VATS- Talc pleurodesis is an indicated procedure for patients that have malignant pleural effusions and recurrent pneumothorax. In patients diagnosed with malignant pleural mesothelioma, pleural effusions have been reported to be present in up to 90% of the patients.
Video-assisted thoracic surgery, commonly referred to as a VATS procedure, is a minimally invasive surgical technique used to treat and diagnose a number of conditions and diseases in the chest -thoracic region. This type of surgery involves using two small- less than 1-inch incisions. Through one incision is the video camera and through the second incision the instruments that the doctor is operating with. There is also a newer type of scope that allows for one incision with the instruments going through an opening in the scope. Some of the conditions it is used for include diagnosis of lung cancer, esophageal cancer and hiatal hernia repair. Minimally invasive refers to the incisions being small as compared to traditional open surgery that open the area that the surgery is taking place. VATS procedures can lessen healing time post procedure and potentially result in a shorter hospital stay and a less painful recovery.
The beginnings of minimally invasive surgery were in the 1940’s with the development of “Waldoes”. By using cables and linkages with remote manipulators it was found that hazardous materials could be moved without any direct human contact involved. In the 1950’s the first telepresence robotic arm was developed. Telepresence is a technology such as virtual reality technology that allow the surgeon to perform the surgery through the scopes. In the 1980’s with major advancements in microelectronics and computing there was also advancement in the medical area. The first laparoscopic cholecystectomy was performed in 1987 by a French physician Dr. Philippe Mouret. During the 1990’s the procedure gained popularity but was not used for any complicated procedures. It has been used successfully for thoracic procedures since the early 1990’s. As robotics advanced and computers progressed VATS surgery gained in popularity. By combining computers and robotics, complicated procedures are now being performed. Currently VATS procedures need to be performed by an experienced surgeon who has specifically trained in this minimally invasive technique.
“Pleurodesis – The creation of fibrous adhesion between the visceral and parietal layers of the pleura, obliterating the pleural cavity: it is performed surgically by abrading the pleura or by inserting a sterile irritant into the pleural cavity in cases of recurrent spontaneous pneumothorax, malignant pleural effusion, and chylothorax.” (Medical Dictionary for the Health Professions and Nursing @Farlex 2012). Pleuradesis are performed to remove all fluid in the pleural space, between the visceral and parietal layers.
In 1910 an internist Hans-Christian Jacobsen was the first to replace fluid with air in the pleural surfaces of two patients with tuberculosis. In the 1950’s pleurodesis was primarily used for tuberculosis treatment for pleural and pulmonary biopsies for diffuse lung disease. Thorascopy was a procedure used to replace fluid with air. Thorascopy is a process in which a small tube, a thorascope, is fixed to a camera and introduced into the chest through tiny incisions in the skin layer through intercostal space. The procedure is usually performed under general anesthesia; the surgeon makes 2 small incisions about an inch long between the ribs and inserts special surgical instruments to perform the procedure. Thoracoscopy evolved into video-assisted thoracic surgery.
Once the fluid is drained chemicals are inserted to start an inflammatory reaction that will help adhere the lung to the inner layer of the rib cage. Sterile medical grade talc is often used. It was first used for talc pleurodesis in 1935. The chemicals that are used talc have a 90-96% success rate, doxycline has around 90%. The goal of the procedure is to form scar tissue and permanent adhesions, so there is no place for the fluid to collect. In the United States talc/pleurodesis comes in two forms- a sterile talc powder and as a talc aerosol canister. Talc/ pleurodesis can be indicated before many thoracentesis procedures are performed on the individual as it may limit the success of the procedure.
The success rate for talc pleurodesis is generally around 90%. The most common post op side effects are fever 10-17% of the time, pain, and GI symptoms. Less common side effects include arrhythmias, dyspnea, respiratory failure, empyema. A rare reaction to the procedure can cause a systemic inflammatory response, this can lead to respiratory failure. It is thought that this is due to the systemic absorption of talc particles.
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