Pleural Surgery in 2026
A Clinician Reference

1. The diagnostic spine

Pleural anatomy and physiology relevant to surgical practice

The pleural space is a potential space between the visceral pleura covering the lung surface and the parietal pleura lining the chest wall. Normal pleural fluid volume is approximately 15 mL, with a daily turnover of approximately one litre resorbed via parietal pleural lymphatics. The visceral pleura has no pain fibres — pleural pain is parietal. Negative intrapleural pressure (approximately −5 cmH₂O at rest) maintains lung expansion against the chest wall.

The pleural borders are surgically relevant. The right costophrenic angle drains posteriorly — the optimum drain site for free-flowing effusion. The pleura crosses the 12th rib laterally posteriorly — a hazard for posterior renal incisions. Superiorly the pleural dome rises 2 cm above the medial third of the clavicle (Sibson’s fascia) — a hazard for subclavian access. The hilum is where the visceral and parietal pleura become continuous; this is the anatomic basis of the lung being mobilised on its hilar pedicle for resection.

Light’s criteria — the discriminator

Pleural fluid is exudate if any one of three criteria is met (sensitivity 98%, specificity 83%): pleural fluid protein to serum protein ratio >0.5; pleural fluid LDH to serum LDH ratio >0.6; or pleural fluid LDH greater than two-thirds of the upper limit of normal serum LDH. A protein threshold of 30 g/L identifies exudate; below 25 g/L identifies transudate; the 25–35 g/L grey zone requires Light’s criteria for resolution. The serum-pleural albumin gradient >12 g/L is a useful adjunct in diuretic-treated patients in whom Light’s criteria misclassify approximately 25% of transudates as exudates.

Light’s criteria — exudate if any one is met

Criterion	Threshold	Performance
1. Protein ratio	Pleural fluid protein ÷ serum protein >0.5	Sensitivity 98% Specificity 83% Any one criterion identifies exudate
2. LDH ratio	Pleural fluid LDH ÷ serum LDH >0.6
3. Absolute LDH	Pleural fluid LDH >⅔ upper limit of normal serum LDH
Diuretic-treated transudate caveat: serum-pleural albumin gradient >12 g/L identifies transudate misclassified as exudate by Light’s criteria (approximately 25% of diuretic-treated transudates).

Pleural fluid biochemistry — thresholds with surgical implication

Pleural fluid value	Threshold	Surgical implication
pH	<7.20	Empyema, malignancy, oesophageal rupture — drain immediately
pH in parapneumonic effusion	<7.30	Complicated parapneumonic effusion — threshold for drainage and escalation
Glucose	<2.2 mmol/L	Strongly supports complicated parapneumonic / empyema
LDH	>1000 IU/L	Supports complicated infection or malignancy
Triglycerides	>1.24 mmol/L (110 mg/dL)	Diagnostic of chylothorax
Cholesterol	>5.18 mmol/L	Suggests pseudochylothorax (chronic inflammatory effusion)
Macroscopic pus	—	Drain immediately regardless of other parameters

The BTS 2023 algorithm

The 2023 BTS Clinical Statement on Pleural Procedures [5] consolidates the diagnostic and procedural framework. Initial assessment of any new effusion includes ultrasound-guided diagnostic aspiration with biochemistry (protein, LDH, pH where indicated), microbiology (Gram stain, culture, sensitive in approximately 60% of cases when sent direct rather than diluted in blood culture bottles), cytology (sensitive for adenocarcinoma in approximately 60% of cases; lower for squamous and mesothelioma), and full blood count differential.

Image-guided pleural biopsy is appropriate where cytology is non-diagnostic and pleural malignancy is suspected; sensitivity exceeds 90% in expert hands. Where image-guided biopsy is non-diagnostic and pleural malignancy remains the working diagnosis, VATS pleural biopsy is the gold standard, providing both tissue diagnosis at sensitivity above 90% and the opportunity for therapeutic pleurodesis at the same procedure. Medical thoracoscopy is an alternative for patients in whom general anaesthesia poses excessive risk.

2. Pleural infection and empyema — the MIST sequence

The BTS 3-stage model

Empyema progresses through three pathological stages. Stage I — exudative: free-flowing inflammatory fluid; pH >7.2; organisms typically absent on direct microscopy; days 1–3. Antibiotics, with or without small-bore drainage, are usually sufficient. Stage II — fibrinopurulent: turbid fluid with fibrin deposition and developing loculations; pH <7.2; positive culture in approximately 40%; days 4–14. Drainage is mandatory; intrapleural fibrinolytic therapy or VATS surgery is the question. Stage III — organising: thick pus with fibrous cortex and lung trapping; rib crowding on imaging; beyond 2–4 weeks. Surgical decortication is required.

BTS 3-stage model of empyema

Stage	Time course	Pleural fluid	Management
Stage I Exudative	Days 1–3	Free-flowing; clear or cloudy; pH >7.2; LDH <1000; glucose >2.2; cultures often negative	Antibiotics ± small-bore drain; fibrinolytics not required
Stage II Fibrinopurulent	Days 4–14	Turbid with fibrin and loculation; pH <7.2; LDH >1000; glucose <2.2; positive culture ~40%	Drain mandatory; intrapleural tPA + DNase (MIST-2); VATS if failure to progress in 5–7 days
Stage III Organising	Beyond 2–4 weeks	Thick pus; fibrous cortex; lung trapping; rib crowding on imaging	Thoracotomy and decortication via the avascular “onion-skin” plane; parietal pleurectomy where indicated

CT features that distinguish established infection from malignancy include lentiform configuration of pleural fluid; visceral pleural enhancement (the “split pleura sign”); hypertrophy and increased density of extrapleural fat (>2 mm); and pulmonary consolidation. The split pleura sign is the most discriminative single feature.

The RAPID score

The RAPID score (Rahman 2014, derived and validated within the MIST-2 population [16]) prognosticates pleural infection and identifies patients at high risk of failed conservative management. Components: R — Renal (urea), A — Age, P — Purulence, I — Infection source (community vs hospital), D — Dietary (albumin). Scores 0–2 carry approximately 3% three-month mortality; 3–4 approximately 9%; 5–7 approximately 31%. RAPID ≥5 should prompt early surgical referral.

RAPID score — components and three-month mortality strata

Component	0 points	1 point	2 points
R — Renal (urea)	≤5 mmol/L	5.1–8 mmol/L	>8 mmol/L
A — Age	<45 years	45–64 years	≥65 years
P — Purulence	Non-purulent	Purulent	—
I — Infection source	Community-acquired	Hospital-acquired	—
D — Dietary (albumin)	≥27 g/L	<27 g/L	—

RAPID risk strata — 3-month mortality

Total score	Risk category	3-month mortality	Action
0–2	Low risk	~3%	Standard management; conservative pathway often successful
3–4	Medium risk	~9%	Close monitoring; low threshold for escalation
5–7	High risk	~31%	Early surgical referral indicated

The MIST trial sequence

Four trials have progressively answered the question of what intrapleural and surgical therapy is required for pleural infection.

The MIST trial sequence at a glance

Trial · Year	Citation	n	Question	Result	Mr Okiror
MIST-1 2005	Maskell, NEJM [6]	454	Intrapleural streptokinase vs placebo	No benefit; streptokinase monotherapy excluded	—
MIST-2 2011	Rahman, NEJM [16]	210	tPA + DNase vs single-agent vs placebo	Combination reduced surgical referral and LOS; BTS-endorsed standard for Stage II	—
MIST-3 2023	Bedawi, AJRCCM [7]	Feasibility	Early VATS vs early intrapleural enzyme therapy	~50% randomised to early VATS may not have needed surgery	Site investigator at GSTT
MIST-4 Recruiting 2026	ISRCTN16328099	Phase III	Definitive RCT — early VATS vs intrapleural enzyme therapy	Recruiting; result will define the contemporary algorithm	GSTT Surgical Lead

Surgical management — VATS for Stage II, decortication for Stage III

For Stage II disease failing conservative or fibrinolytic management within 5–7 days, VATS pleural debridement and washout is the operation. Goals are complete evacuation of pus, division of all loculations, full mobilisation of the lung, and adequate drainage. Reported VATS success rates for Stage II are 80–90%, with shorter length of stay than continued conservative management. Conversion to thoracotomy is required where dense adhesions, incomplete decortication, or haemorrhage demand it.

For Stage III organising empyema, thoracotomy and decortication is the standard. The operation removes the fibrous cortex from the visceral pleura through the correct avascular “onion-skin” plane between visceral pleura and cortex — dissection in the wrong plane causes lung injury and bleeding. Parietal pleurectomy is added where a thick rind with rib crowding has produced restrictive physiology. Two drains (apical and basal) are placed to ensure full lung re-expansion. Thoracoplasty is reserved as a last resort for non-expandable lung or persistent space.

For unfit patients or post-pneumonectomy empyema, alternatives include rib resection and drainage (subperiosteal resection of a single rib, usually 8th or 9th posteriorly, with or without saline irrigation per Clagett), and open window thoracostomy (Eloesser flap) with marsupialisation of the pleural space and outpatient packing. Post-pneumonectomy empyema with bronchopleural fistula carries approximately 50% mortality after right pneumonectomy; immediate management requires positioning the patient right-side down to prevent contralateral soiling, alongside open drainage and bronchial stump reinforcement (omentum, latissimus dorsi, or serratus anterior flap).

At Guy’s and St Thomas’, the empyema service is delivered by the thoracic surgical team. MIST-4 surgical leadership specifically is Mr Okiror’s; the broader empyema service includes the wider GSTT thoracic surgical team. Private cases are operated at London Bridge Hospital with full ITU and respiratory back-up.

3. Spontaneous pneumothorax — the BTS 2023 reframe

Classification

By mechanism: spontaneous (primary or secondary), traumatic, iatrogenic. By physiology: simple, tension (mediastinal shift, obstructive shock). By wound: open (sucking chest wound), closed.

Primary spontaneous pneumothorax (PSP): rupture of subpleural blebs or bullae, classically in tall, thin young men (M:F approximately 6:1). Lifetime recurrence is approximately 30% after the first episode and approximately 60% after the second. Secondary spontaneous pneumothorax (SSP): in patients with underlying lung disease — COPD (the commonest cause), interstitial lung disease, cystic fibrosis, malignancy, Pneumocystis infection, connective tissue disease (Marfan, Ehlers–Danlos). SSP carries higher mortality and is approximately ten times more likely to require intervention than PSP.

The PSP RCT and the BTS 2023 reframe

The PSP RCT (Brown et al., NEJM 2020) [17] randomised 316 adults with moderate-to-large primary spontaneous pneumothorax to immediate intervention (chest drain) or conservative management. Conservative management was non-inferior for lung re-expansion at 8 weeks, with fewer adverse events and lower rates of recurrence. The trial fundamentally challenged the previous algorithmic approach in which radiographic size determined the intervention pathway.

The BTS 2023 Clinical Statement [5] consolidated this evidence. The contemporary first-line approach is to manage stable patients conservatively or via ambulatory pathway with a Heimlich valve and outpatient follow-up — even with a sizeable pneumothorax. Aspiration and chest drain remain options where conservative management fails or where the patient is symptomatic with breathlessness or hypoxia.

Surgical indications

Surgery (VATS bullectomy and pleurodesis) remains indicated in the following situations:

Indication	Rationale
Persistent air leak beyond approximately 5 days	Conservative management has failed; surgery is the next definitive step
Second ipsilateral pneumothorax	Recurrence risk approaches 60%; surgery prevents the next episode
First contralateral pneumothorax	Bilateral risk now established
Synchronous bilateral pneumothoraces	Management is operative; conservative is not safe
Spontaneous haemopneumothorax	Operative haemostasis required
Tension pneumothorax (recurrent)	Recurrence implies persistent structural defect

Single-episode surgical referral is also appropriate in selected groups: pregnancy (operative timing planned around delivery); at-risk professions (pilots, divers, remote workers) where pneumothorax recurrence carries unusual operational risk; connective tissue disease (Marfan, Ehlers–Danlos, vascular EDS where risk is materially elevated); SSP with significant breathlessness even with small pneumothorax. Catamenial pneumothorax in women of reproductive age requires VATS with diaphragmatic mesh repair and gynaecology liaison — covered in detail on the thoracic endometriosis page.

Operative technique

VATS bullectomy with apical pleurectomy or pleural abrasion is the standard. Recurrence rates after VATS bullectomy and pleurodesis are approximately 5%, against 1–2% for thoracotomy and approximately 25–30% for chemical pleurodesis alone — surgery is the definitive treatment. RCT evidence supports mechanical pleurodesis (pleural abrasion) as equivalent to pleurectomy for preventing recurrence in PSP. Patient-facing pneumothorax page →

4. Malignant pleural effusion — the post-AMPLE era

Aetiology and diagnosis

The commonest primary sites for malignant pleural effusion are lung (37%), breast (17%), unknown primary (10%), lymphoma (10%), and gynaecological malignancy (10%). Mechanisms include direct pleural infiltration, lymphatic obstruction at hilar or mediastinal nodes, and hypoalbuminaemia. Pleural fluid cytology is positive in approximately 60% of cases (lower for mesothelioma). CT-guided pleural biopsy and VATS pleural biopsy carry sensitivities above 90%.

The LENT prognostic score

The LENT score (Clive et al., Thorax 2014) [11] prognosticates median survival in malignant pleural effusion using LDH, ECOG performance status, neutrophil-to-lymphocyte ratio, and tumour type. Median survival ranges from approximately 319 days in the low-risk group to approximately 56 days in the high-risk group. The score frames the choice between IPC (preferred for short prognosis) and pleurodesis (preferred for longer prognosis with expandable lung).

The three RCTs

Trial	Comparison	Result
TIME2 (Davies, JAMA 2012) [9]	IPC vs chest tube and talc pleurodesis	Equivalent symptom control and quality of life; IPC reduced hospital days
AMPLE-1 (Thomas, JAMA 2017) [8]	IPC vs chest tube and talc pleurodesis	Reduced total hospital days with IPC; equivalent dyspnoea control
IPC-Plus (Bhatnagar, NEJM 2018) [10]	IPC + intrapleural talc vs IPC alone	Talc-via-IPC achieved higher pleurodesis rates in patients without trapped lung

Decision framework

In contemporary practice, the choice of intervention is individualised. Trapped lung, prior failed pleurodesis, and short prognosis favour IPC. Expandable lung with longer prognosis favours talc pleurodesis at thoracoscopy — either medical thoracoscopy or VATS, with the additional benefit of pleural biopsy at the same procedure. Talc-via-IPC (per IPC-Plus) is now standard in patients with IPC in situ where pleurodesis is desired. MesoTrap is an ongoing trial specifically in mesothelioma comparing IPC against VATS-pleurodesis — results awaited.

For patients with malignant pleural effusion at Guy’s and St Thomas’, decision-making is multidisciplinary, integrating respiratory medicine, oncology, palliative care, and thoracic surgery. Private cases are managed equivalently at London Bridge Hospital and The Lister Hospital Chelsea.

5. Mesothelioma — the surgical role in 2026

Epidemiology and pathology

UK mesothelioma incidence is approximately 2,700 cases per year — the highest national rate globally, a legacy of industrial asbestos use peaking in the 1960s and 1970s. Latency is 20–60 years (mean approximately 40 years). The amphibole asbestos fibres (crocidolite, amosite) are most carcinogenic; chrysotile (white asbestos) is less so. The UK incidence peak is believed to have passed (approximately 2015) but disease prevalence remains high and will persist for decades.

Histological subtypes carry distinct prognosis. Epithelioid (50–70%): best prognosis, median survival 12–18 months in the modern era. Sarcomatoid (10–20%): worst prognosis, median survival 4–7 months. Biphasic (20–30%): intermediate. Molecular markers include BAP1 loss (commonest mutation, IHC useful diagnostically; germline BAP1 = familial mesothelioma), NF2 loss, and CDKN2A/p16 deletion (associated with sarcomatoid histology).

Mesothelioma histological subtypes — prevalence, prognosis, surgical relevance

Subtype	Prevalence	Median survival	Surgical relevance
Epithelioid	50–70%	12–18 months	The histology in which radical surgery has historically been considered; following MARS-2, even epithelioid mesothelioma is no longer routinely operated on
Biphasic	20–30%	Intermediate	Mixed epithelioid and sarcomatoid components; prognosis driven by sarcomatoid fraction
Sarcomatoid	10–20%	4–7 months	Surgery offers no realistic survival benefit; not a surgical disease

Diagnosis — stepwise

Step 1: pleural fluid cytology, positive in approximately 30–40% in mesothelioma (lower than for adenocarcinoma). Step 2: CT-guided Tru-Cut pleural biopsy, sensitivity approximately 75–80%. Step 3: medical thoracoscopy or VATS pleural biopsy, sensitivity above 90% — the gold standard. Immunohistochemistry panel: calretinin, WT1, CK5/6 (positive in mesothelioma) versus TTF-1, CEA, BerEP4 (negative in mesothelioma; positive in adenocarcinoma).

Staging is according to the IASLC TNM 8th edition (the framework into which Mr Okiror’s 2019 staging chapter fits) [2]. Prophylactic port-site radiotherapy after diagnostic VATS is no longer recommended — the SMART trial (Lancet Oncology 2016) demonstrated no benefit and the practice has been abandoned.

The historical arc — how we got here

Surgical management of mesothelioma has been progressively reframed across two decades.

The EPP era and MARS-1. Extrapleural pneumonectomy (EPP) was the maximalist surgical operation, removing pleura, lung, diaphragm, and pericardium en bloc. The MARS-1 feasibility RCT (Treasure 2011) randomised 50 patients and reported excess deaths in the EPP arm with poor quality of life. EPP was de-emphasised in UK practice from this point.

The GSTT pleurectomy/decortication programme. Through the 2010s, Lang-Lazdunski and colleagues at Guy’s and St Thomas’ published a series of papers on pleurectomy/decortication (P/D) combined with hyperthermic pneumoperitoneum and adjuvant chemoradiotherapy [15], establishing GSTT as one of Europe’s busiest mesothelioma surgical programmes through this period.

MesoVATS (Rintoul, Lancet 2014) [14] randomised VATS pleurectomy against talc pleurodesis for malignant pleural effusion in mesothelioma. There was no difference in overall survival, with the pleurodesis group spending fewer days in hospital. VATS pleurectomy offered better symptom control in selected patients.

CheckMate 743 (Baas, Lancet 2021) [13] randomised 605 patients with unresectable malignant pleural mesothelioma to first-line ipilimumab plus nivolumab versus platinum-pemetrexed chemotherapy. Overall survival benefit favoured immunotherapy: 18.1 versus 14.1 months overall, with the most striking benefit in the sarcomatoid subgroup (18.1 vs 8.8 months, HR 0.46). The combination is now NICE-approved as TA1071 first-line for unresectable mesothelioma.

MARS-2 (Lim, Lancet Respiratory Medicine 2024) [12] is the trial that closed the question of radical surgery in pleural mesothelioma. 335 patients with resectable pleural mesothelioma were randomised to extended pleurectomy/decortication plus chemotherapy versus chemotherapy alone. Surgery did not improve overall survival (13.2 vs 13.7 months) and was associated with significantly higher grade 3–5 adverse events (60% vs 30%). The conclusion is that extended pleurectomy/decortication should not be performed for diffuse mesothelioma outside clinical trials.

Other recent trials reframing systemic therapy include IND.227 (pembrolizumab plus chemotherapy, 2023) and BEAT-meso (atezolizumab-bevacizumab-chemotherapy, 2024). The MesoTrap trial comparing IPC against VATS pleurodesis is awaited.

The contemporary surgical role at GSTT

Guy’s and St Thomas’ has a large mesothelioma practice and a specialist mesothelioma multidisciplinary team. Following MARS-2, surgery is no longer a routine part of multimodality treatment for mesothelioma as it was previously. The role of surgery now is in:

Diagnostic biopsy. VATS pleural biopsy in selected cases where image-guided biopsy has not yielded a diagnosis or the differential requires direct pleural visualisation.

Management of pleural effusions. Pleurodesis at the time of diagnostic VATS, or via indwelling pleural catheter, for symptom palliation.

Very occasionally, patients with isolated, non-diffuse disease may be surgical candidates. For diffuse mesothelioma, surgery is not offered.

The MDT pathway in 2026

First-line systemic therapy in unresectable disease is ipilimumab plus nivolumab (CheckMate 743, NICE TA1071) [13] or platinum-pemetrexed-based chemotherapy. Palliative care is integrated from diagnosis. Trial enrolment is woven into the MDT pathway as a normal element of care, not as a separate consideration. Patients are discussed at the GSTT specialist mesothelioma MDT; private patients are discussed at the equivalent multidisciplinary forum at London Bridge Hospital.

6. Chylothorax

Aetiology and anatomy

Traumatic chylothorax is the commonest type in thoracic surgical practice. Post-oesophagectomy is the leading cause (incidence 1–4% in published series). Lung resection with mediastinal lymphadenectomy, mediastinal dissection, blunt or penetrating thoracic trauma, and central venous catheterisation are other traumatic causes. Non-traumatic causes include malignancy (lymphoma is the leading non-traumatic cause; lung cancer and mediastinal tumours less commonly), thoracic irradiation, superior vena cava obstruction, tuberculosis, sarcoidosis, and lymphangioleiomyomatosis. Idiopathic chylothorax accounts for approximately 15%.

The thoracic duct arises from the cisterna chyli at L1–L2, enters the thorax through the aortic hiatus, runs in the right paravertebral position below T5, crosses to the left at T4–T5, and drains into the left subclavian-jugular venous angle. The clinical pearl: right-sided chylothorax indicates duct injury below T5 (cisterna chyli to crossover); left-sided chylothorax indicates injury above T5.

The management ladder

Conservative (first-line, 2–4 weeks): pleural drainage; low-fat or medium-chain-triglyceride diet (or NPO with TPN in high-output cases); octreotide 100–200 mcg three times daily subcutaneously, reducing lymph flow by approximately 50%; treatment of the underlying cause.

Interventional radiology: thoracic duct embolisation (TDE) by IR is performed at Guy’s and St Thomas’ with the same IR team that supports thoracic surgery at London Bridge Hospital. Reported success rates are 70–80%. TDE is appropriate where conservative management fails (typically output exceeding approximately 1 L/day for 5 days) or where surgery is not feasible.

Surgery: VATS or open thoracic duct ligation where TDE has failed or is not feasible. Mass ligation from the inferior pulmonary vein to the subcarinal fossa — ligating all tissue between the aorta, the azygos vein, and the spine — is the preferred surgical approach, more reliable than attempted identification of the duct itself. Pleurodesis can be combined at the same operation. Pleuroperitoneal shunt is an option in malignant chylothorax where life expectancy is short.

Detailed management algorithms, surgical technique, post-operative follow-up, and the SORBS criteria are on the chylothorax page →

7. Other primary pleural malignancies and rare tumours

A minority of pleural surgical presentations sit outside the four common categories. Each has its own management algorithm.

Solitary fibrous tumour of the pleura

A mesenchymal tumour arising from the pleura, distinct from mesothelioma in origin and behaviour. Most are benign and pedunculated; a minority are sessile, large, and aggressive. The operation is wide local resection with negative margins. STAT6 immunohistochemistry is the contemporary diagnostic marker. Long-term follow-up is required; late recurrence is documented.

Stage IVa thymoma with pleural drop metastases

Thymoma with pleural seeding is a distinct entity from primary pleural malignancy. Multimodality management with neoadjuvant chemotherapy followed by surgical resection of pleural deposits at thoracotomy or VATS is associated with five-year survival of approximately 75% in published series. The management is integrated through the GSTT thymoma MDT.

Primary pleural sarcomas, angiosarcoma, melanoma

Rare entities. Pleural sarcoma is referred to the London Sarcoma Service and the Royal National Orthopaedic Hospital (Stanmore) for definitive management. Pleural angiosarcoma carries a poor prognosis and management is largely palliative. Primary pleural melanoma is exceptionally rare and managed in liaison with the regional melanoma MDT.

8. Where pleural surgery is delivered

Mr Okiror operates privately at London Bridge Hospital and The Lister Hospital Chelsea. NHS practice is at Guy’s and St Thomas’.

London Bridge Hospital and The Lister Hospital Chelsea

London Bridge Hospital is the primary private centre. Diagnostic VATS pleural biopsy, VATS decortication for empyema, VATS bullectomy and pleurodesis for pneumothorax, indwelling pleural catheter insertion, and surgical assessment for chylothorax are all performed privately at London Bridge Hospital. The Lister Hospital Chelsea provides a second private operating base for patients in west and south-west London. Newsweek World’s Best Hospitals 2026 ranked London Bridge Hospital tenth in the UK; St Thomas’ first; Guy’s second.

Trial leadership at GSTT — what is currently active

Mr Okiror’s pleural-disease trial leadership at Guy’s and St Thomas’ is currently:

• MIST-4 (ISRCTN16328099) — GSTT Surgical Lead, currently recruiting. Phase III multicentre RCT of early VATS surgery versus intrapleural enzyme therapy in pleural infection.
• PRO-SEAL (ISRCTN15099654) — sole EBV operator and GSTT Surgical Lead. Trial of prolonged air leak management.
• MIST-3 (Bedawi, AJRCCM 2023) — recruiting site investigator [7].

Eligible patients at Guy’s Hospital may be offered enrolment as part of routine care. Trial enrolment is discussed at consultation. Adjacent endobronchial valve work for emphysema (where Mr Okiror is the sole EBV/LVRS operator at GSTT and at London Bridge Hospital) is covered in the emphysema surgery 2026 flagship.

Pathway, contact, and referral

Private appointments at London Bridge Hospital and The Lister Hospital Chelsea are typically available within 2–3 working days. Self-referrals are welcome. NHS referrals follow the standard Guy’s and St Thomas’ thoracic surgical pathway. Cross-speciality referrals are welcome from respiratory medicine, oncology, palliative care, anaesthesia, intensive care, and rheumatology — complex multidisciplinary cases are routinely accepted.

References

1. Okiror L, Lang-Lazdunski L. Surgery for Pleural Diseases. In: Light RW, Lee YCG (eds). Light’s Textbook of Pleural Diseases. 3rd edition. Boca Raton, FL: CRC Press; 2016. Chapter 47. ISBN 978-1-4822-2250-0. DOI 10.1201/b19146-54. (Mr Okiror first author.)
2. Okiror L, Bille A. Staging of Malignant Pleural Mesothelioma. In: Ceresoli GL, Bombardieri E, D’Incalci M (eds). Mesothelioma: From Research to Clinical Practice. Springer; 2019. Chapter 12, pp 177–184. ISBN 978-3-030-16883-4. DOI 10.1007/978-3-030-16884-1_12. (Mr Okiror first author.)
3. Okiror L, Kalkat MS, Rajesh PB. Primary Tumours. In: Parikh D, Rajesh PB (eds). Tips and Tricks in Thoracic Surgery. London: Springer; 2018. Chapter 3, pp 37–51. ISBN 978-1-4471-7353-3. DOI 10.1007/978-1-4471-7355-7_3. (Mr Okiror first author; chapter also co-described the standardised three-port anterior VATS lobectomy in §3.6.1.)
4. Okiror L. Mesothelioma. In: Key Questions in Thoracic Surgery. Shrewsbury: tfm Publishing; 2016. ISBN 978-1-903378-86-1. (Mr Okiror author.)
5. British Thoracic Society. BTS Clinical Statement on Pleural Procedures. 2023. (Contemporary UK standard for diagnostic and therapeutic pleural procedures, incorporating the post-PSP-RCT pneumothorax framework and post-MIST-2 pleural infection algorithm.)
6. Maskell NA, Davies CWH, Nunn AJ, Hedley EL, Gleeson FV, Miller R, et al. UK controlled trial of intrapleural streptokinase for pleural infection (MIST-1). N Engl J Med 2005;352(9):865–74. PMID 15745977.
7. Bedawi EO, Stavroulias D, Hedley E, Blyth KG, Kirk A, De Fonseka D, Edwards JG, Internullo E, Corcoran JP, Marchbank A, Panchal R, Caruana E, Kadwani O, Okiror L, Saba T, Purohit M, Mercer RM, et al; Maskell NA, Belcher E, Rahman NM. Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial — MIST-3. Am J Respir Crit Care Med 2023 Dec 15;208(12):1305–15. DOI 10.1164/rccm.202305-0854OC. PMID 37820359. (Mr Okiror recruiting site investigator at GSTT.)
8. Thomas R, Fysh ETH, Smith NA, Lee P, Kwan BCH, Yap E, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the AMPLE randomized clinical trial. JAMA 2017;318(19):1903–12. PMID 29164255.
9. Davies HE, Mishra EK, Kahan BC, Wrightson JM, Stanton AE, Guhan A, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnoea in patients with malignant pleural effusion: TIME2 randomised controlled trial. JAMA 2012;307(22):2383–9. PMID 22610520.
10. Bhatnagar R, Keenan EK, Morley AJ, Kahan BC, Stanton AE, Haris M, et al. Outpatient talc administration by indwelling pleural catheter for malignant effusion (IPC-Plus). N Engl J Med 2018;378(14):1313–22. PMID 29617585.
11. Clive AO, Kahan BC, Hooper CE, Bhatnagar R, Morley AJ, Zahan-Evans N, et al. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax 2014;69(12):1098–104. PMID 25143005.
12. Lim E, Waller D, Lau K, Steele J, Pope A, Ali C, et al; MARS 2 Trialists. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3, multicentre, open-label, randomised controlled trial. Lancet Respir Med 2024;12(6):457–66. (Definitive trial removing extended P/D from routine multimodality treatment in diffuse mesothelioma.)
13. Baas P, Scherpereel A, Nowak AK, Fujimoto N, Peters S, Tsao AS, et al. First-line nivolumab plus ipilimumab in unresectable malignant pleural mesothelioma (CheckMate 743): a multicentre, randomised, open-label, phase 3 trial. Lancet 2021;397(10272):375–86. PMID 33485464. (NICE TA1071; first-line ipi/nivo for unresectable MPM.)
14. Rintoul RC, Ritchie AJ, Edwards JG, Waller DA, Coonar AS, Bennett M, et al. Efficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial. Lancet 2014;384(9948):1118–27. PMID 24942631.
15. Lang-Lazdunski L, Bille A, Belcher E, Cane P, Landau D, Lal R, Spicer J. Pleurectomy/decortication, hyperthermic pneumoperitoneum and long-term outcome in malignant pleural mesothelioma. J Thorac Oncol 2012;7(4):737–43. (GSTT institutional series.)
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18. Society for Cardiothoracic Surgery in Great Britain and Ireland. SCTS National Thoracic Surgery Audit 2024–25. Operative outcomes data including Guy’s and St Thomas’ NHS Foundation Trust footer-audited returns.

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