The non-functioning pleuro-peritoneal shunt: revise or replace?

Pleural malignancy commonly leads to troublesome and recurrent effusion. Cure is not possible and effective palliation is important for the 2-3 months median survival following diagnosis. We have previously emphasised the role of pleuro-peritoneal shunts (PPS) in this situation. A number of shunts (11%) malfunction and we have revised our policy as to how best to deal with this problem. We studied our 70 patients who required the insertion of 71 PPS over seven years: there were 8 cases (11%) of non-functioning shunts necessitating re-exploration. In two cases the shunt was blocked due to infection which may have been present prior to insertion of the shunt. In these cases the shunt was removed and drainage was performed. In one shunt non-function was due to obstruction of the pleural limb and it was re-positioned successfully. The remaining five shunts were found to be blocked by fibrinous tissue. Replacement of two of these led to a functioning shunt until the death of the patients, while the three shunts which were revised failed to function. One shunt became infected and was removed and the other two became blocked again. Following subsequent replacement the function was restored until the death of the two patients. We conclude that non-functioning pleuro-peritoneal shunts should be replaced rather than revised to avoid subsequent complications.