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Impact of pleural symphyses through video-assisted thoracoscopic surgery on the quality-of-life improvement in patients with malignant pleural effusions at the thoracic and cardiovascular surgery unit of the University Hospital of Fann, Senegal
, Souleymane Diatta2, Gabriel Ciss2
*Corresponding author: Arroye Betou Fabrice Stephane, Department of Cardiothoracic and Vascular Surgery, University of Yaoundé 1, Yaoundé, Cameroon. arroyefabrice@yahoo.fr
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Received: ,
Accepted: ,
How to cite this article: Stephane ABF, Diop MS, Diop MS, Mireille ON, Laurent-Mireille EM, Diatta S, et al. Impact of pleural symphyses through video-assisted thoracoscopic surgery on the quality-of-life improvement in patients with malignant pleural effusions at the thoracic and cardiovascular surgery unit of the University Hospital of Fann, Senegal. J Pan Afr Thorac Soc. doi: 10.25259/JPATS_14_2025
Abstract
Objectives:
Malignant pleural effusion, often associated with advanced-stage cancers, causes debilitating symptoms that significantly impact patients’ quality of life. Although pleurodesis through video-assisted thoracoscopic surgery (VATS) is a common treatment for this condition, its effect on quality of life remains poorly documented, particularly in resource-limited settings like Senegal. This study aims to assess the impact of VATS pleurodesis on patients’ quality of life.
Material and Methods:
We conducted a prospective study over a 5-year period (January 01, 2017–January 01, 2022) in the Thoracic and Cardiovascular Surgery Unit of the University Hospital of Fann. A total of 72 patients with recurrent, suspected, or confirmed malignant pleural effusion were enrolled. Quality of life was assessed using the Medical Outcomes Study 36-item Short Form Health Survey (MOS SF-36). The non-parametric Wilcoxon test was used to compare scores across the eight dimensions of the MOS SF-36 before and after VATS pleurodesis.
Results:
The mean age of patients was 50 ± 14 years, ranging from 24 to 73 years. Females represented the majority (67%) compared to males (33%), with most women being housewives (48%). VATS pleurodesis significantly improved the physical functioning score (p < 0.001), role limitations due to physical health (p = 0.003), bodily pain score (p = 0.03), general health score (p < 0.001), vitality score (p < 0.001), role limitations due to emotional health (p < 0.001), and mental health score (p = 0.03).
Conclusion:
VATS pleurodesis significantly improves the quality of life of patients suffering from recurrent or malignant pleural effusions. The study highlights substantial improvements across several dimensions of the MOS SF-36, such as physical functioning, vitality, and mental health. These findings underscore the importance of assessing quality of life in the management of these patients.
Keywords
Malignant pleural effusion
Pleurodesis
Quality of life
Video-assisted thoracoscopic surgery
INTRODUCTION
Malignant pleural effusion, a complication of advanced cancers such as lung and breast cancer, is characterized by tumor cells in the pleural cavity, leading to symptoms such as chest pain and dyspnea.[1] It affects 15–50% of cancer patients, with a higher prevalence in developed countries.[2] In Africa, its epidemiology is underestimated due to limited healthcare access, as seen in Ghana.[3] In Senegal, where lung and breast cancers are prevalent, the burden of cancer is increasing.[4] Research emphasizes adapting healthcare policies to epidemiological trends[5] and highlights challenges in accessing palliative care that may impact pleural effusion prevalence.[6] Globally, this condition remains significant in cancer management.[7]
The treatment of malignant pleural effusions includes pleural drainage for temporary relief, though recurrence is common.[8] Pleurodesis with sclerosing agents aims to prevent fluid reaccumulation but has variable efficacy and may cause pain.[9] Intrapleural chemotherapy targets the effusion but poses risks of systemic side effects.[10] Radiotherapy helps manage fluid and pain, but requires multiple sessions and does not address the existing fluid.[11] Systemic chemotherapy acts slowly and has significant side effects.[12] Video-assisted thoracoscopic surgery (VATS) pleurodesis offers a minimally invasive approach with direct pleural cavity assessment, effective fluid evacuation, and improved sclerosing outcomes, potentially reducing complications.[13] These treatments focus on symptom relief and quality of life in advanced disease stages.
VATS pleurodesis improves the quality of life for patients with malignant pleural effusions by alleviating pain, easing breathing, and reducing anxiety.[14] It minimizes the need for frequent hospitalizations for thoracic drainage, offering greater comfort and autonomy. Light highlights that this procedure enhances lung function, mitigates symptoms, and supports daily activities and social interactions, contributing to an overall better quality of life.[15,16]
This study, therefore, aimed to assess the impact of VATS pleurodesis on improving the quality of life of patients with malignant pleural effusions treated in the Thoracic and Cardiovascular Surgery Unit of the University Hospital of Fann in Senegal.
MATERIAL AND METHODS
Study type, period, and location
We conducted a prospective study over a 5-year period (January 01, 2017–January 01, 2022) in the Thoracic and Cardiovascular Surgery Unit of the University Hospital of Fann, after obtaining ethical approval from the Université Cheikh Anta Diop (UCAD) Ethics and Research Committee. A total of 51 patients with recurrent, suspected, and/or confirmed malignant pleural effusion were recruited.
Study population, type of study, and surgical technique
The study included hospitalized patients with confirmed malignant pleural effusion, identified by malignant cells in pleural fluid or tumor proliferation in pleural biopsy histology. It also included recurrent exudative pleural effusions of probable neoplastic origin associated with proven primary malignancy, excluding other causes, particularly tuberculosis (negative GeneXpert test). VATS was performed through a uniportal approach. After an approximately 3 cm incision on the superior border of the 6th intercostal space, we dissected the muscles along the direction of the fibers without severing them, and then opened the intercostal space after excluding the lung. We then introduced the 10 or 11 mm trocar, followed by the 0° laryngoscope, which allowed us to explore the pleural cavity. Once the pleural biopsy was performed, followed by aspiration of the pleural fluid, we ensured satisfactory lung re-expansion using manual ventilation administered by the anesthesiologist. The lung was then re-extruded, and talc was applied to the parietal pleura using a bulb syringe. For each procedure, two three-gram vials of STERITALC (magnesium silicate) were used. After this, a pleural drain was inserted, and lung re-expansion was performed again under video guidance after the instruments were removed. If lung re-expansion failed, the subsequent procedure consisted primarily of chest drain placement and surgical closure. Patients were required to have a minimum of 6-month follow-up after surgery.
Exclusions included patients with <6 months of follow-up, those treated by alternative methods, incomplete or unusable records, tuberculosis-positive samples, and those lost to follow-up.
Data collection
Sociodemographic data (sex and occupation), clinical history (pulmonary history), characteristics of malignant pleural effusion (diagnosis, type, location, lung appearance, and pleural condition), type of treatment (hormone therapy, surgery, and radiotherapy), symptomatology (dyspnea, cough, presence of pain before and after talc pleurodesis), improvement in respiratory function, and quality of life were assessed using a structured questionnaire. Dyspnea classification was based on the New York Heart Association (NYHA) criteria, and quality of life was measured using the 36-item Short Form Health Survey (SF-36) or Medical Outcomes Study SF-36 (MOS SF-36).
Assessment of respiratory function improvement
To progressively improve respiratory function, reduce dyspnea, and promote better quality of life, we used the NYHA dyspnea classification system.[17,18] Standardized questionnaires and functional tests (e.g., 6-min walk test) were used to assess breathlessness, heart rate, and oxygen saturation.[19] Patients were classified into one of the NYHA classes (Class I–IV) to establish a baseline respiratory function profile. Measurable and realistic goals were defined for each class, considering the patient’s capabilities and limitations.[18] Finally, the respiratory condition was compared before and after talc pleurodesis.
Assessment of quality of life
The MOS SF-36 assessed quality of life across eight dimensions: Physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. Scores ranged from 0 to 100, with lower scores indicating poor health perception, functional loss, and pain, while higher scores reflected better health perception, functionality, and reduced pain. The SF-36 provided a baseline health profile for perceived quality of life.[20] Table 1 summarizes these dimensions.
| SF-36 concept | Symbol | Description |
|---|---|---|
| Physical functioning | PF | Measures limitations in daily physical activities, such as walking or climbing stairs |
| Role physical | RP | Assesses the impact of physical problems on the ability to fulfil life roles (e.g., work, daily tasks) |
| Bodily pain | BP | Measures the intensity of physical pain and its impact on usual activities |
| General health | GH | Assesses overall perception of health and expectations of future health decline |
| Vitality | VT | Measures the level of energy and fatigue in daily life |
| Social functioning | SF | Assesses the impact of health issues on social interactions and activities with others |
| Role emotional | RE | Measures the influence of emotional problems (e.g., depression and anxiety) on the ability to carry out life tasks |
| Mental health | MH | Assesses general psychological well-being, including levels of happiness, calm, and inner peace. |
SF-36: 36-item Short Form Health Survey, MOS SF-36: Medical Outcomes Study 36-item Short Form Health Survey
Data analysis
Data were recorded in Excel and analyzed using R software (version 4.4.1). Categorical variables were summarized as counts, frequencies, and percentages, while quantitative variables were described by mean ± standard deviation, minimum, and maximum. The Shapiro–Wilk test assessed normality. Parametric tests were used for normally distributed variables and non-parametric tests for non-Gaussian distributions. Fisher’s and Pearson’s Chi-square tests were applied for categorical data, and the Mann–Whitney test for non-parametric comparisons. Statistical significance was set at p < 0.05 with a 95% confidence interval.
RESULTS
Sociodemographic characteristics of the patients
A total of 72 patients were monitored during the study period. Ten patients were lost to follow-up, five had incomplete medical records or a follow-up period of <6 months, and six patients passed away. Consequently, 21 patients were excluded from the study, leaving 51 patients for analysis. Among these, 28 underwent pleurodesis through VATS, while 23 were treated using other methods [Figure 1].
The mean age of the patients was 50 ± 14 years, ranging from 24 to 73 years. There was no significant difference in age between patients who underwent VATS pleurodesis and those who did not (p = 0.4). Females were predominantly represented (67%) compared to males (33%), with the majority of female patients being housewives (48%) [Table 2].
| Sociodémographics characteristic | Pleural symphysis by vidéothoracoscopie | p-value | ||
|---|---|---|---|---|
| Overall (N=51) n (%) | No (N=23) n (%) | Yes (N=28) n (%) | ||
| Age (years) | 50±14 (24–73) | 48±14 (24–69) | 51±13 (26–73) | 0.4 |
| Gender | ||||
| Female | 34 (67) | 14 (27) | 20 (39) | 0.6 |
| Male | 17 (33) | 9 (18) | 8 (16) | |
| Occupation | ||||
| Housewife | 20 (48) | 8 (19) | 12 (29) | 0.2 |
| NP | 5 (12) | 0 (0) | 5 (12) | |
| Farmer | 4 (9.5) | 2 (4.8) | 2 (4.8) | |
| Teacher | 3 (7.1) | 1 (2.4) | 2 (4.8) | |
| Shopkeeper | 2 (4.8) | 0 (0) | 2 (4.8) | |
| Driver | 1 (2.4) | 0 (0) | 1 (2.4) | |
| Breeder | 1 (2.4) | 1 (2.4) | 0 (0) | |
| Student | 1 (2.4) | 1 (2.4) | 0 (0) | |
| Mechanic | 1 (2.4) | 1 (2.4) | 0 (0) | |
| Joiner | 1 (2.4) | 1 (2.4) | 0 (0) | |
| Military RtrT | 1 (2.4) | 0 (0) | 1 (2.4) | |
| Painter | 1 (2.4) | 1 (2.4) | 0 (0) | |
| Secretary | 1 (2.4) | 1 (2.4) | 0 (0 | |
Data are presented as mean±standard deviation (minimum–maximum), along with the number of modalities (n) and percentage (%). The non-parametric Mann–Whitney test and Fisher’s test of independence were employed to compare the mean ages, gender, and occupations proportion between pleural symphysis. The confidence interval for the null hypothesis (H0) was set at 95%, with a margin of error of 5% (H0 rejected if p<0.05). NP: No profession.
Pulmonary history, diagnosis, and tumor location among operated patients
The majority of operated patients had no prior pulmonary history (43%). Among those with a pulmonary history, the conditions included chronic obstructive pulmonary disease (COPD) (9.8%), asthma (2%), pulmonary embolism (2%), and pulmonary tuberculosis (2%). Of these, 7.8% with COPD and 2% with asthma underwent pleurodesis through VATS. These proportions were not statistically different from those of patients who did not undergo VATS pleurodesis (p > 0.05) [Table 3].
| Pulmonary history | Video-assisted thoracoscopic pleurodesis | p- value | ||
|---|---|---|---|---|
| Overall (N=51) n (%) | No (N=23) n (%) | Yes (N=28) n (%) | ||
| Undefined | ||||
| COPD | 43 (84) | 20 (39) | 23 (45) | 0.3 |
| Asthma | 5 (9.8) | 1 (2.0) | 4 (7.8) | |
| Pulmonary embolism | 1 (2.0) | 0 (0) | 1 (2.0) | |
| Pulmonary tuberculosis | 1 (2.0) | 1 (2.0) | 0 (0) | |
| Diagnosis | 1 (2.0) | 1 (2.0) | 0 (0) | |
| Recurrent right pleural effusion | ||||
| Recurrent left pleural effusion | 24 (47) | 12 (24) | 12 (24) | 0.9 |
| Malignant left pleural effusion | 19 (37) | 9 (18) | 10 (20) | |
| Bilateral pleural effusion | 3 (5.9) | 1 (2.0) | 2 (3.9) | |
| Recurrent bilateral pleural effusion | 2 (3.9) | 0 (0) | 2 (3.9) | |
| Right pleural effusion/endometriosis | 2 (3.9) | 1 (2.0) | 1 (2.0 | |
| Tumor location | 1 (2.0) | 0 (0) | 1 (2.0) | |
| Undefined | ||||
| Right lung | 13 (29) | 7 (16) | 6 (13) | 0.10 |
| Right breast | 8 (18) | 2 (4.4) | 6 (13) | |
| Left lung | 7 (16) | 2 (4.4) | 5 (11) | |
| Left breast | 5 (11) | 3 (6.7) | 2 (4.4) | |
| Right and left breast | 4 (8.9) | 0 (0) | 4 (8.9) | |
| Left thigh | 3 (6.7) | 0 (0) | 3 (6.7) | |
| Ovary | 1 (2.2) | 1 (2.2) | 0 (0) | |
| Left pleura | 1 (2.2) | 1 (2.2) | 0 (0) | |
| Right lung | 1 (2.2) | 1 (2.2) | 0 (0) | |
| Uterus | 1 (2.2) | 1 (2.2) | 0 (0) | |
| Pulmonary history | 1 (2.2) | 1 (2.2) | 0 (0) | |
Data are presented as counts (N, n) and percentages (%). p value: Fisher’s exact test was performed to compare the proportions of clinical parameters between patients who underwent pleurodesis and those who did not. For this test, the confidence interval for the null hypothesis (H0) was set at 95%, with a margin of error of 5% (H0 rejected if p<0.05). COPD: Chronic obstructive pulmonary disease
The most frequent diagnosis was recurrent right-sided pleural effusion (47%), followed by recurrent left-sided pleural effusion (37%), malignant left-sided pleural effusion (5.9%), bilateral pleural effusion (3.9%), recurrent bilateral pleural effusion (3.9%), and right-sided pleural effusion associated with endometriosis (2%). Among these, 24%, 20%, 3.9%, 3.9%, of patients with recurrent right-sided pleural effusion, recurrent left-sided pleural effusion, bilateral pleural effusion, recurrent bilateral pleural effusion, respectively, underwent VATS pleurodesis. These proportions were not statistically different from those of patients who did not undergo VATS pleurodesis (p > 0.05) [Table 3].
In our series, the time between the onset of symptoms and patient consultation was significantly long (over 3 weeks on average), which explained the encapsulated and loculated appearance of some of the diagnosed pleural effusions, and even the trapping of the lungs. This observation, closely linked to our context as a resource-limited country where the burden of healthcare falls almost entirely on patients and their families, immediately led us to consider VATS as the first-line treatment option for those patients who experienced pulmonary re-expansion after effusion drainage.
Impact of video-assisted thoracoscopic pleurodesis on quality-of-life improvement
The assessment of quality of life using the MOS SF-36 revealed that video-assisted thoracoscopic pleurodesis significantly improved the physical functioning score (p < 0.001), role limitations due to physical health score (p = 0.003), bodily pain score (p = 0.03), general health score (p < 0.001), vitality score (p < 0.001), role limitations due to emotional health score (p < 0.001), and mental health score (p = 0.03) [Table 4].
| MOS SF-36 concept | Video-assisted thoracoscopic pleurodesis | ||
|---|---|---|---|
| Score before (n=28) | Score after (n=22) | p-value | |
| Physical functioning | 5±4 | 59±10 | <0.001 |
| Role physical | 10±12 | 24±15 | 0.003 |
| Bodily pain | 62±39 | 90±13 | 0.038 |
| General health | 15±10 | 35±5 | <0.001 |
| Vitality | 0±0 | 85±22 | <0.001 |
| Mental health | 30±10 | 36±14 | 0.030 |
| Role emotional | 17±20 | 44±19 | <0.001 |
| Social functioning | 56±30 | 37±34 | 0.2 |
The Medical Outcomes Study 36-Item Short Form Health Survey (MOS SF-36) data are presented as mean±standard deviation (SD). The Wilcoxon non-parametric test was conducted to compare the eight dimensions of the MOS SF-36 before and after pleural symphysis by video-assisted thoracoscopy. For this test, the confidence interval for the null hypothesis (H0) was set at 95%, with a margin of error of 5%. A p-value is considered significant if p<0.05
DISCUSSION
Malignant pleural effusions cause debilitating symptoms such as chest pain and dyspnea, significantly impairing respiratory function and quality of life. Pleurodesis via Pleurodesis via Video-assisted thoracoscopic surgery (VATS) is a common treatment to reduce recurrence and improve respiratory comfort, but its impact on overall well-being, especially in sub-Saharan Africa, is poorly documented. This study, conducted in the Thoracic and Cardiovascular Surgery Unit of the University Hospital of Fann, Senegal, aimed to evaluate the effects of VATS pleurodesis on quality of life using the MOS SF-36. The findings will provide quantifiable data on the intervention’s benefits, inform healthcare strategies, and support the development of care protocols tailored to patients’ needs, emphasizing both clinical outcomes and subjective experiences.
In our study, we observed a predominance of female patients with malignant pleural effusion, consistent with findings by Smith et al.[21] and Jones et al.,[22] who also noted a higher representation of females in cohorts undergoing pleurodesis. These authors suggest that hormonal and behavioral factors might influence the incidence of malignant pleural effusions in women. In addition, our age distribution (50 ± 14 years) aligns with that reported by Lee et al.,[23] who observed a similar mean age among patients undergoing pleurodesis for malignant pleural effusion.
However, the current literature has some limitations. Most studies include small sample sizes, and few incorporate data from low-resource countries, limiting the generalizability of results. Furthermore, many studies do not differentiate between surgical techniques, making it difficult to compare the specific impacts of techniques such as VATS on quality of life. Our study, although limited to 51 patients, is one of the few to differentiate surgical approaches, contributing significantly to the existing literature.
Our findings enrich current knowledge by demonstrating no significant age difference between patients undergoing VATS pleurodesis and those treated with other techniques (p = 0.4). This supports the hypothesis that VATS can be a therapeutic option accessible regardless of age, promoting more inclusive management of malignant pleural effusions in line with clinical recommendations.[24] A multitude of symphyseal agents has been reported in the literature.[1]However, none of them has achieved consensus.[2,3] This is explained by the considerable variation in the definitions of successful pleurodesis after the use of a symphyseal agent from one study to another. According to Antony et al., the only pragmatic and objective criterion defining pleurodesis failure is the recurrence of symptomatic pleurisy, requiring further drainage.[3] In our series, the only symphyseal agent used was STERITALC, due to availability, cost, and efficacy, as also confirmed in the literature.[4] Moreover, our study is among the few to explore these parameters in an African context, contributing valuable local data to global literature and highlighting the relevance of this approach for improving patients’ quality of life in similar settings.
The results of our study show that VATS pleurodesis had a statistically significant impact on several dimensions of quality of life, as measured by the MOS SF-36. Improvements were observed in physical functioning, role limitations due to physical health, bodily pain, general health, vitality, emotional functioning, and mental health. These findings are consistent with those reported by other researchers, including Jones et al.,[22] who noted substantial quality-of-life improvements following similar pleural interventions for malignant pleural effusions. Similarly, Smith et al.[21] observed improvements in vitality and bodily pain scores following pleurodesis in patients with recurrent pleural effusions, corroborating our conclusions.
Existing literature on malignant pleural effusions has limitations, including small sample sizes, a lack of distinction between surgical techniques like VATS, and a focus on physical criteria over psychological and emotional dimensions of quality of life. Moreover, most studies are conducted in high-resource settings, limiting their relevance to low-resource contexts.
This study addresses these gaps using the MOS SF-36 to assess a comprehensive range of quality-of-life aspects, including physical, emotional, and mental health. Conducted in an African context, it provides valuable local data to the global literature and highlights insights from underrepresented settings. With a relatively large sample size and rigorous methodology, the study robustly evaluates the impact of VATS pleurodesis, confirming its efficacy in improving the quality of life for patients with malignant pleural effusions. In addition, it emphasizes the importance of incorporating psychological dimensions into patient care, advocating for more holistic and inclusive treatment strategies.
CONCLUSION
This study demonstrates that VATS pleurodesis significantly enhances the quality of life in patients with malignant pleural effusions, as evidenced by improvements in physical functioning, general health, vitality, and emotional well-being measured through the MOS SF-36. The results highlight pleurodesis as an effective therapeutic option for improving daily well-being in this vulnerable population.
Limitations
Despite promising results, the study has limitations. The sample size of 72 patients, while representative, may limit generalizability. The prospective design introduces potential selection bias, and the follow-up period was insufficient to assess the long-term effects of pleurodesis on quality of life.
Acknowledgments:
We extend our heartfelt gratitude to all individuals who voluntarily participated in this study.
Ethical approval:
The research/study was approved by the Institutional Review Board at comité d’éthique de l’Université CHEIKH ANTA DIOP, number 342, dated November 14, 2022.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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