Is Video-Assisted Thoracic Surgery (VATS) with decortication indicated for trapped lung in patients with malignancy?

VATS Decortication for Trapped Lung in Malignancy

Indwelling pleural catheters (IPCs), not VATS decortication, should be the first-line treatment for trapped lung in malignancy, as IPCs provide symptomatic improvement in >94% of patients with shorter hospital stays and lower morbidity. 1, 2

Primary Recommendation: IPCs Over VATS Decortication

The European Respiratory Society/European Association for Cardio-Thoracic Surgery guidelines explicitly recommend IPCs as the preferred initial management for malignant trapped lung. 1, 2 This recommendation is based on:

• Symptomatic benefit in >94% of patients across five studies totaling 133 patients 1
• Superior effusion control compared to talc pleurodesis, with better dyspnea-free exercise scores (7.8 versus 4.5, p=0.02) 1
• Significantly shorter hospital stays compared to surgical interventions 1
• Minimal hospitalization requirements with outpatient management capability 2, 3

When VATS Decortication May Be Considered

VATS decortication is reserved for highly selected patients only and should not be routine practice. 1 The specific criteria include:

• Good performance status with ability to tolerate general anesthesia and surgery 4
• Mesothelioma patients where ongoing trials (MesoTRAP) are evaluating surgical pleurectomy/decortication versus IPC 1, 5
• Failed IPC management or specific patient preference after thorough counseling 4
• Symptomatic patients with entrapped lung who cannot benefit from chemical pleurodesis (grade 2C recommendation) 1

Evidence Supporting Limited Role of VATS Decortication

The evidence for VATS decortication in malignant trapped lung is weak:

• Only one small case series by Yim et al. reported "good outcomes" in seven patients with trapped lung undergoing VATS decortication 1
• No randomized controlled trials have been completed comparing VATS decortication to IPC in malignancy (MesoTRAP trial is ongoing) 1, 5
• The MesoVATS trial showed no survival benefit for video-assisted thoracoscopic partial pleurectomy, with more complications, longer hospital stays, and higher costs 6
• VATS-P/D showed lower complication rates than open approaches but still carries significant surgical risk 7

Critical Pitfalls to Avoid

Do not attempt pleurodesis in trapped lung - this will fail due to inability of visceral and parietal pleura to appose, subjecting patients to unnecessary procedures, prolonged hospitalization, and significant pain without benefit. 2, 8

Do not subject palliative patients to major surgery - median survival for malignant pleural effusion is only 20 weeks, with 1-year mortality of 83.6%. 3 Patients should not spend significant portions of remaining life recovering from palliative procedures. 3

Practical Algorithm for Decision-Making

1. Confirm trapped lung diagnosis (radiologically or via VATS if already performed) 1
2. Insert IPC as first-line treatment for symptomatic relief 1, 2
3. Reserve VATS decortication only for:
   • Mesothelioma patients enrolled in clinical trials 1, 5
   • Highly selected patients with excellent performance status who have failed IPC management 4
   • Patients specifically requesting surgery after informed discussion of risks/benefits 1

Complications and Monitoring

IPC complications (generally minor and manageable): pain (35% lasting <3 days), cellulitis, catheter blockage, infection, or fracture. 1, 3 No empyema reported in most series. 1

VATS decortication complications (more significant): bleeding, infection, respiratory failure, cardiovascular complications, and prolonged recovery. 4, 7