Tan Carol, Sedrakyan Artyom, Browne John, Swift Simon, Treasure Tom
Thoracic Unit, Guy's Hospital, St Thomas' Street, London SE1 9RT, United Kingdom.
Eur J Cardiothorac Surg. 2006 May;29(5):829-38. doi: 10.1016/j.ejcts.2005.12.025. Epub 2006 Apr 12.
The aim of this study was to review systematically the available evidence on pleurodesis for malignant effusion, focusing on the choice of the agents, route of delivery and other strategies to improve outcomes. Four electronic databases (MEDLINE, EMBASE, Web of Science and Cochrane Controlled Trials Register) were searched, reference lists checked and letters requesting details of unpublished trials and data sent to authors of previous trials. Studies of malignant pleural effusion in humans were selected with no language restrictions applied. Criteria for randomised clinical trial (RCT) eligibility were random allocation of patients and non-concurrent use of another experimental medication or device. Methodological quality evaluation of the trials was based on randomisation, blinding, allocation concealment and intention to treat analysis. A random effect model was used to combine the relative risk estimates of the treatment effects whenever pooling for an overall effect was considered appropriate. Forty-six RCTs with a total of 2053 patients with malignant pleural effusions were reviewed for effectiveness of pleurodesis. Talc tended to be associated with fewer recurrences when compared to bleomycin (RR, 0.64; 95% CI, 0.34-1.20) and, with more uncertainty, to tetracycline (RR, 0.50; 95% CI, 0.06-4.42). Tetracycline (or doxycycline) was not superior to bleomycin (RR, 0.92; 95% CI, 0.61-1.38). When compared with bedside talc slurry, thoracoscopic talc insufflation was associated with a reduction in recurrence (RR, 0.21; 95% CI, 0.05-0.93). Strategies such as rolling the patient after instillation of the sclerosing agent, protracted drainage of the effusion and use of larger chest tubes were not found to have any substantial advantages. Talc appears to be effective and should be the agent of choice for pleurodesis. Thoracoscopic talc insufflation is associated with fewer recurrences of effusions compared with bedside talc slurry, but this is based on two small studies. Where thoracoscopy is unavailable bedside talc pleurodesis has a high success rate and is the next best option.
本研究旨在系统回顾有关恶性胸腔积液胸膜固定术的现有证据，重点关注药物选择、给药途径及其他改善治疗效果的策略。检索了四个电子数据库（MEDLINE、EMBASE、科学网和Cochrane对照试验注册库），检查了参考文献列表，并向以往试验的作者发送信件，索要未发表试验的详细信息及数据。入选了关于人类恶性胸腔积液的研究，无语言限制。随机临床试验（RCT）的纳入标准为患者随机分配，且不同时使用另一种试验性药物或装置。试验的方法学质量评估基于随机化、盲法、分配隐藏和意向性分析。每当认为合并总体效应合适时，使用随机效应模型合并治疗效果的相对风险估计值。对46项RCT（共2053例恶性胸腔积液患者）进行了胸膜固定术有效性的回顾。与博来霉素相比，滑石粉导致的复发似乎较少（RR，0.64；95%CI，0.34 - 1.20），与四环素相比，不确定性更大（RR，0.50；95%CI，0.06 - 4.42）。四环素（或强力霉素）并不优于博来霉素（RR，0.92；95%CI，0.61 - 1.38）。与床边滑石粉悬液相比，胸腔镜滑石粉吹入术可降低复发率（RR，0.21；95%CI，0.05 - 0.93）。未发现诸如硬化剂注入后让患者翻身、长时间引流胸腔积液及使用更大的胸管等策略有任何实质性优势。滑石粉似乎有效，应作为胸膜固定术的首选药物。与床边滑石粉悬液相比，胸腔镜滑石粉吹入术导致的胸腔积液复发较少，但这基于两项小型研究。若无法进行胸腔镜检查，床边滑石粉胸膜固定术成功率高，是次优选择。
