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Welcome to part two of the Behind the Night clinical challenges in thoracic surgery, with your Swedish thoracic surgery team.

We're discussing complex pleural effusions and impayma.

In part one, we discussed intru pleural, fibrinolinic therapy for the management of these effusions.

We talked about the MIS-2 trial, which demonstrated TPA and DNAs are effective in draining the tests.

But randomized clinical trial data is lacking when it comes to comparing intru pleural fibrinolinics to surgical management.

Recall in part one, our case discussed a 39-year-old male, with three days of symptoms, who presented with a large, left-sided paranumonic effusion, which was successfully treated with lytic therapy.

In part two, we'll discuss the nuances of surgical management of these patients, including de-cortication with vats versus open-throw economy, as well as what to do when faced with someone who is a poor surgical candidate, but isn't responding to medical treatment alone.

Hello, and welcome to part two in clinical challenges in thoracic surgery, complex pleural effusions and impayma.

In part one, we discussed a 39-year-old male, with a complex paranumonic pleural effusion, who underwent lytic therapy, with excellent resolution of his effusion and symptoms.

In part two, we're going to change the scenario up a bit, as we discuss the nuances of the surgical management of pleural effusions and impayma. Enjoy.

So, what about if this patient actually came in, and they had two months of a cough, shortness of breath, was progressively worsening, modally elevated leukocytosis, chest X-ray shows a large, right pleural effusion, but on CT rather than a relatively benign, no major eloculations.

Instead, this has multiple eloculations, severe pleural think thickening over a centimeter, blunted, rounded edges. Well, what's going to be different about this scenario compared to our initial patient, that was more of an acute picture?

So, Peter, this is where we start talking about jumping right into maybe surgical management of a complicated pleural effusion with a trap lung, and the thick rind and the cronicity of a symptom suggests that this is more like a chronic impayma at this point in time, or a chronic pleural space with a trap lung in.

This is a patient, who we believe is less likely to be successful with lytic therapy alone, but remember, these are still clinical judgments without published data to back them.

So, as before, he would start, he started an IV at about therapy, if there's instability, respiratory distress, secondary to his effusion, a chest tube would be placed for source control or to at least start to drain some of the fluid.

But beyond that, we need to start discussing surgical options, though, as a set, tube is always the first choice to figure out what we've got before we get going down too far down the pathway.

But, so before we allow Cali to talk here, I just want to say that for the purposes of a randomized clinical trial, it's important that we don't use this sort of judgment, and that all these patients are at least discussed and included in a randomized clinical trial.

Agreed? Agreed.

They meet inclusion criteria. Correct. If they meet inclusion criteria that are set up up priori. So, I think it's just critically important that while there's a lot of discussion, sheer decision-making in art, the purposes of a well-designed randomized clinical trial is that we answer these questions and patients that are appropriate are enrolled.

And, Dr. Gordon's trial, everybody got a tube first to see whether or not the effusion would drain its entirety on its own before we decided about the litix or not.

So, and that still remains a very good teaching point for all the folks on the listing on the podcast is we always put a tube first to figure out what we've got.

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