Comparison of Thoracoscopic Talc Pleurodesis by Thoracic Epidural or General Anesthesia

Randomized Study of Thoracoscopic Talc Pleurodesis Performed by Thoracic Epidural or General Anesthesia

Video-assisted thoracoscopic surgery (VATS) talc pleurodesis is often carried out in patients with malignant recurrent pleural effusion to relieve symptoms and prevent recurrence. General anesthesia and one lung ventilation is the standard type of anesthesia employed for VATS although recently, thoracic epidural anesthesia (TEA) in awake spontaneously ventilating patients is being increasingly employed to perform several cardio-thoracic surgery procedures in an attempt of minimize operative risks and facilitate resumption of daily-life activity. The investigators have reasoned that for a simple and palliative procedure such as talc pleurodesis in cancer patients is, use of general anesthesia and one-lung ventilation might be considered a potential cause of morbidity and delayed recovery. The investigators have also hypothesized TEA could be considered an optimal type of anesthesia in this setting leading to a fast recovery a reduced overall workload in medical care. In this single-center randomized study, the investigators have comparatively assessed the impact of awake TEA versus general anesthesia and one-lung ventilation on comprehensive results of VATS talc pleurodesis.

VATS, awake thoracic surgery, pleurodesis, talc, TEA, epidural anesthesia, Video-Assisted, Anesthesia Epidural

Thoracoscopic talc pleurodesis performed in awake patients through sole thoracic epidural anesthesia.

Thoracoscopic talc pleurodesis performed in awake patients through sole thoracic epidural anesthesia.

PMC is aimed at evaluating the overall workload in medical care throughout the the entire perioperative period and until discharge. PMC was computed as a comprehensive multidimensional variable including hospitalization time and extra-routine nursing/clinical/pharmacological requirements and costs(grades 1-3).

Ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2), arterial carbon dioxide tension (PaCO2)

Perioperative changes in cardiocirculatory variables including heart rate (HR) and mean arteial pressure (MAP)

Forced expiratory volume in one second(FEV1), forced vital capacity (FVC), peak expiratory flow (PEF)

From date of operation until the date of redo pleurodesis or assessed every 6 months or until date of death from any cause

Inclusion Criteria: Recurrent pleural effusion at the computed tomography occupying at least 1/3 of the hemithorax in patients with recent history of malignancy. Karnofsky performance status ≥ 50 ASA score II-III Acceptance of the randomly assigned anesthesia protocol Radiologic evidence of lung re-expansion after previous drainage/thoracentesis Absence of blood clotting disorders (INR < 1.5) No contraindications to TEA No neurological or psychiatric disturbance contraindicating awake surgery Exclusion Criteria: Patients refusal of random assignment to treatment arm Patients refusal or noncompliance to TEA Patients refusal or noncompliance to general anesthesia and one-lung ventilation Unfavourable anatomy for TEA Previous surgery of the thoracic spine Coagulation disorders (thromboplastin time < 80%, prothrombin time > 40 sec, platelet count < 200/nL or bleeding disorders

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Pompeo E, Dauri M; Awake Thoracic Surgery Research Group. Is there any benefit in using awake anesthesia with thoracic epidural in thoracoscopic talc pleurodesis? J Thorac Cardiovasc Surg. 2013 Aug;146(2):495-7.e1. doi: 10.1016/j.jtcvs.2013.03.038. Epub 2013 Apr 17. No abstract available.