The role of video-assisted thoracoscopic surgery for management of symptomatic pleural effusion after coronary artery bypass surgery: a best evidence topic report

A best evidence topic in thoracic surgery was written addressing whether video-assisted thoracoscopic surgery (VATS) talc pleurodesis could be justified in patients with pleural effusion (PE) after coronary artery bypass graft (CABG) surgery and no-responded to repeated thoracentesis. Ten papers were identified to answer the question. Of these, two were case-series study including ≥4 patients, 7 retrospective analytical studies, and one observational study but no randomized controlled trial (RCTs) was included in the analysis. The score of the level of evidence was low; only one study presented a level of evidence of 2, 7 studies a level of 3b; and two studies a level of evidence of 4. The incidence of symptomatic post-CABG PE ranged from 2% to 9.7%. Management strategies included medical management, thoracentesis, and/or surgical drainage. Most of the authors treated early and late PE with thoracentesis or chest drainage, while VATS with pleurodesis was reserved only for selected patients with persistent effusion after repeating thoracentesis and/or chest drainage. All studies but one do not include follow-up, thus rendering it difficult to define the real role of thoracentesis or chest drainage as definitive treatments for effusion, given the incomplete data regarding how many patients’ effusions recur. Conversely, with follow up reported, no case of recurrence was found after VATS procedure. In patients who underwent delayed VATS, it was common to identify the formation of tenacious peel that trapped the lung. In three cases conversion to thoracotomy was required to decorticate the inflammatory peel that covered the pleura and did not allow the lung re-expansion. However, only five papers showed that VATS for management of post-CABG PEs is safe and efficacious and its use could help to prevent trapped lung through the resection of adhesions and loculations sometimes associated with multiple previous thoracentesis or chest drainage. As the low grade of evidence from the present analysis, future randomized controlled studies are wanted to define the real effectiveness of VATS in this field.