Minimally invasive pericardial window surgery with video-assisted thoracoscopy in patients with malignancy

Introduction

Pericardial effusion can occur as a result of various local and systemic diseases. This large amount of effusion accumulating in the pericardium is generally seen in conditions such as malignancies, tuberculous pericarditis, myxedema, vasculitis, connective tissue diseases, hypercholesterolemia, and parasitosis [1]. There are many different mechanisms that cause the development of pericardial effusion in patients undergoing oncological treatment. It can occur either by direct invasion or metastatic spread of the primary disease, and can also be viewed as a complication of antineoplastic treatments. In some patients, it may also develop due to chemotherapeutic toxicity, radiation toxicity, or opportunistic infections in the setting of immunosuppressive therapy [2]. Regardless of the etiology, depending on the amount of pericardial effusion, cardiac tamponade that disrupts the patient’s hemodynamics may develop. Emergency drainage intervention is required in these patients to eliminate existing cardiac compression.
There are many approaches for pericardial effusion drainage and treatment. Different techniques such as subxiphoid and transthoracic approaches, pericardiocentesis, percutaneous balloon pericardiotomy, pericardial sclerosis, and videothoracoscopy can be used, but which one is more effective is still controversial [3]. Minimally invasive drainage of pericardial effusion can be done with the aid of a catheter, transxiphoid procedures or by opening a pericardial window [4–6]. When choosing a drainage method, the stage of the tumor, the amount of pericardial effusion and the symptoms it produces must be taken into account. In emergency situations such as cardiac tamponade or in the case of significant effusion, initial relief can be achieved with pericardiocentesis. However, many studies have shown that opening a pericardial window is more effective for long-term survival in these patients [7].
Pericardial window with video-assisted thoracoscopic surgery (VATS) is an effective procedure for malignant pericardial effusion. In this article, we share the results of our patients who were diagnosed with primary malignancy and who underwent pericardial window surgery due to symptomatic pericardial effusion.

Material and methods

Patients who underwent pericardial window surgery with videothoracoscopy due to recurrent and symptomatic pericardial effusion in our clinic between March 2015 and September 2023 were included in the study. All patients had malignant etiology. Patients without a diagnosis of malignancy were excluded from the study. Patients at high cardiac risk were treated under sedation. To maintain cardiac function, all patients eligible for general anesthesia were operated on using single lung ventilation.

Surgical technique

Pericardial window surgery was used as a therapeutic option for symptoms in the case of pericardial effusion affecting severe effusion accumulation and associated cardiac work. The anesthesia team decided to operate with general anesthesia or sedation. Sedation was applied to high-risk patients for general anesthesia. In this technique, applied with the help of VATS, port incisions were determined according to the localization of the effusion. The patient was placed in the supine position, and a support was placed under the back and raised 45°. The pericardium was opened using endoscissors, and the effusion in the pericardium was evacuated with an aspirator. Later, the pericardium was suspended with an endo- dissector and a window with an average diameter of 2 × 2 cm was created in the pericardium (Fig. 1). Pleural biopsy was also taken after it was seen that the effusion was drained completely. At the end of the operation, a Hemovac drain was placed in the chest cavity and the operation was terminated. Pericardial effusion can occur as a result of various local and systemic diseases. This large amount of effusion accumulating in the pericardium is generally seen in conditions such as malignancies, tuberculous pericarditis, myxedema, vasculitis, connective tissue diseases, hypercholesterolemia, and parasitosis [1]. There are many different mechanisms that cause the development of pericardial effusion in patients undergoing oncological treatment. It can occur either by direct invasion or metastatic spread of the primary disease, and can also be viewed as a complication of antineoplastic treatments. In some patients, it may also develop due to chemotherapeutic toxicity, radiation toxicity, or opportunistic infections in the setting of immunosuppressive therapy [2]. Regardless of the etiology, depending on the amount of pericardial effusion, cardiac tamponade that disrupts the patient’s hemodynamics may develop. Emergency drainage intervention is required in these patients to eliminate existing cardiac compression.

Results

The study included 24 patients with malignancy etiology and opening pericardial windows with video‑assisted thoracoscopic surgery (VATS). Eighteen (75%) of the patients were male and 6 (25%) were female. The average age was 56 ±14.1 (24–76) years. The mean ECOG score of the patients was 2.33. All the patients had symptoms such as rapid fatigue, shortness of breath and pretibial edema (Table 1). The patients were evaluated preoperatively in terms of cardiac functions by echocardiography and the amount of pericardial effusion was measured. As radiological imaging, a chest X-ray was taken and computed tomography of the thorax was performed with intravenous contrast (Fig. 2). Thus, pericardial thickness, presence of tumor invading the pericardium, amount and localization of pericardial effusion, presence of pleural effusion and metastatic nodules in the pleura were examined.
The pericardial window was opened on the right side in 17 (71%) patients and on the left in 7 (21%) patients. The VATS procedure was performed under sedation in 5 patients and general anesthesia in 19 patients. For the surgical intervention, a uniport incision was used in 7 patients, a biportal incision in 6patients, and a triport incision in 11 patients. The mean operation time was 50.3 ±12.4 minutes. The patients were taken to the intensive care unit for 1 day in the postoperative period, and there were no patients whose intensive care unit period was prolonged.
Hemovac drainage was placed in the hemothorax. After the effusion drainage fell below 200 ml/day and the absence of fluid was checked with chest radiography (Fig. 3), the drainage was removed and the patient was discharged. The average duration of hospital stay was 5.1 ±2.3 (3–10) days. Since recurrence was observed in only one patient, a pericardial window was subsequently opened for this patient due to left hemothorax. Pathological results of patients in pericardial biopsies: pericardial metastasis of the primary tumor in 16 (67%) patients, in 5 (21%) patients reported as benign and in 3 (12%) patients as chronic pericarditis (Table 2). In pericardial effusion pathology, the results of 14 patients were compatible with primary malignancies, while those of the remaining 10 patients were reported as benign pericardial effusion (Table 2). Postoperative complications were atrial fibrillation in 1 patient and wound infection in 1 patient. Mortality was observed in 1 patient in the first postoperative month in our series. We did not have any patients whose pericardial effusion recurred during outpatient clinic controls.

Discussion

The incidence of massive pericardial effusion is gradually increasing in patients diagnosed with malignancy. It is most commonly seen in patients with a diagnosis of lung and breast cancer, and it is reported that only 50% of these effusions are malignant [8]. The primary goal in these patients is to prevent the occurrence of cardiac tamponade [9]. In asymptomatic patients, oncological treatment for the tumor is in the foreground, and in patients with massive pericardial effusion, effusion drainage is required. The general view in pericardial effusion drainage is in favor of choosing the most minimally invasive procedure. In this way, the chemotherapy of the patient is not interrupted and the patient is not delayed in receiving treatment [10]. Pericardial window opening with video-assisted surgery, which has been increasingly reported in recent years, can be applied as a minimally invasive technique. In particular, VATS is a useful technique both for viewing the pleural surface and taking a biopsy and for surgical intervention in the pericardium [11]. It has been reported that this surgery improves the quality of life in patients with chemotherapy-resistant malignant pericardial effusion and has positive effects on survival [12].
Triviňo et al. [13] reported in a series of 56 patients that opening a pericardial window with the help of VATS is an effective method, especially for chronic pericardial effusions. In their series, 23% of the patients had malignant diagnoses and no intraoperative mortality was observed. In our series, 67% of the patients had malignant pericardial biopsy results. We think that the high result here is due to the fact that all of our patients were being followed up for primary malignant disease. Rocco et al. [14] successfully used the uniportal technique in patients during pericardial window opening with VATS. They also performed an anterior mediastinal biopsy in 1 patient from this series. Although it is a series of 4 patients and includes a limited number of patients, this is important because it shows that the operation can be performed uniportally. In our series, a pericardial window was opened with uniportal VATS in 7 patients, and in 2 of these patients, the procedure was performed under sedation and local anesthesia.
With the help of minimally invasive techniques such as VATS, the recovery time and overall hospital stay of thoracic surgery patients are shortened. We can see this in the study of Fibla et al. [15]; in their study including 12 patients, the average length of stay in hospital was found to be 3.8 days. The pericardial window was opened on the left side in all patients, and it was reported that all of these patients also had pleural effusion. In our series, pleural biopsy was performed in all patients at the same time, and the pleural pathology was found to be malignant tumoral infiltration in 18 patients. Unlike Fibla’s study, our patient hospitalization period was 5.1 days. Also differing from our study, Fibla stated that in 8 of 12 patients, chemical pleurodesis with talc was applied [15]. We did not apply chemical pleurodesis in any of our patients in order not to prevent the drainage of pericardial effusion into the pleural space.
There are also studies in which sclerotic agents are applied to the pericardial space to prevent recurrence of pericardial effusion. In the study of Anderson et al. [16], they compared various methods in the treatment of pericardial effusion in 59 patients diagnosed with malignancy. As a result of that study, sclerotic agents such as tetracycline or doxycycline hydrochloride were administered to the pericardial space with the aid of a catheter in 10 patients. They found that this treatment was both effective and low-cost in selected patients [16]. In the study of Niclauss et al. [17], the results of 49 patients who underwent pericardiotomy were evaluated. It was found that the recurrence rate of pericardial effusion was low in patients who received bleomycin intrapericardially, but this procedure did not improve survival. Bischiniotis and colleagues [18] recommended pericardiocentesis followed by cisplatin instillation to prevent recurrence of malignant pericardial effusion, especially in patients with a diagnosis of non-small cell lung cancer, and stated that this technique prevents recurrence of effusion.
Lung cancers are the origin of malignancy in many studies in which pericardial window surgery is performed [19–21]. In our study, lung cancers were the most common tumor, with a rate of 42% in pericardial pathology results. When we look at the literature, breast cancer and hematological malignancies are also reported as tumors with a high rate of spread in the pericardium [20, 21]. In these patients, primary tumor histology and the continuation of oncological treatment in addition to pericardial effusion therapy are important reasons for increased survival [22]. Therefore, performing the pericardial window procedure with a minimally invasive technique such as VATS enables the patient to return to the treatment earlier.

Conclusions

It is important to use minimally invasive techniques instead of invasive procedures such as thoracotomy in patients with malignancy who are being followed up for pericardial effusion. Performing major surgery in addition to treatments that disrupt the general condition of the patient such as chemotherapy and radiotherapy will increase the rate of morbidity and mortality. However, by opening a pericardial window with minimally invasive techniques, patient recovery accelerates in the postoperative period and the duration of hospital stay is shortened. Therefore, uniportal or multiportal VATS can be recommended as an ergonomic and minimally invasive technique in patients who are followed up for malignancy. Our study has shown that the pericardial window procedure performed with VATS is a safe and effective palliative treatment method. Interpretation can also be made in terms of survival with multi-center studies involving larger patient series.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References