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Eur J Cardiothorac Surg 2000;18:143-146
© 2000 Elsevier Science NL

The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions

Onur Genc, Mario Petrou, George Ladas, Peter Goldstraw

Department of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, London, UK

Received 12 November 1999; received in revised form 22 February 2000; accepted 22 February 2000.

Corresponding author. Tel.:+44-171-351-8559; fax: +44-171-351-8560
e-mail: p.goldstraw{at}rbh.nthames.nhs.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 
Objective: Over the last 15 years we have managed patients with malignant pleural effusion, using a single procedure with thoracoscopy and talc pleurodesis or shunt as appropriate. Talc pleurodesis remains our primary treatment option but in those patient shown to have the ‘trapped lung syndrome’, in whom pleurodesis would fail, we have been using a pleuroperitoneal shunt. Methods: This retrospective review was undertaken to evaluate the mortality and morbidity of pleuroperitoneal shunts in the management of malignant pleural effusions and to assess their long-term results. Three hundred and sixty patients were treated for malignant effusions during the period 1983–1998, 160 (44.4%) of whom had a pleuroperitoneal shunt inserted. There were no intraoperative deaths and the hospital mortality was three patients (1.87%). Follow up was available for 88.1% of patients. The median survival of all malignant cases was 7.7 months (range 1–72 months). Mesothelioma patients survived somewhat longer with a median survival of 10.1 months. Results: Shunt complication occurred in 21 patients (14.8%). Twelve patients developed shunt occlusion, requiring revision in five and replacement in seven. The shunt was removed in eight patients due to skin erosion in one patient and infection in seven patients. The distal limb of shunt was broken in one patient and the shunt was replaced. One patient developed malignant seeding along the chest wall at the site of shunt insertion but there were no incidences of peritoneal deposits. Effective palliation was achieved in 95% of patients. Conclusions: Pleuroperitoneal shunt insertion provides effective and safe palliation for malignant pleural effusion when associated with the ‘trapped lung syndrome’. There are however complications which require revision or shunt removal. There is no evidence that peritoneal deposits result from pleuroperitoneal shunting.

Key Words: Pleuro-peritoneal shunts • Malignant • Pleural effusion


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 References
 
Malignancy is the most common cause of exudative pleural effusion (75%), the incidence increasing with age [1].

At autopsy in patients who died with malignancy, the incidence of malignant pleural effusion was 16%. Carcinoma of the lung, breast, ovary, stomach and lymphomas account for 80% of all malignant pleural effusions. Malignant Pleural effusions cause significant morbidity in patients whose survival is limited [1]. The main symptoms at diagnosis are dyspnoea (96%), chest pain (57%) and cough (44%) [2]. The volume of pleural fluid in most malignant effusions exceeds 500 ml. Dyspnoea is moderate or severe in 75% of patients, limiting exercise and impairing quality of life [1]. Repeated aspiration may result in infection or tumour implantation and may predispose to the formation of a cortex limiting re-expansion.

The prognosis of patients with malignant pleural effusions is poor, with reported 1- and 6-month mortality rates of 54 and 85%, respectively [1,3].

The goal of treatment is palliation by a single intervention, which should be reliable and safe, cause little discomfort, avoid prolonged hospitalization and provide lasting relief of symptoms [3].

Treatment options include needle thoracocentesis, tube thoracostomy and pleurodesis. Thoracocentesis is an essential first step in the diagnosis and treatment of pleural effusion. Repeated needle thoracocentesis can provide temporary symptomatic relief, but most effusions reaccumulate within 1–3 days and almost all recur within 30 days [4]. A 30-day success rate of up to 70% with tube thoracostomy alone has been reported although long-term control of effusion is rare [5]. Talc pleurodesis has been shown by numerous investigators to have a success rate from 81 to 100% [1,5,6]. However, the ability of the lung to completely re-expand after fluid evacuation is necessary if the pleural surfaces are to come into contact, an essential prerequisite to obtain pleurodesis. In the case of trapped lung where lung re-expansion is inadequate to achieve pleurodesis, an alternative treatment using a pleuroperitoneal shunt has been advocated [3,5]. This allows the lung to expand to its maximal degree, and this, coupled with mediastinal shift, will improve dyspnoea.

We report here our clinical experience over 15 years with this device (pleuro-peritoneal shunt, Denver Biomedical, Inc., Denver, CO) in the management of recurrent malignant pleural effusion.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 References
 
Between January 1983 and December 1998, 360 patients were referred to the thoracic surgical unit at the Royal Brompton Hospital (London, UK) and at the Middlesex Hospital (London, UK) for the treatment of recurrent malignant pleural effusion.

The pathology for all patients is shown in Table 1. The most frequent neoplasms were carcinoma of breast, malignant mesothelioma and lung cancer.


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  		Table 1. Pathology of malignant pleural effusion

 
Two hundred (55.6%) patients underwent talc pleurodesis and 160 patients (44.4%) required the insertion of pleuro-peritoneal shunt, as determined at the time of surgery (see below). Of these 89 were male and 71 female. Their mean age was 59.26 years, (range 24–87 years). Ninety-five patients (59.3%) in the shunt group had been treated before referral with one or more modalities (Table 2). All such cases were treated in conjunction with oncological colleagues who supervised other modalities of therapy, where appropriate.


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  		Table 2. Previous pleural interventions before referral

 
After induction of general anaesthesia, rigid bronchoscopy was performed in all patients to exclude endobronchial obstruction. The pleural space was examined by video-assisted thoracoscopic surgery (VATS) or by a 5–7 cm-thoracotomy. The open technique was preferred if there had been repeated previous pleural interventions with the formation of pleural adhesions and fibrin deposits.

The pleural effusion was drained and adhesions were divided with diathermy coagulation. A through assessment was made of the pleura and lung surface and biopsies were taken from appropriate areas of the parietal pleura. The degree of lung expansion was then assessed with sustained positive pressure ventilation at 25 cm of water. In 200 patients, lung expansion was adequate to fill the hemithorax and allow apposition of visceral and parietal surfaces and chemical pleurodesis carried out by talc insufflation. In the 160 patients who form the basis of this report, however, there was a thickened restrictive cortex encasing the lung preventing adequate expansion (trapped lung syndrome). In these patients, chemical pleurodesis was considered inappropriate and an internal pleuroperitoneal shunt was inserted.

A 3-cm transverse incision is then made in the ipsilateral rectus sheath, exposing the peritoneal cavity. The pleuroperitoneal shunt is tunnelled under the skin from the chest to the abdomen with the pumping chamber lodged in a subcutaneous pocket overlying the costal margin. The pleural and peritoneal limbs are then introduced into the respective cavities under direct vision. Normal saline is introduced into the pleural space to prime the pump and check shunt function. The site of pump chamber is marked on the skin to facilitate pumping by the nurse in the early postoperative period and, subsequently, by the patient.

The follow-up data was obtained from out-patient clinic or from referring practitioners by letter.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 References
 
The results for the pleuro-peritoneal shunt group are only presented. There were no intraoperative deaths. All patients tolerated general anaesthesia and we did not resort to local anaesthesia in any case. There were three early deaths due to progressive respiratory failure (a hospital mortality rate of 1.87%). In these patients the effusion was the only reversible component of their multi-factorial dyspnoea. Such patients frequently have other significant components to their dyspnoea, chest wall fibrosis from surgery and/or radiotherapy, bronchial obstruction by tumour or malignant lymph nodes and lymphangitis. However after shunting these other factors appeared dominant and lead to their demise.

The mean hospital stay was 6.2 days (range 2–26 days). Follow-up data was available for 141 of the 160 patients (88.1%). The other patients came from oncologists abroad who provided no follow-up information. The median survival of evaluated cases was 7.7 months (range 2 weeks to 72 months). Mesothelioma patients survived longer with a median survival of 10.1 months. The median survival for evaluated patients following shunt insertion is shown in Table 3.


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  		Table 3. Survival following shunt insertion

 
Shunt specific complications occurred in 21 patients (14.8%) (Table 4). Twelve patients (8.5%), developed shunt occlusion a mean of 2.7 months following insertion (range, 4 days to 9 months), requiring revision in five patients and replacement in seven. Effective palliation was achieved after the second procedure in all patients.


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  		Table 4. Details of shunt complications

 
The shunt was removed in eight patients (5.6%), a mean of 2.75 months post insertion, (range, 1 week to 5 months). The shunt was removed because of infection in seven patients (4.37%), and of these four had a chest drain inserted and three had developed spontaneous pleurodesis. In the other patient the shunt was removed because of skin erosion, 9 months post insertion. On a further patient the distal limb of the shunt was fractured requiring shunt replacement. The shunt was removed at the patient's request in two patients but it is not considered as a complication.

One of the patients with metastatic breast cancer, whose shunt was removed went on to develop malignant seeding along the shunt line at seventh months following insertion but there were no cases of peritoneal deposits. All but seven patients (4.9%) obtained good palliation with no recurrence of symptoms and no significant reaccumulation of fluid on chest radiograph. Thus effective palliation was achieved in approximately 95% of patients.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
References
 
Recurrent intractable pleural effusions due to malignant disease present a difficult management problem. The prognosis of patient with malignant pleural effusions is generally poor, with reported 1- and 6-month mortality rates of 54 and 85%, respectively [1]. Some malignant effusions, particularly lymphomas, are amenable to systemic chemotherapy or radiation therapy. Whilst others, particularly lung cancer are unresponsive to treatment. Thoracocentesis is an essential first step in the diagnosis and treatment of pleural effusion. Repeated needle thoracocentesis can provide temporary symptomatic relief, but most effusions re-accumulate within 1–3 days and almost all recur within 30 days [4]. Frequent thoracocenteses are associated with an increased risk of pneumothorax, empyema and pleural fluid loculation. Repeated therapeutic thoracentesis should be limited to patients with poor life expectancy (i.e. <1 month) [5].

Chest tube drainage and sclerotherapy remain the treatment of choice but repeated attempts are also debilitating and may result in fluid loculation and empyema. Pleurectomy is a major surgical procedure associated with considerable morbidity and some mortality [3,7].

The principles underlying effective local treatment for malignant pleural effusion are to drain the pleural fluid completely, then instil an effective sclerosing agent and ensure that the lung is completely re-expanded during the process of pleurodesis. Talc has been shown to be the most effective sclerosing agent with a success rate from 81 to 100% [1,5,6]. Tetracycline, has a success rate of around 70–75% [5,7]. Ninety-five (58.7%) of the patients in our series had failed previous treatment attempts before referral with one or more modalities such as thoracocentesis, intercostal chest drain or pleurodesis (mainly tetracycline) (Table 2).

Failure of attempted pleurodesis, may be due to incomplete drainage of the effusion; the distribution of sclerosing agents within the pleural cavity being prevented by fibrin debris or adhesions from previous failed pleurodesis; or the lung being restricted by cortex, preventing apposition of the parietal and visceral pleural surfaces (also known as the trapped lung syndrome) [3]. Decortication in these situations is a major procedure associated with a high morbidity (23%) and mortality (10%) and is therefore best avoided in patients with a limited life expectancy [3,5]. An alternative and effective approach is continuous shunting of the pleural fluid into the peritoneal cavity. This provides effective palliation in patients in whom a cortex limits lung expansion and pleurodesis would fail. Now we insert a shunt if there is any doubt as to the adequacy of lung reexpansion.

A recent option for intermittent, long term drainage of symptomatic, recurrent malignant pleural effusions is the Pleurx Pleural Catheter (Denver Biomedical Inc.) which consists of a fenestrated silicone catheter with a natural latex rubber valve mechanism and a polyester cuff. The place of this device in the long-term management of these patients remains to be defined.

Early and late complications in our series are significant. Shunt complication occurred in 21 patients (14.8%), and comparable with other reports [8,9]. The failure rate due to infection requiring rib resection and tube insertion is only 4.9%. This is surprising as many of these patients had repeated pleural interventions.

In our experience, symptomatic recurrence of pleural effusion indicates shunt failure; we would re-explore and consider shunt replacement as long as there are no other contraindications. Non-functioning shunts should be replaced rather than revised [10].

The question of tumour implantation into the peritoneal cavity is a valid one but considering the poor overall survival and the lack of any alternative effective treatment, this is an acceptable risk [3]. Peritoneal seeding, whilst a theoretical risk with such shunts, has not occurred in our practice and has not been reported in the literature to our knowledge. One of our patients had malignant seeding along the shunt track at 7 months but we had no incidence of peritoneal deposits.

Our series is the largest reported to date [6,8–12], and shows that the insertion of pleuroperitoneal shunt can provide effective palliation for patients with recurrent symptomatic malignant effusion where the presence of trapped lung makes them unsuitable for pleurodesis.

All the patients in whom the shunt remained functional obtained good palliation of symptoms even when seen at operation to have a restrictive cortex preventing any degree of lung expansion. Although drainage of a massive effusion by the shunt would not alter expansion of trapped lung (sometimes the lung expands to a limited degree), improved contralateral lung expansion would be expected. Especially this may account for the benefit demonstrated in these patients.

The procedure is safe and simple and patients are capable of caring for their shunts after a few days training. Early hospital discharge can be achieved and patients can continue their medical care and social life without the need for further thoracocentesis.


   Footnotes
 
Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 

  1. Sahn A.S. Malignancy metastatic to the pleura. Clin Chest Med 1998;19(2):351-361.[Medline]
  2. Moragon E.M., Aparicio J., Sanchis J., Menendez R., Rogado M.C., Sanchis F. Malignant pleural effusion: prognostic factors for survival and response to chemical pleurodesis in a series of 120 cases. Respiration 1998;65:108-113.[Medline]
  3. Wong P.S., Goldstraw P. Pleuroperitoneal shunts: review. Br J Hosp Med 1993;50(1):16-21.[Medline]
  4. Anderson C.B., Philpott G.W., Ferguson T.B. The treatment of malignant pleural effusion. Cancer 1974;33:916-922.[Medline]
  5. Grossi F., Penucci M.C., Tixi L., Cafferata M.A., Ardizzoni A. Management of malignant pleural effusions. Drugs 1998;55(1):47-58.[Medline]
  6. Petrou M., Kaplan D., Goldstraw P. Management of reccurrent pleural effusions. Cancer 1995;75:801-805.[Medline]
  7. Keller S.M. Current and future therapy for malignant pleural effusion. Chest 1993;103:63-67.
  8. Little A.G., Kadowki M.H., Ferguson M.K., Staszek V.M., Skinner D.B. Pleuroperitoneal shunting alternative therapy for pleural effusions. Ann Surg 1988;208:443-450.[Medline]
  9. Ponn R.B., Blancaflor J., D'Agostino R.S., Kiernan M.E., Toole A.L., Stern H. Pleuroperitoneal shunting for intractable pleural effusions. Ann Thorac Surg 1991;51:605-609.[Abstract]
  10. Al-Kattan K.M., Kaplan D.K., Goldstraw P. The non-functioning pleuro-peritoneal shunt: revise or replace?. Thorac Cardiovasc Surgeon 1994;42:310-312.[Medline]
  11. Hussain S.A. Pleuroperitoneal shunt in reccurrent pleural effusions. Ann Thorac Surg 1986;41(6):309-311.
  12. Tsang V., Fernando H.C., Goldstraw P. Pleuroperitoneal shunt for reccurrent malignant pleural effusions. Thorax 1990;45:369-372.[Abstract]



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