The diminishing role of surgery in pleural disease

Our plain-English summary of The diminishing role of surgery in pleural disease, by H.E. Davies, A. Rosenstengel, Y.C. Lee (Current Opinion in Pulmonary Medicine, 2011).

The study

• Authors: H.E. Davies, A. Rosenstengel, Y.C. Lee
• Journal: Current Opinion in Pulmonary Medicine
• Published: 2011;17(4):247-54
• Type of article: Review
• Cited by: 18 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Purpose Of Review: Pleural disease is common. Traditionally, many patients were subjected to surgery for diagnosis and treatment. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal and their use is based on anecdotal series with selection bias. The evidence (or the lack) of benefits of surgery in common pleural conditions is reviewed.

Recent Findings: Recent studies do not support the routine therapeutic use of surgery in patients with malignant pleural effusions, empyema or mesothelioma. Four randomized studies have failed to show significant benefits of thoracoscopic poudrage over bedside pleurodesis. Surgery as first-line therapy for empyema was studied in four randomized studies with mixed results and no consistent benefits. Cumulative evidence suggests that radical surgery in mesothelioma, especially extrapleural pneumonectomy, is not justified. Advances in imaging modalities and histopathological tools have minimized the need for surgery in the workup of pleural effusions. Complications associated with surgery are increasingly recognized.

Summary: Surgery has associated perioperative risks and costs, and residual pain is not uncommon. Many conventional pleural surgeries have not been assessed in randomized studies. Pulmonologists should be aware of the evidence that supports surgical interventions, or the lack of it, in order to make informed clinical decisions and optimize patient care.

In plain English

This article was a review, not a new study. The authors looked at published evidence on surgery for common pleural diseases: diagnosing pleural effusions, pleural infection (empyema), malignant pleural effusions, malignant pleural mesothelioma, chylothorax and pneumothorax. The article does not discuss asbestos exposure. The authors reported that no randomized trial to date had shown a benefit of thoracoscopic talc poudrage over bedside chemical pleurodesis. In the largest such trial, by Dresler and colleagues, success rates were similar (75%) at 30 days. They wrote that randomized trials of early surgery for empyema showed no major advantage, for example on mortality. For mesothelioma, they cited perioperative mortality of about 4% for extrapleural pneumonectomy even in the most experienced centers. They also cited a retrospective series by Flores and colleagues: median survival was 14.3 months after extrapleural pneumonectomy (208 patients), 15.8 months after pleurectomy/decortication (176 patients), and 12.7 months after exploratory thoracotomy that found inoperable disease (174 patients). The authors concluded that radical surgery in mesothelioma, especially extrapleural pneumonectomy, is not justified.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Narrative review of published studies on surgery in pleural disease
• Who was studied: No new patients were studied. The review covered published studies of patients with pleural effusions, pleural infection/empyema, malignant pleural effusions, malignant pleural mesothelioma, chylothorax and pneumothorax.
• Exposure: Surgical and less invasive procedures for pleural disease: thoracotomy, video-assisted thoracoscopic surgery (VATS), pleuroscopy, thoracoscopic talc poudrage versus bedside talc slurry, extrapleural pneumonectomy (EPP), and pleurectomy/decortication. No asbestos or fiber exposure was studied.
• Main results:
  • Malignant pleural effusion: according to the authors, no randomized trial had shown a benefit of thoracoscopic talc poudrage over bedside chemical pleurodesis.
  • In the Dresler et al. trial of talc poudrage versus talc slurry, success rates were similar (75%) at 30 days.
  • Empyema: in four randomized trials comparing first-line VATS with conservative treatment, no major advantage (for example on mortality) was documented for early surgery.
  • Mesothelioma: perioperative mortality after extrapleural pneumonectomy was approximately 4% even in the most experienced centers (Sugarbaker et al.).
  • Flores et al. retrospective series: median survival was 14.3 months after EPP (n = 208), 15.8 months after pleurectomy/decortication (n = 176), and 12.7 months after exploratory thoracotomy with inoperable disease (n = 174).
  • MARS trial: of 300 patients referred as potentially suitable, only 50 were eligible and randomized.
  • Diagnosis: pooled case series of pleuroscopy showed a diagnostic sensitivity for malignant pleural disease of 92.6% (95% confidence interval 91.0% to 93.9%).
  • Furrer et al. reported chronic intercostal neuralgia (persistent pain) in up to 44% of patients at 6 months after thoracotomy.
• The authors' conclusion: The authors concluded that randomized studies had not shown a significant advantage for surgery in pleural infection, malignant effusions and mesothelioma, and that radical surgery in mesothelioma, especially extrapleural pneumonectomy, is not justified.
• Limitations the authors state:
  • The authors noted that most pleural surgical procedures have not been subjected to high-quality clinical appraisal or randomized studies.
  • The authors stated that claims of improved long-term survival after EPP are almost certainly a result of selection bias.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Selection Bias, Pleural Effusion, Empyema, Mesothelioma, Pleurodesis, First-line Therapy, Extrapleural Pneumonectomy (EPP).

Related studies

• Benign asbestos pleural diseases — S.J. Chapman, W.O. Cookson, et al. (2003)
• Asbestos-related pleural disease in Western Australian gold-miners — Y.C. Lee, N.H. De Klerk, et al. (1999)
• Cytoreductive surgery and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience — M. Migliore, D. Calvo, et al. (2015)
• Diagnosis and initial management of nonmalignant diseases related to asbestos — American Thoracic Society (2004)
• Asbestos-related pleural disease and asbestosis: a comparison of CT and chest radiography — A.C. Friedman, S.B. Fiel, et al. (1988)
• Asbestos content of lung tissue in asbestos associated diseases: a study of 110 cases — V.L. Roggli, P.C. Pratt, et al. (1986)

Browse more research in Current Opinion in Pulmonary Medicine, or return to medical research.