Pleuroperitoneal shunts and indwelling external catheters

Indwelling catheters provide a means of symptomatic relief in those patients with malignant pleural effusions who either cannot tolerate a general anesthetic and have a trapped lung, or have a trapped lung which is not amenable to video-assisted thoracoscopic surgery.

Pleuroperitoneal shunts consist of a pumping chamber that transports approximately 1 to 2 ml of pleural fluid with each compression. Pumping for 10-min intervals approximately four times daily is required for adequate drainage of most effusions. The entire system is intracorporeal, with the pump portion placed in the subcutaneous tissues. Fluid is pumped from the intrapleural space into the abdominal cavity where it is resorbed by the peritoneal cavity. The procedure can be performed under local anesthesia and there is minimal discomfort afterwards ( 1988). A pocket for the pump is made in the subcutaneous tissue from an incision in the lateral part of the inframammary crease. The pleural catheter is inserted at the superolateral aspect of the incision using the Seldinger technique. The abdominal catheter is then tunneled subcutaneously across the costal margin and directed downwards, into the peritoneal cavity, via a 2- to 3-cm skin incision carried down through the peritoneum (Little §t...§.l; 1.9.88).

In approximately 10 per cent of patients the shunt will become occluded, necessitating a replacement ( Little etM 1988). The use of such a device is strictly palliative and should be reserved for those patients who have known metastatic disease, since there is concern with respect to pleuroperitoneal seeding ( Little e.t.a/ 1988).

External indwelling catheter drainage is an alternative for palliative management of malignant pleural effusion. The catheter is placed in the intrapleural space and drains externally when effusions are symptomatic. Insertion is carried out with local anesthesia in the operating suite. The patient is placed in 30° of Trendelenburg, and local anesthetic is used to infiltrate the two incision sites made in the anterolateral chest. The incisions are approximately 1 cm in length and are made perpendicular to the direction of the ribs at approximately the sixth intercostal space. The intercostal membrane and pleural space are entered through the most lateral incision using a needle and then the catheter is inserted using the Seldinger technique. The remainder of the catheter is tunneled through the subcutaneous tissue towards the second incision, where it exits the body, and the catheter is adjusted such that the felt cuff sits underneath the skin at the medial incision. The lateral incision is closed completely and the medial incision is closed around the catheter which is sutured in place ( Little eLal 1988).

The failure rate is reported to be less than that of the pleuroperitoneal shunt ( Ljttje.efa/ 1988). However, infection may occur at the exit site, requiring antibiotic therapy and possible removal.

The drainage technique used for a pleural effusion must be patient specific. Early drainage of parapneumonic effusions can best be achieved with tube thoracostomy, while more complex effusions with loculations often require decortication and lysis of adhesion to allow lung re-expansion and subsequent pleurodesis. The palliative management of malignant pleural effusions must be as painless and uncomplicated as possible in order to afford these patients improved quality of their remaining life.

Chapter References

Keller, S.M. (1993). Current and future therapy for malignant pleural effusion. Chest, 103, 63S-7S.

Little, A.G., Kadowaki, M.H., Ferguson, M.K., Staszek, V.M., and Skinner, D.B. (1988). Pleural-peritoneal shunting. Annals of Surgery, 208, 443-50. Quigley, R.L. (1995). Thoracentesis and chest tube drainage. Critical Care Clinics, 11, 111-26.

Sahn, S.A. (1993). Management of complicated parapneumonic effusions. American Review of Respiratory Disease, 148, 813-17.

Weingardt, J.P., Guico, R.R., Nemcek, A.A., Li, Y.P., and Chiu, S.T. (1994). Ultrasound findings following failed, clinically directed thoracenteses. Clinical Ultrasound, 22, 419-26.

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