and Mohamed and Shaban [22], who reported that most cases of malignant pleural effusion were diagnosed as mesothelioma (54.9 and 47%, respectively), followed by adenocarcinoma (14.1 and 22.2%, respectively). However, this was not consistent with the findings of Mootha et al. [20] and Prabhu and Narasimhan [19], who reported that the most common pleural malignancy among the patients studied was adenocarcinoma (20 and 22%).

Among our studied patients, there was no mortality. However, there were different sonograghic amounts of fluid after pigtail insertion and before the minithoracoscopic procedure. Six (30%) patients had pleural volume fluid less than or equal to 1500 ml, five (25%) had pleural volume fluid 1500–3000 ml, and nine (45%) had pleural volume fluid more than 3000. The average length of hospital stay was 6.6±7 days, and the duration of drainage after the procedure was 2.8±1.4 days. However, post-thoracoscopic complications occurred in four (20%) patients, surgical emphysema in one (5%) patient, bleeding during the procedure in one (5%) patient, and failure of re-expansion in two (10%) patients ([Table 3]).MT is a tolerable and safe technique, with a very low mortality rate. In 2010, the BTS Pleural Disease Guideline reported an overall mortality of 0.34%. In many studies that used MT as a diagnostic procedure, the mortality rate was 0%. However, therapeutic MT with talc poudrage had a mortality rate of 0.69%; thus, this approach was safe, minimally invasive, and efficient [24],[25].

Very similar results, in terms of the length of hospital stay and duration of chest tube drainage, were reported by Cassina et al. [26] and Hornik et al. [27].

The results of many studies were in agreement with the above-mentioned results. Mohamed and Shaban [22] reported no mortality and no major complications in their work; however, some minor complications were reported by them such as subcutaneous emphysema (two patients), prolonged air leak (one patient), wound infection (11 patients), and empyema (11 patients). Also, Shawgo [28] concluded that minor complications may be present after MT such as subcutaneous emphysema (5.3%), fever (3.6%), and residual pneumothorax (8.3%).

In this study, pigtail catheters facilitate and overcome different obstacles such as draining of massive effusion to relieve hypoxemia and intractable cough. Also, they created safe tracts in mild effusion and kyphoscoliotic patients. After ensuring a secure entrance, minithoracoscopy, because of its small size, does not cause pressure pain against the chest wall. This advantage is especially notable in patients with narrow intercostal spaces or small chests, thus leading to better tolerance [29].


  Conclusion Top


Minithoracoscopes can be considered revolutionary equipment in standard MT as they can be applied safely after pigtail insertion, making patients’ conditions more stable and enabling safe introduction in difficult and inaccessible cases of effusions by the standard procedure; furthermore, they are well tolerated by patients with narrow intercostal spaces.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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