The Diminishing Role of Surgery in Pleural Disease

Helen E. Davies; Andrew Rosenstengel; Y.C. Gary Lee

Disclosures

Curr Opin Pulm Med. 2011;17(4):247-254. 

In This Article

Abstract and Introduction

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.

Introduction

Pleural diseases are common; over 1 500 000 patients develop a new pleural effusion annually in the USA alone.[1] Pleural effusion can arise from more than 60 causes, and establishing the cause and effective treatment can be challenging.

Thoracic surgery traditionally plays a major role in the workup and management of pleural effusions, from pleural biopsies to pleurodesis and from empyema to pneumothorax. Various aggressive pleural surgeries have been developed over the years: from the description of Clagett procedure in 1963[2] – a three-stage radical procedure with chest wall resection to create a permanent open window for pleural empyema – to modern day extrapleural pneumonectomy (EPP) for mesothelioma, which involves resection of lung, chest wall, hemidiaphragm, pericardium and regional lymph nodes. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal (let alone randomized studies) and their use is based largely on anecdotal series often flawed with selection bias.

The aim of management of pleural diseases is to deliver the diagnosis and best management with the least invasive procedure(s), shortest hospitalization period and lowest procedural morbidity and cost. Realization of the lack of evidence for many pleural surgeries, and the growing documentation of their procedure-related complications, has prompted the pleural community to examine 'conventionally accepted' pleural surgical approaches using randomized trials. Not surprisingly, many (e.g. thoracoscopic poudrage) have failed to demonstrate any significant benefits. Advances in imaging techniques, histopathology methods and therapeutic protocols further contribute to a reduction in need for invasive surgeries. Worldwide, in recent decades, the role of surgical intervention for the diagnosis and management of pleural disease has diminished significantly.

Clinicians must be critically aware of the evidence (or lack of evidence) supporting a specific surgical intervention before subjecting their patient to an operation. Progress can only be made if clinicians continue to challenge the truthfulness of 'conventional wisdom' and work toward less invasive means to achieve better patient care.

In this review, we discuss the role of surgery in commonly encountered pleural diseases and highlight the deficit in evidence that supports many 'accepted' surgical interventions, and the advances in pleural research which suggest parity or superiority of noninvasive approaches.

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