Pleuroperitoneal Shunting for Malignant Pleural Effusions z ALEX G. LITTLE, MD, MARK K. FERGUSON, MD, HARVEY M. GOLOMB, MD, PHILIP C. HOFFMAN, MD, NICHOLAS J. VOGELZANG, MD, AND DAVID B. SKINNER, MD zyxw Traditional therapy for malignant pleural effusions includes thoracentesis or tube drainage with instillation of irritants to achieve pleurodesis. This zyxwvu can require a lengthy hospitalization, causes pain and discomfort, and has an appreciable failure rate. Because of these drawbacks, the authors used a shunting device to transfer fluid to the peritoneal cavity in 17 patients with malignant pleural effusions. Eleven patients had undergone previous therapeutic thoracenteses and three had chest tube placement with failed sclerosis. The shunt was a subcutaneous valved pump chamber with attached pleural and peritoneal catheters, which used manual compression to transfer fluid against the normal abdominal/pleural pressure gradient. Op- erative placement under local or general anesthesia was performed without complication. Five patients achieved minimal benefit, either because of moribund status (2) or their inability to compress the pump effectively (3). In the other 12 patients, there was radiographic evidence of diminished or stabilized pleural effusion; respiratory symptoms were effectively palliated, and no further treatment for their effusion was required. Peritoneal dissemination of malignant cells has not been clinically detected. We feel that pleu- roperitoneal shunting is a valid new method for treatment of malignant pleural effusionswhich zyx can effectively palliate respiratory symptoms with low morbidity. Advantages include the absence of external tubing and the possibility for only a short hospitalization or even outpatient placement. Shunting is applicable for patients who are able to perform the requisite pumping and is particularly suitable for those with trapped lungs or who have failed attempted pleural sclerosis. zyxwvu Cancer 58:2740-2743, 1986. RADITIONAL THERAPY for malignant pleural effu- zyxwv T sions consists of thoracentesis or intercostal tube drainage with subsequent instillation of pleural irritants to achieve pleurodesis. These processes can require a lengthy hospitalization, cause pain and discomfort for the patient and have an appreciable complication and failure rate.' zyxwvuts Because of these drawbacks we have used a shunting device to transfer pleural fluid to the peritoneal cavity in patients with symptomatic malignant pleural effusions to determine the risks of placement, to evaluate associated morbidity, and to assess efficacy of palliation of respiratory symptoms. zyxwvutsr Materials and Methods Patient Population A total of 19 ( 15 unilateral and 2 bilateral) pleuroper- itoneal shunts were placed in 17 patients with cytologically proven malignant pleural effusions. The primary malig- nancy was cancer of the lung in ten patients, of the kidney From the Departments of Surgery and Medicine, The University of Chicago Medical Center, Chicago, Illinois. Address for reprints: Alex G. Little, MD, The University of Chicago, Department of Surgery (Box 168), 5841 S. Maryland Avenue, Chicago, Illinois 60637. Accepted for publication June 1 1, 1986. in one, colon in two, esophagus in two, and prostate in one. One patient had metastatic Ewing's sarcoma. All were receiving systemic therapy for their primary malignancy. Multiple therapeutic thoracenteses had failed to resolve the effusion in 1 1 patients, in four of whom nonexpansion of the lung, trapped lung, following thoracentesis was ra- diographically documented. Three other patients had chest tube placement with unsuccessful attempts at pleural sclerosis by injection of tetracycline. All patients were judged to be symptomatic from their pleural effusion with marked dyspnea attributed to restriction of lung expan- sion. Materials The silicone rubber shunt (Figure 1) consists of a valved pump chamber with attached fenestrated pleural and peritoneal catheters, known as the Denver Pleuro-Peri- toneal Shunt (Denver Biomaterials, Inc., Denver, CO). Although spontaneous flow occurs when the pressure gra- dient exceeds one cm of water, manual compression of the pump chamber is usually required because the pleural/ abdominal pressure gradient is typically negative. The pump chamber capacity is approximately 1.5 cc; the force required for compression is small as the valves open at a positive pressure of about one cm of water. A pumping 2740