Detection of pleural adhesions with sonography

Increase of Micro-vessels Beneath the Pleural Surface on CT Predicts Pleural Adhesions

BACKGROUND

Pleural adhesions are often troublesome in lung surgeries. In some dense pleural adhesions, blood vessels between lung and chest wall (BVLC) are found during surgery. Theoretically, BVLC would increase the amount of blood flow just below the visceral pleura and could allow blood vessels beneath the pleural surface to be clearly visualized on CT. In this study, we investigated whether it was possible to identify the typical CT findings of cases with BVLC.

METHODS

Medical records and imaging findings of 186 patients who underwent surgery for lung tumors in our institution were retrospectively reviewed.

RESULTS

BVLC was found in 56 patients, of whom 44 (79%) had findings on preoperative CT that indicated increase of micro-vessels just below pleura. In the 21 patients with BVLC of ≥1 mm vessel diameter, the same CT findings were recognized in 19 cases (90%).

CONCLUSION

Our results indicate that the CT finding of increased micro-vessels just below pleura has the potential to be used as a novel predictor of pleural adhesion.

Prediction of preoperative intrathoracic adhesions for ipsilateral reoperations: sliding lung sign

Introduction

Video-assisted thoracic surgery (VATS) for ipsilateral reoperations is controversial, because after the first surgical intervention, pleural adhesions occur frequently in the thoracic cavity and/or chest wall. This study assessed the usefulness of preoperative ultrasonography to reduce the incidence of lung injury at the time of the initial port insertion during secondary ipsilateral VATS.

Materials and methods

This was a retrospective, single-center study. Nine patients who underwent thoracic surgery at Vanvitelli Hospitalfrom September 2019 to February 2022, were scheduled for a second VATS surgeryon ipsilateral lung, because of inconclusive intraoperative histologic examination. All nine patients underwent preoperative ultrasonography to assess the possible presence of pleural adhesions. We evaluated the lung sliding, since the presence of pleural adhesions does not permit to appreciate it.

Statistical analysis

Hard severe adhesions were observed in all nine patients without sliding lung sign (specificity 100%). In this series, the sensitivity, PPV, and NPV of the sliding lung sign were 93%, 100% and 94% respectively.

Results

The presence of the lung respiratory changes can be evaluated as the “sliding lung sign” by chest ultrasonography; we believe that the sliding lung sign might also predict intrathoracic adhesion.

Conclusions

Preoperative detection of pleural adhesions using transthoracic ultrasonography was useful for ipsilateral secondary pulmonary resection patients undergoing VATS. Using preoperative ultrasonography can improve the safety and feasibility of placing the initial port in VATS.

Preoperative Lung Ultrasound to Detect Pleural Adhesions: A Systematic Review and Meta-Analysis

The usage of lung ultrasound as a preoperative examination for thoracic surgeries remains controversial. Our systematic review and meta-analysis aimed to evaluate preoperative lung ultrasound diagnostic accuracy for detecting pleural adhesions. We searched articles published in MEDLINE, Embase, CENTRAL, and the International Clinical Trials Registry Platform until October 2020. Inclusion criteria were observational studies, case-control studies, and case series assessing preoperative lung ultrasound diagnostic accuracy. The study quality of included articles was evaluated using the modified quality assessment of diagnostic accuracy studies-2 tool. The pooled sensitivity and specificity were calculated using the bivariate random-effects model. The overall quality of evidence was summarized using the grading of recommendations, assessment, development, and evaluation approach. Eleven articles were included in our systematic review. A high risk of bias was noted regarding undefined pleural adhesions and non-predefined pathological diagnosis. Based on the ten articles included for meta-analysis, the pooled sensitivity and specificity were 71% [95% confidence interval (CI), 56%-82%], and 96% (95% CI, 89%-99%), respectively. The overall quality of evidence was moderate. Our systematic review revealed that lung ultrasound had high specificity. It may serve as a rule-in test for detecting pleural adhesions before thoracic surgeries, which may assist surgeons in preparation for a prolonged surgery or increased risk of complications that occurred by trocar insertion such as bleeding and persistent air leak.

Utility of the sliding lung sign for the prediction of preoperative intrathoracic adhesions

Background

To assess the potential of the ultrasonographic sliding lung sign to detect severe intrathoracic adhesions before surgery.

Methods

This was a prospective, single-center, observational study including all patients aged 20-89 years undergoing elective thoracic surgery. Patients with pneumothorax, pyothorax, hemothorax, chylothorax, and hydrothorax were excluded. We recorded the ultrasound sliding lung sign, surgical characteristics, and follow-up parameters: past medical history, respiratory function, chest X-ray findings, and computed tomography (CT) findings. Severe intrathoracic adhesion was defined as the need for adhesiolysis requiring more than 30 minutes.

Results

A total of 168 patients consented to participate. All 15 patients without the sliding lung sign had hard severe adhesions [specificity 100%, sensitivity 88.2%, positive predictive value (PPV) 100%, negative predictive value (NPV) 98.7%, and area under curve (AUC) 0.94]. There were two false-negative results, both of which were soft adhesions. Although blunting of the costophrenic (CP) angle, CT findings, past medical history, and restrictive lung disease were identified as significant risk factors of severe intrathoracic adhesion, all areas under the curve were low (0.71, 0.71, 0.69, 0.61, respectively). Thoracotomy frequency, intraoperative bleeding, operative time, and postoperative hospitalization were significantly greater in these patients than in those with non-severe adhesions.

Conclusions

The ultrasound sliding lung sign could be used to predict severe intrathoracic adhesions before surgery. Preoperative confirmation of the ultrasound sliding lung sign is important for planning surgical approaches and implementing appropriate safety management.

Prediction of Pleural Adhesions by Lung Ultrasonography: An Observational Study

OBJECTIVE

Pleural adhesion makes video-assisted thoracoscopic surgery (VATS) an arduous procedure and can increase postoperative pain from accompanying adhesiolysis. For the present study, the feasibility of lung ultrasonography for the prediction of pleural adhesions and postoperative pain in VATS was investigated.

DESIGN

Blinded, prospective, observational study.

SETTING

Tertiary teaching hospital, Seoul, South Korea.

PARTICIPANTS

Sixty patients (American Society of Anesthesiologists physical status I to III) scheduled to undergo VATS were assessed for eligibility. After exclusions, 53 patients were enrolled and followed-up.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were evaluated with lung ultrasonography during deep spontaneous respiration before induction of anesthesia, and surgeons confirmed the presence of pleural adhesions during the surgery. Pain was evaluated using a numeric rating scale and by the amount of opioid consumption until 24 hours postoperatively. Lung ultrasonography showed acceptable predictability of pleural adhesions, with the area under the receiver operating characteristic curve (0.75, 95% confidence interval [CI] 0.67-0.83) and high specificity (0.97, 95% CI 0.91-0.99) but low sensitivity (0.53, 95% CI 0.38-0.68). The pain score was not different between sonographic adhesion (+) and (-) groups; however, the sonographic adhesion (+) group consumed more opioids until 24 hours postoperatively (fentanyl 675 [558-805] μg v 420 [356-476] μg; p < 0.001).

CONCLUSIONS

Lung ultrasonography may help with planning postoperative pain management in VATS; however, it was a better tool for ruling out rather than detecting pleural adhesions.

Ultrasonography in the diagnosis of lung adhesion before surgery

Background The presence of pleural adhesions may render video-assisted thoracoscopic surgery difficult or impossible. The aim of this study was to assess the value of chest ultrasonography in the detection of pleural adhesions prior to thoracotomy. Methods Between 2013 and 2014, 42 consecutive patients undergoing thoracotomies (including video-assisted thoracicsurgery) were evaluated with chest ultrasonography. These patients underwent a preoperative ultrasonic examination of the chestwall using a 7.5-10-MHz linear ultrasound probe at 7 points along the chest wall. We measured the movement of the visceral pleuralslide. Results In the upper thoracic wall,ultrasonography demonstrated a sensitivity of 63.0%, a specificity of 66%, a negative predictive value of 77%, a positive predictive evalue of 50.0%, and an overall accuracy of 65.0%. And for the lower thoracic wall, ultrasonography demonstrated a sensitivity of 81.0%, a specificity of 59.0%,a negative predictive value of 89.0%, a positive predictivevalue of 44.0%, and an overall accuracy of 65.0%. Conclusion Chest ultrasonography is moderately accurate in detecting the presence and location of pleural adhesions. The use of preoperative chest sonographic findings to plan trocar placement and to determine the need for an open approach is valuable in helping prevent visceral injury and facilitating video-assisted thoracoscopic surgery.

Preoperative detection of pleural adhesions by respiratory dynamic computed tomography

BACKGROUND

Video-assisted thoracic surgery (VATS) plays an important role in thoracic surgery because it is less invasive. However, the existence of severe pleural adhesions may make VATS difficult and complicated. The aim of this study was to assess the utility of inspiration and expiration computed tomography (respiratory dynamic CT (RD-CT)) in evaluation of pleural adhesions preoperatively.

METHODS

RD-CT was performed on 107 patients undergoing thoracotomies (both VATS and open). We assessed synchronous motion during respiration on RD-CT. Comparing the results of RD-CT and intraoperative findings, we assessed the utility of preoperative evaluation.

RESULTS

A negative correlation between sliding score and adhesion grade was revealed. Sliding score in adhesion negative patients was significantly higher than that in adhesion positive patients (P < 0.0001). The sensitivity of RD-CT was 63.6%, specificity was 74.1%, and accuracy was 72%. Among 62 patients with a CT-Respiration Ratio of less than 0.65, the sensitivity of RD-CT was 77.8%, specificity was 86.8%, and accuracy was 85.5%.

CONCLUSIONS

RD-CT may be clinically useful for detecting the presence of pleural adhesions. It can be adopted as one of the criteria for deciding the surgical approach.

Diagnostic and prognostic implications of pleural adhesions in malignant effusions

BACKGROUND AND OBJECTIVE

We aimed to examine the frequency of pleural adhesions and to determine their relationship with pleural tumor burden, pleural fluid (PF) biochemistries, PF cytologic yield, and survival in patients with malignant pleural effusion (MPE).

METHODS

We performed retrospective analysis of 540 consecutive patients with MPE who underwent medical thoracoscopy. Pleural lesion rating and grade of pleural adhesions based on a thoracoscopic score model were recorded.

RESULTS

Sixty percent of patients with MPE were found to have adhesions in the pleural space. The sensitivity of PF cytology was 71% if there were no pleural adhesions, and 20% if the maximum adhesion score was reached (p < 0.01). The extent of pleural adhesions correlated positively with the pleural tumor burden, and inversely with PF pH. The median survival of patients with minimal or no adhesions in the pleural space was 9 months as compared with patients with the highest grade of adhesions, whose median survival was 5 months (p < 0.01).

CONCLUSION

MPE are often loculated. The higher the grade of pleural adhesions, the greater the tumor burden exists, and paradoxically the lower the PF cytologic yield. The presence of pleural adhesions in MPE implies a poor prognosis.

Preoperative Detection of Pleural Adhesions by Chest Ultrasonography

BACKGROUND

The presence of pleural adhesions may render video-assisted thoracoscopic surgery difficult or impossible. The aim of this study was to assess the value of chest ultrasonography in the detection of pleural adhesions prior to thoracotomy.

METHODS

Between October 2001 and September 2002, 42 consecutive patients undergoing thoracotomies (including video-assisted thoracic surgery) were evaluated with chest ultrasonography. These patients underwent a preoperative ultrasonic examination of the chest wall using a 7-MHz linear ultrasound probe at 7 points along the chest wall. We measured the movement of the visceral pleural slide.

RESULTS

When restricted viscera sliding was defined as less than 1 cm of excursion at the upper thoracic wall during exaggerated respirations, ultrasonography demonstrated a sensitivity of 63.6%, a specificity of 79.4%, a negative predictive value of 87.7%, a positive predictive value of 50.0%, and an overall accuracy of 75.6%. When restricted viscera sliding was defined as less than 2 cm of excursion at the lower thoracic wall during exaggerated respirations, ultrasonography demonstrated a sensitivity of 81.5%, a specificity of 81.0%, a negative predictive value of 96.0%, a positive predictive value of 44.0%, and an overall accuracy of 81.0%.

CONCLUSIONS

Chest ultrasonography is moderately accurate in detecting the presence and location of pleural adhesions. Use of preoperative chest sonographic findings to plan trocar placement and to determine the need for an open approach is valuable in helping prevent visceral injury and facilitating video-assisted thoracoscopic surgery.