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41 Although there is no consensus about the need for inserting chest tubes intraoperatively, it may be recommended when the pleural opening is large (>5?cm), several defects are produced in the same hemidiaphragm, or the patient undergoes full-thickness resection or extensive liver mobilization.40 Using this strategy, postoperative pleural effusions and pneumothoraces requiring drainage were reported in only 5% of 63 diaphragmatic stripping or coagulation procedures.40 In another series, pleural effusions developed in 37% of 148 patients submitted to diaphragmatic surgery during which the Angiogenesis inhibitor pleural space was opened in half the cases.44 However, the effusions were symptomatic enough to warrant a secondary chest tube drainage or pleural puncture in just 14% of the subjects. Malignant pleural effusions upstage the disease but are not a contraindication to initial cytoreductive abdominal surgery. In other words, they do not predict by themselves a suboptimal debulking. A report of 58 patients classified as stage IV PTPRJ OC only on the basis of malignant pleural effusions demonstrated a survival benefit when the disease was optimally debulked (residual disease SCR7 order tumour burden may have a substantial influence on further OC therapy. Because the goal of surgical cytoreduction is to achieve a state of no visible residual disease in any location, pleural tumour debulking should also be theoretically striven for when feasible. video-assisted thoracoscopic surgery (VATS) is the optimal method to evaluate and remove as much disease burden as possible in the pleural cavity. In the first series that made use of thoracoscopy for the management of stage IV OC, the procedure was mostly performed at the time of the abdominal surgery by introducing the laparoscope into the chest cavity through the diaphragm.46 Of 30 patients, 10 (33%) had pleural implants that were excised, whereas three (10%) had unresectable intrathoracic disease that lead to abbreviated attempts at abdominal cytoreduction.46 The significant impact of VATS, before a planned abdominal exploration, on the global therapeutic strategy was reinforced in a report of 42 patients with OC and pleural effusions affecting one third or more of the hemithorax.24 VATS revealed macroscopic pleural disease in 29 (69%) patients, the majority (18 patients) having nodules greater than 1?cm. Based on thoracoscopic findings, the primary management plan (i.e.