CORRESPONDENCE

Year : 2020  |  Volume : 37  |  Issue : 4  |  Page : 354-355

Medical thoracoscopic cryoevacuation: A novel technique to manage retained hemothorax

Madhu Sudan Barthwal, Tushar Sahasrabudhe
Department of Respiratory Medicine, Dr. D Y Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India

Correspondence Address:
Madhu Sudan Barthwal
Department of Respiratory Medicine, Dr. D Y Patil Medical College, Hospital and Research Centre, Pune, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/lungindia.lungindia_364_19

1. Authors have rightly mentioned in the introduction that induction of medical thoracoscopy and CryoProbe has opened newer vistas in the field of interventional pulmonology. However, higher costs, limited availability, and more invasiveness are important limiting factors for using such newer modalities in our country. In view of this, we must not abandon simpler, lesser invasive, and affordable interventions such as closed pleural biopsy, which have fairly good diagnostic yield of 70%–80% and should be used as the first line of investigation. Similarly, intrapleural fibrinolytic therapy (IPFT) is an easier, safer, and cost-effective intervention to deal with clotted/retained hemothorax, which we would like to elaborate here
2. IPFT in loculated effusions of various etiologies has been in use in our country for the last two decades.^[2] Various studies on the use of IPFT in clotted hemothorax has shown a success rate of 91%–93%.^[3],[4] The mean duration between diagnosis and initiation of IPFT was 4–25 days.^[3] IPFT has been recommended as the first-line therapy in clotted hemothorax before proceeding to minithoracotomy, thoracoscopy, or pleural decortication.^[3] IPFT, in clotted hemothorax of 2 weeks' duration in a 6-year-old child, was successfully used for the first time in our institution in 2005, but somehow, it could not be reported [Figure 1] and [Figure 2]. First reported case of successful IPFT in clotted hemothorax in a 34-year-old male was by Agarwal et al. in 2006.^[5] In a 5-year study of IPFT in loculated pleural collections by Barthwal et al., out of 12 cases of traumatic clotted hemothorax, 11 (91.6%) had successful resolution.^[6] In this study, the duration between occurrence of hemothorax and initiation of IPFT, also known as age of effusion, was 1–4 weeks. The cases, which do not respond to IPFT, can then be subjected to either video-assisted thoracoscopic surgery or conventional thoracotomy
3. The standard therapeutic approach in the present case should have been first doing an intercostal tube drainage (ICD) under ultrasonography (USG) guidance and when the drainage would have become insignificant with tube being correctly positioned and patent, re-evaluating the patient with USG or contrast-enhanced computed tomography (CT) thorax for estimation of size of remaining fluid and associated loculations or organization.^[2] After confirming the presence of clotted or retained hemothorax (which was done on the basis of CT thorax in the present case), authors should have then chosen the various modalities including the newer technique used in the present case. It will be pertinent to mention here that in comparison to CT scan, USG is a better modality for assessment of free fluid and loculations and for guiding drainage. Further, initial drainage of a significant amount of hemothorax with ICD (1.45 L in this case) before intervention would have significantly reduced the risk of thoracoscopic intervention under general anesthesia
4. The first therapeutic modality in the present case should have been IPFT in view of her presentation within 8 days of trauma (lesser the duration of effusion, better the effectiveness of IPFT), lesser invasiveness, and cost-effective aspects of IPFT. The risk associated with medical thoracoscopy and cryoevacuation under single-lung ventilation in an 82-year-old patient is significantly higher in comparison to IPFT. In addition, IPFT as a first modality in such cases becomes much more relevant in our country where other options are either not available or nonaffordable in most of the centers. Even in centers where these more invasive and costly procedures are available along with adequate expertise, not using IPFT as the first line of therapy may not be justifiable. Authors have surprisingly not even mentioned this modality in discussion. This may encourage increased usage of this type of newer modalities, especially among younger pulmonologists who have more penchants for interventions.

Figure 1: Chest radiograph showing clotted hemithorax (left) with a chest tube in situ Click here to view

Figure 2: Chest radiograph showing complete resolution after intrapleural fibrinolytic therapy Click here to view

References

1.	Srinivasan A, Sivaramakrishnan M, Pattabhiraman VR, Vinod VG. Medical thoracoscopic cryoevacuation: A novel technique to manage retained hemothorax. Lung India 2019;36:356-9.   [PUBMED]  [Full text]
2.	Barthwal MS. Intrapleural fibrinolytic therapy in complicated parapneumonic effusion and empyema: Present status. Indian J Chest Dis Allied Sci 2008;50:277-82.
3.	Inci I, Ozçelik C, Ulkü R, Tuna A, Eren N. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax. Chest 1998;114:160-5.
4.	Kimbrell BJ, Yamzon J, Petrone P, Asensio JA, Velmahos GC. Intrapleural thrombolysis for the management of undrained traumatic hemothorax: A prospective observational study. J Trauma 2007;62:1175-8.
5.	Agarwal R, Aggarwal AN, Gupta D. Intrapleural fibrinolysis in clotted haemothorax. Singapore Med J 2006;47:984-6.
6.	Barthwal MS, Marwah V, Chopra M, Garg Y, Tyagi R, Kishore K, et al. A five-year study of intrapleural fibrinolytic therapy in loculated pleural collections. Indian J Chest Dis Allied Sci 2016;58:17-20.