What are the reasons why Video-Assisted Thoracic Surgery (VATS) with pleurodesis may not prevent pleural effusion reaccumulation?

Reasons Why VATS with Pleurodesis May Not Prevent Pleural Effusion Reaccumulation

The primary reason VATS with pleurodesis fails to prevent pleural effusion reaccumulation is the presence of large diaphragmatic defects that require surgical repair rather than pleurodesis alone. 1

Main Causes of Pleurodesis Failure After VATS

Anatomical Factors

• Large diaphragmatic defects that cannot be adequately addressed by pleurodesis alone require direct surgical repair 1
• Incomplete visualization of the entire pleural surface during VATS, especially when performed under local anesthesia, may result in missing areas requiring treatment 1
• Trapped lung or incomplete lung expansion prevents apposition of the pleural surfaces, making pleurodesis ineffective 1
• Mainstem bronchial occlusion can prevent adequate pleurodesis 1

Technical Factors

• Suboptimal technique during the procedure, including inadequate talc distribution or insufficient mechanical abrasion 1
• Less intense pleural inflammatory reaction induced by VATS procedures compared to open thoracotomy, resulting in less effective pleurodesis 1
• Use of single-agent pleurodesis rather than combination approaches (mechanical plus chemical) which have lower recurrence rates (10% vs 33%) 1
• Inappropriate patient selection for the procedure 1

Patient-Related Factors

• Female gender is associated with higher treatment failure rates 1
• Patients with polycystic kidney disease have higher failure rates when treated for pleuro-peritoneal leaks 1
• Early leaks (occurring within 30 days of initiating peritoneal dialysis) are more difficult to treat successfully 1
• Presence of a cortex of malignant tissue covering the pleural surfaces can prevent effective pleurodesis 1

Specific Scenarios with Higher Failure Rates

Malignant Pleural Effusions

• Continued production of pleural fluid by malignant cells may overwhelm the adhesions created by pleurodesis 1
• Tumor progression can disrupt pleural adhesions formed during pleurodesis 1
• Systemic therapy response: If the underlying malignancy responds to systemic therapy after failed pleurodesis, effusion may still recur 1

Pleuro-Peritoneal Leaks

• In peritoneal dialysis patients, recurrence following pleurodesis has been attributed to large diaphragmatic defects that require surgical repair 1
• Conventional tube thoracostomy-directed pleurodesis has only a 48% success rate in these cases 1
• When using VATS for pleuro-peritoneal leaks, combined mechanical and chemical pleurodesis techniques are more effective than either approach alone 1

Improving Success Rates

• Combined approaches (mechanical pleurodesis with prolene mesh plus chemical pleurodesis with talc) have shown the lowest recurrence rates (10%) 1
• Additional procedures during thoracoscopy such as endoscopic suturing and repair using Teflon patches can help prevent recurrences 1
• For peritoneal dialysis patients, a rest period of 3-4 weeks after surgical repair or pleurodesis is recommended before reinitiating dialysis 1
• In patients with trapped lung and malignant effusion, pleuroperitoneal shunting may be more appropriate than pleurodesis 1

Complications That May Contribute to Failure

• Respiratory failure and acute respiratory distress syndrome, especially with small particle talc, may disrupt the pleurodesis process 2
• Chest pain, fever, and inflammatory responses may be necessary for successful pleurodesis but can also complicate recovery 2
• Re-expansion pulmonary edema related to rapid evacuation of pleural fluid can compromise the pleurodesis process 2