Long-term outcomes after pleural decortication for patients with chronic sterile, non-malignant pleural effusion

Introduction

Pleural effusion is a common clinical manifestation resulting from various systemic, malignant, infectious, and inflammatory diseases (1). The treatment and prognosis of pleural effusion vary depending on the underlying cause and the characteristics of the effusion (2,3). Recurrent and chronic pleural effusions can lead to trapping of the ipsilateral lung, and decortication is employed to facilitate lung re-expansion and alleviate respiratory symptoms in cases unresponsive to drainage and/or fibrinolytics (4-6).

Most studies on pleural decortication have focused on malignant, infectious, or postoperative pleural effusions, leaving a significant gap in the understanding of its application in benign, sterile effusions (4,7-11). While the role of decortication for empyema is well-established (12-14), and management strategies for malignant pleural effusions have been extensively reported (15,16), the efficacy of decortication in chronic sterile, non-malignant pleural effusions (CSNMPE) has not been established. There is a paucity of research on the long-term outcomes of decortication in patients with CSNMPE. This condition is frequently associated with severe systemic comorbidities, including congestive heart failure (CHF), chronic renal failure (RF), hepatic dysfunction, and autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis. Given that the 30-day mortality rates for hospitalized patients with pleural effusions secondary to organ failure or various benign etiologies have been reported to be relatively high at 30–35%, compared to 13% and 22% in patients with empyema or malignant pleural effusions respectively (17), it is clinically important to investigate the significance of performing decortication surgery in this category of CSNMPE known to have a poor prognosis. This study aims to evaluate the long-term outcomes of decortication in patients with CSNMPE and to discuss future treatment strategies for this patient category. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1203/rc).

Methods

Study design and ethics statement

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional review board (IRB) of Northwestern University (No. STU00220348) and individual consent for this retrospective analysis was waived.

Inclusion and exclusion criteria

Medical records of patients who underwent pleural decortication at a single institution between January 1, 2012, and December 31, 2022, were reviewed. Patients younger than 18 years old and those with pleural effusions secondary to malignancy, infection, lung transplant, trauma, or postoperative complications were excluded (Figure 1).

Figure 1 Inclusion of patients with chronic sterile non-malignant pleural effusion.

Definition of CSNMPE

CSNMPE was operationally defined as a pleural effusion that persisted for more than 4 weeks without clinical or laboratory evidence of infection or malignancy. Infection was ruled out through repeated negative results from pleural fluid cultures and the absence of systemic signs of infection such as fever or elevated inflammatory markers. Malignancy was excluded based on negative cytological examination of pleural fluid, imaging studies showing no suspicious masses or pleural thickening, and histopathologic confirmation from pleural biopsy, which was routinely performed intraoperatively.

Candidacy for pleural decortication

Although no uniform protocol was in place, eligibility for pleural decortication was typically based on persistent respiratory symptoms, radiographic evidence of trapped lung despite prior conservative management [e.g., thoracentesis, pleurodesis, or indwelling pleural catheters (IPCs) placement], and multidisciplinary consensus among pulmonology, thoracic surgery, and radiology teams.

Data

Data collection involved a comprehensive review of electronic medical records (EMRs), with cases identified using relevant Current Procedural Terminology (CPT) and International Classification of Disease (ICD)-9/10 codes. Preoperative variables included patient demographics, comorbidities, imaging findings from chest X-ray (CXR) and computed tomography (CT), pleural fluid characteristics, prior effusion management (e.g., thoracentesis frequency and use of IPCs), and the time from initial pleural fluid detection to decortication surgery. Pulmonary function tests were excluded from the analysis due to inconsistent timing and frequency. Intraoperative data included the surgical approach (minimally invasive or open thoracotomy), extent of decortication, operation time, and any additional procedures, such as chemical pleurodesis. The extent of decortication was determined intraoperatively by the attending surgeon. Total decortication indicated grossly complete removal of fibrous peel over the lung surface and pleural cavity, while partial decortication was applied when only segmental or limited areas of peel could be safely excised. In most cases, the initial assessment began with minimally invasive surgery (MIS), and after evaluating the extent and complexity of the decortication, conversion to thoracotomy was performed if necessary. Postoperative outcomes included subjective symptom improvement, surgery-related complications, length of hospital stay, readmissions, extent of lung re-expansion on chest images, and survival time. Clinical improvement was assessed retrospectively based on symptom documentation in the EMR, including descriptions of dyspnea or chest discomfort. Standardized symptom scoring systems were not employed, as data was extracted from routine clinical notes rather than collected prospectively. All patients underwent at least one follow-up radiologic evaluation (CXR or CT) within 6 months after surgery. Interval of follow-up imaging was performed based on clinical indications and availability. There were no losses to follow-up or transfers of care to other institutions. The radiographic extent of lung re-expansion was assessed by comparing the preoperative CXR with the CXR taken 3–6 months postoperatively. Pleural gap distance was assessed at the lung base by measuring the separation between the costophrenic angle and the adjacent lung border. Pleural gap reduction (%) was calculated as [(Preoperative Gap – Postoperative Gap)/Preoperative Gap] ×100. Pleural gap reduction, defined as the extent of lung re-expansion, was categorized as follows: [−1] worsened lung volume; [0] no change; [1] mild improvement (<25%); [2] moderate improvement (25–75%); [3] significant improvement (>75%).

Endpoints

The primary endpoints were overall survival at 1, 3, and 5 years. Secondary endpoints included prognostic factors associated with survival.

Statistical analysis

Descriptive statistics were used to summarize patient characteristics and clinical outcomes. To identify prognostic factors associated with survival, both univariable and multivariable analyses were performed in a cohort of 25 patients who underwent decortication. Due to the limited sample size, univariable analysis was conducted by dichotomizing clinically relevant variables and comparing survival between groups using the log-rank test. For multivariable analysis, a Cox proportional hazards model was constructed. The initial model included variables that were statistically significant in univariable analysis, as well as clinically important variables even if they were not statistically significant. The model was then simplified by sequentially removing non-significant variables to obtain a final, parsimonious model. Hazard ratios (HRs) and 95% confidence intervals (CIs) were reported for statistically significant variables (P<0.05). All analyses were performed using R (version 4.4.2).

Results

A total of 311 patients who underwent pleural decortication were identified by our institutional Electronic Data Warehouse, of which 286 patients were excluded due to empyema (n=183), non-malignant hemothorax (n=66), malignancy (n=15), postoperative loculation (n=15), pneumothorax and/or hemothorax (n=5), and chylothorax (n=2). A total of 25 patients who received pleural decortication for CSNMPE were included in this study (Figure 1).

The median age was 67 years (range, 34–84 years), with a predominance of male (84%) and White (84%) patients. Preoperative comorbidities were notable for hypertension (HTN; 72%), CHF (48%), cancer treatment history (40%), diabetes mellitus (DM; 28%), RF (24%), and liver cirrhosis (LC; 20%). Thoracentesis was performed in all patients prior to surgery, with a mean ± standard deviation (SD) of 2.4±1.9 procedures per patient. Seven patients (28%) underwent IPC placement, with a median duration of 7 days (range, 2–236 days). Among them, 5 had short-term drainage of less than 2 weeks, while 2 had long-term drainage exceeding 6 months. Additional preoperative interventions included talc pleurodesis in 3 patients (12%) and fibrinolysis in 2 patients (8%). Ten patients (40%) had a history of thoracic surgery: five had undergone coronary artery bypass grafting, two had video-assisted thoracic surgery (VATS) pleurodesis for pleural effusion, two had heart valve repair and/or replacement, and one had a heart transplant. All patients with prior chest surgeries underwent interval imaging to confirm the absence of post-operative loculations before developing pleural effusions. The median time from initial detection of pleural effusion on chest imaging to decortication was 6.6 months (range, 0.7–94.4 months). Preoperative characteristics are detailed in Table 1.

CSNMPE was classified into the following etiologies: cardiac (n=7), hepatic (n=4), renal (n=4), multifactorial (n=5), autoimmune (n=2), and unknown (n=3) (Figure 2). Multifactorial etiology was defined as cases where at least two factors—cardiac, renal, hepatic, or autoimmune—contributed to the development of pleural effusion. Right-sided effusions were predominant, occurring in 16 patients (64%), and total lung decortication was achieved in 23 of 25 patients (92%). The operative approach was VATS in 12 cases (48%), robotic-assisted in 1 case (4%), and open thoracotomy in 12 cases (48%). The mean operation ± SD time was 192.5±74.7 minutes, and the median hospital length of stay was 7 days (range, 4–70 days). The mean ± SD estimated blood loss (EBL) was 400.0±355.6 mL. Intraoperatively, three patients required 1 unit of red blood cell (RBC), and one patient required 2 units. Postoperative complications occurred in 9 of 25 patients (36%), as summarized in Table 2. According to the Clavien-Dindo classification, six patients experienced Grade II complications. These included acute kidney injury, cardiac arrhythmia, subclavian vein deep vein thrombosis combined with prolonged air leak, right ventricular dysfunction following surgery for heart failure-related effusion, chylothorax with prolonged air leak, and suspected ipsilateral pneumonia. All were managed with pharmacologic or conservative treatment and resolved without further intervention. One patient with underlying chronic obstructive pulmonary disease (COPD), who had previously undergone coronary artery bypass grafting and aortic valve replacement before decortication, developed recurrent pleural effusion requiring a 14-Fr catheter drainage (Grade IIIa) and ultimately died of septic shock at 10.4 months postoperatively. Another developed recurrent bilateral pleural effusion and ipsilateral empyema requiring a Clagett procedure (Grade IIIb), who subsequently died of cardiogenic shock on postoperative 7.1 months. The most severe complication occurred in a patient who underwent decortication for hepatic hydrothorax following liver transplantation and subsequently died from recurrent pleural effusion with respiratory failure on postoperative 4.1 months (Grade V).

Figure 2 Pleural effusion etiology.

Two additional patients, who were discharged without complications, died within one year after decortication: one from cardiogenic shock and another, who had undergone preoperative hemodialysis, from unknown causes. Another patient developed small bilateral pleural effusions nearly 5 years after decortication, following acute decompensation before death. The median overall survival time was 65.3 months (range, 2.6–144.6 months). The survival rates at 1-, 3-, and 5-year were 80.0%, 63.8%, and 50.1% respectively (Figure 3). Radiographic improvement was observed in 24 patients (96%). Significant lung volume improvement (>75%) occurred in 20 patients (80%), while 2 patients (8%) showed moderate improvement and another 2 (8%) had mild improvement. Only 1 patient showed no improvement.

Figure 3 Overall survival curve in patients with decortication.

After decortication, 18 of 25 patients (72%) experienced improvement in clinical symptoms, including exertional dyspnea and persistent cough. Two patients (8%) remained asymptomatic before and after the procedure. The remaining five patients (20%) continued to experience exertional dyspnea, attributed to CHF (n=2), asbestosis (n=1), or recurrent pleural effusion (n=2).

In the univariable analysis to identify survival-related prognostic factors, the presence of ascites, a history of cancer treatment, EBL, RBC transfusion, and effusion recurrence were significantly associated with poor survival (Table 3). These variables, along with clinically relevant factors, such as the interval from pleural effusions to surgery and surgical approach, that were not statistically significant in the univariable analysis, were included in a multivariable Cox proportional hazards model. Ascites and effusion recurrence were later removed during model simplification because they lost significance in the multivariable context. The final model identified a history of cancer treatment (HR: 11.77, 95% CI: 1.96–70.62, P<0.01), pleural effusion duration (HR: 1.05 per month, 95% CI: 1.01–1.09, P=0.01), and EBL (HR: 1.005 per mL, 95% CI: 1.002–1.008, P<0.01) as independent negative prognostic factors for survival duration (Table 4).

Discussion

Most patients with CSNMPE are managed with non-operative treatments including medications, thoracentesis (18), chest tube drainage (19), or pleurodesis (20). However, it has been reported that approximately 10–20% of patients fail conservative treatment and may require decortication due to recurrent, symptomatic pleural effusion with entrapment of the lung (21,22). This study evaluated the long-term outcomes of pleural decortication for CSNMPE, explored its role as a therapeutic option for this disease entity and identified prognostic factors for survival. Our findings demonstrate that pleural decortication effectively provides significant symptom relief and radiographic improvement, with a median survival of 65.3 months. The 1-, 3-, and 5-year survival rates were 80.0%, 63.8%, and 50.1%, respectively. Our results showed a higher 1-year survival rate (80%) compared to those reported by Walker et al. (23) for patients with cardiac (43%), renal (54%), and hepatic (75%) pleural effusion. This may be because our study included only patients who underwent decortication surgery, most of whom had unilateral pleural effusion, which is generally associated with a better prognosis (24). We found that the 3- and 5-year survival rates after decortication remain high. Although few existing studies allow for direct comparisons of long-term survival outcomes, advancements in drug development, mechanical assist devices, organ transplant technology, and precision medicine in recent decades may have played a significant role in improving survival rates in patients with heart, liver, kidney, or lung failure (25-28).

Even under the clinical definition of CSNMPE, a wide range of underlying pathophysiologies may be present. When comparing survival outcomes by etiology, the unknown group (n=3) showed the most favorable long-term prognosis, with a 5-year survival rate of 100%. In contrast, the RF (n=4) and the autoimmune (n=2) groups had the poorest outcomes, with a 5-year survival rate of 0%. The multifactorial (n=5), cardiac (n=7) and hepatic (n=4) groups demonstrated intermediate outcomes, with 5-year survival rates of 50.0%, 57.1% and 75%, respectively. However, these findings should be interpreted with caution due to the small sample sizes within each subgroup and the potential influence of confounding factors. The subgroup analysis is exploratory in nature and requires validation in future prospective studies.

There is a paucity of reports on the long-term outcomes of decortication in patients with CSNMPE caused by autoimmune diseases. Kim et al. (5) reported a case of refractory bilateral massive pleural effusion in systemic lupus erythematosus that was successfully managed with pleurectomy and remained recurrence-free for 2 years. Heidecker et al. reported a case of pleural effusion due to a trapped lung secondary to sarcoidosis. Although long-term survival outcomes were not provided, they demonstrated that pleural effusion was resolved, and respiratory symptoms improved following partial decortication via thoracotomy (29). Our study included two cases of patients with autoimmune diseases: Neither patient experienced pleural effusion recurrence; however, the patient with sarcoidosis died at 27.3 months due to coronavirus disease 2019 (COVID-19), while the patient with psoriatic arthritis died at 38.4 months from pneumonia. An immunocompromised state is suspected to have significantly contributed to pneumonia-related mortality. The 30-day mortality rate following decortication for parapneumonic empyema has been reported to range from 3% to 9%, which represents a substantial operative risk that should not be underestimated in clinical decision-making (10,11,30,31). In our study, the CSNMPE group demonstrated a relatively low 30- and 90-day mortality rate (0% and 4%, respectively). This favorable outcome may be attributed to several factors. First, all surgeries were performed at a single high-volume center by experienced thoracic surgeons, ensuring consistent, high-quality surgical techniques. Second, the implementation of rigorous perioperative management protocols likely contributed to the early detection and prompt management of postoperative complications. Lastly, timely surgical intervention and careful patient selection may have further reduced the risk of mortality, despite the presence of significant underlying comorbidities.

To better understand and reduce surgical risk, several studies have focused on identifying prognostic factors associated with poor outcomes. Using the Society of Thoracic Surgeons Database, Towe et al. (11) identified multiple risk factors among patients with parapneumonic empyema and benign pleural effusion, including advanced age, estimated glomerular filtration rate (eGFR) <60, COPD, abnormal body mass index, higher American Society of Anesthesiologists (ASA) class, Zubrod performance status, and thoracotomy. Notably, delayed surgical intervention was also associated with worse outcomes. Zorbas et al. developed a predictive scoring model using data from a cohort of patients who underwent decortication irrespective of the underlying pathology (32). In this model, disseminated cancer emerged as the strongest risk factor for 30-day mortality. Other significant predictors included age ≥65 years, ventilator dependence, active hemodialysis, open wounds or wound infection, impaired preoperative functional status, systemic inflammation (systemic inflammatory response syndrome, sepsis, or septic shock), CHF, preoperative transfusion, dyspnea, and COPD. In our study, no variables were found to be significantly associated with postoperative complications. Notably, even factors that are potentially related to surgical complexity—such as preoperative talc pleurodesis (n=3) and previous chest surgery—did not show statistical significance. This may be attributed to the limited number of cases with complications (n=9) and the relatively small sample size. Our multivariable analysis revealed that a history of cancer treatment, greater intraoperative EBL, and a longer duration of pleural effusion were associated with poor survival outcomes after decortication surgery. Although the results should be interpreted with caution due to their exploratory nature, delaying decortication in patients with CSNMPE may lead to worse outcomes, as is seen in patients undergoing late surgical intervention for empyema (8,11,32). Prolonged disease progression can result in advanced fibrous adhesions and lung entrapment, complicating surgery and increasing the risk of conversion to thoracotomy, bleeding, prolonged air leak, and extended operation time. These findings are supported by data from our study which demonstrated an increased hazard of 5% per additional month from initial diagnosis of pleural effusion to surgical decortication. A ‘not too early, not too late’ strategy for surgical intervention may improve outcomes by minimizing intraoperative and postoperative complications, facilitating lung re-expansion, and avoiding unnecessary operations.

Despite these promising results, this study has several limitations. The retrospective design and small sample size (n=25) limit the generalizability of the findings and the robustness of statistical analyses. In particular, the limited sample size precludes robust multivariable analysis, and some HRs show extremely wide confidence intervals, undermining their reliability. In addition, the heterogeneity of underlying etiologies and surgical approaches complicates the ability to draw firm conclusions regarding optimal management for specific subgroups within the CSNMPE population.

We also acknowledge the potential for selection bias in our study, primarily due to the absence of a defined denominator for all CSNMPE patients. Without a standardized, prospectively applied protocol for determining “failure of conservative treatment”, the criteria for surgical candidacy may have varied across cases. However, as shown in Table 1, all patients underwent at least one drainage procedure (e.g., thoracentesis), with a mean of 2.4 procedures per patient. Furthermore, 28% received IPCs, with a median dwell time of 7 days. The median interval between initial diagnosis and decortication was 6.6 months, indicating that surgical intervention was typically reserved for patients with persistent or refractory disease after prolonged conservative management. We hope that providing this clinical context helps reduce the risk of potential selection bias and enhances the transparency and reproducibility of our study.

The lack of functional and objective outcome data such as pulmonary function tests or oxygen requirements before and after decortication hinders a comprehensive evaluation of the procedure’s impact on respiratory outcomes. This limitation confines the assessment of functional improvement to subjective symptom reporting and radiographic interpretation. Another limitation of this study is the use of an unvalidated grading system to assess lung re-expansion. The grading was based on two-dimensional radiographic changes rather than objective volumetric or quantitative imaging criteria, which may introduce subjectivity and limit reproducibility. Larger, prospective multicenter trials with standardized surgical protocols are warranted to validate these findings and refine patient selection criteria.

Conclusions

In conclusion, pleural decortication may represent a beneficial therapeutic option for selected patients with CSNMPE who do not respond to conservative management. In our small retrospective cohort, the procedure was associated with symptom relief, radiographic improvement, and prolonged survival in some cases. While these findings are encouraging, they should be interpreted as exploratory and hypothesis-generating. The potential benefits of early intervention, including reduction in surgical complexity and morbidity, warrant further prospective validation.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1203/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1203/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1203/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1203/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional review board (IRB) of Northwestern University (No. STU00220348) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Jany B, Welte T. Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment. Dtsch Arztebl Int 2019;116:377-86. [Crossref] [PubMed]
2. Karkhanis VS, Joshi JM. Pleural effusion: diagnosis, treatment, and management. Open Access Emerg Med 2012;4:31-52. [Crossref] [PubMed]
3. Quinn T, Alam N, Aminazad A, et al. Decision making and algorithm for the management of pleural effusions. Thorac Surg Clin 2013;23:11-6. v. [Crossref] [PubMed]
4. Rathinam S, Waller DA. Pleurectomy decortication in the treatment of the “trapped lung” in benign and malignant pleural effusions. Thorac Surg Clin 2013;23:51-61. vi. [Crossref] [PubMed]
5. Kim S, Park H, Cho YK, et al. Refractory Pleural Effusion in Systemic Lupus Erythematosus Treated by Pleurectomy. J Rheum Dis 2017;24:43-7.
6. Doelken P. Clinical implications of unexpandable lung due to pleural disease. Am J Med Sci 2008;335:21-5. [Crossref] [PubMed]
7. Boffa DJ, Mason DP, Su JW, et al. Decortication after lung transplantation. Ann Thorac Surg 2008;85:1039-43. [Crossref] [PubMed]
8. Lin CM, Chen YL, Cheng YF, et al. Optimal timing for video assisted thoracic surgery decortication for improved survival in chronic empyema. Sci Rep 2024;14:24548. [Crossref] [PubMed]
9. Rappaport JM, Siddiqui HU, Tang A, et al. Pleural space management after lung transplant: Early and late outcomes of pleural decortication. J Heart Lung Transplant 2021;40:623-30. [Crossref] [PubMed]
10. Tong BC, Hanna J, Toloza EM, et al. Outcomes of video-assisted thoracoscopic decortication. Ann Thorac Surg 2010;89:220-5. [Crossref] [PubMed]
11. Towe CW, Carr SR, Donahue JM, et al. Morbidity and 30-day mortality after decortication for parapneumonic empyema and pleural effusion among patients in the Society of Thoracic Surgeons’ General Thoracic Surgery Database. J Thorac Cardiovasc Surg 2019;157:1288-1297.e4. [Crossref] [PubMed]
12. Yang HC, Han J, Lee S, et al. Evaluation of decortication in patients with chronic tuberculous empyema by three-dimensional computed tomography densitometry. Thorac Cardiovasc Surg 2013;61:159-66. [Crossref] [PubMed]
13. Shin JA, Chang YS, Kim TH, et al. Surgical decortication as the first-line treatment for pleural empyema. J Thorac Cardiovasc Surg 2013;145:933-939.e1. [Crossref] [PubMed]
14. Bhatnagar R, Maskell NA. Treatment of complicated pleural effusions in 2013. Clin Chest Med 2013;34:47-62. [Crossref] [PubMed]
15. Bashour SI, Mankidy BJ, Lazarus DR. Update on the diagnosis and management of malignant pleural effusions. Respir Med 2022;196:106802. [Crossref] [PubMed]
16. Tan C, Sedrakyan A, Browne J, et al. The evidence on the effectiveness of management for malignant pleural effusion: a systematic review. Eur J Cardiothorac Surg 2006;29:829-38. [Crossref] [PubMed]
17. Markatis E, Perlepe G, Afthinos A, et al. Mortality Among Hospitalized Patients With Pleural Effusions. A Multicenter, Observational, Prospective Study. Front Med (Lausanne) 2022;9:828783. [Crossref] [PubMed]
18. Walker SP, Bintcliffe O, Keenan E, et al. Randomised trial of indwelling pleural catheters for refractory transudative pleural effusions. Eur Respir J 2022;59:2101362. [Crossref] [PubMed]
19. Harris K, Chalhoub M. The use of a PleurX catheter in the management of recurrent benign pleural effusion: a concise review. Heart Lung Circ 2012;21:661-5. [Crossref] [PubMed]
20. Glazer M, Berkman N, Lafair JS, et al. Successful talc slurry pleurodesis in patients with nonmalignant pleural effusion. Chest 2000;117:1404-9. [Crossref] [PubMed]
21. Rashid-Farokhi F, Pourdowlat G, Nikoonia MR, et al. Uremic pleuritis in chronic hemodialysis patients. Hemodial Int 2013;17:94-100. [Crossref] [PubMed]
22. Machicao VI, Balakrishnan M, Fallon MB. Pulmonary complications in chronic liver disease. Hepatology 2014;59:1627-37. [Crossref] [PubMed]
23. Walker SP, Morley AJ, Stadon L, et al. Nonmalignant Pleural Effusions: A Prospective Study of 356 Consecutive Unselected Patients. Chest 2017;151:1099-105. [Crossref] [PubMed]
24. DeBiasi EM, Pisani MA, Murphy TE, et al. Mortality among patients with pleural effusion undergoing thoracentesis. Eur Respir J 2015;46:495-502. [Crossref] [PubMed]
25. Sapna F, Raveena F, Chandio M, et al. Advancements in Heart Failure Management: A Comprehensive Narrative Review of Emerging Therapies. Cureus 2023;15:e46486. [Crossref] [PubMed]
26. Ho D, Quake SR, McCabe ERB, et al. Enabling Technologies for Personalized and Precision Medicine. Trends Biotechnol 2020;38:497-518. [Crossref] [PubMed]
27. Vandenbriele C, Bertoldi LF, Bruno F, et al. The role of temporary mechanical circulatory support in heart failure. Eur Heart J Suppl 2025;27:iv39-46. [Crossref] [PubMed]
28. Magyar CTJ, Li Z, Aceituno L, et al. Temporal evolution of living donor liver transplantation survival-A United Network for Organ Sharing registry study. Am J Transplant 2025;25:406-16. [Crossref] [PubMed]
29. Heidecker JT, Judson MA. Pleural effusion caused by trapped lung. South Med J 2003;96:510-1. [Crossref] [PubMed]
30. Mikkola R, Kelahaara J, Heikkinen J, et al. Poor late survival after surgical treatment of pleural empyema. World J Surg 2010;34:266-71. [Crossref] [PubMed]
31. Schweigert M, Solymosi N, Dubecz A, et al. Surgery for parapneumonic pleural empyema--What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome? Surgeon 2016;14:69-75. [Crossref] [PubMed]
32. Zorbas KA, Abbas AE, Song KJ, et al. A simple prediction score for postoperative mortality after decortication. J Thorac Dis 2023;15:6483-92. [Crossref] [PubMed]