We were surprised that Rahman et al did not mention video assisted thoracoscopic surgery in investigating malignant pleural effusion.1For more than 15 years it has been the cornerstone of investigation and palliation of such disease in those fit for general anaesthesia.1 Complex loculated effusions can be evacuated and the pleural cavity debrided appropriately.
The systematic examination of the mediastinum, pericardium, and diaphragm as well as the visceral pleura and underlying lung is easily and safely performed. Multiple targeted pleural biopsies can be performed, as well as biopsies of mediastinal nodes as required.
The expansion of the lung in response to positive pressure ventilation determines the appropriate method of palliation. If there is apposition of the visceral and parietal pleura talc pleurodesis is the method of choice, where this does not occur talc is detrimental and potentially leads to empyema. In most series, surgical talc insufflation provides superior palliation to talc slurry.
Lastly, as a thoracic surgeon operating on a large volume of patients with malignant mesothelioma, video assisted thoracoscopic surgery represents an excellent staging tool and determinant of the best surgical option for such patients..
Competing interests: None declared.
References
- 1.Rahman NM, Davies RJO, Gleeson FV. Investigating suspected malignant pleural effusion. BMJ 2007;334:206-7. (27 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]