Impact of additional pleurodesis in video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax

Video-assisted thoracic surgery for primary spontaneous pneumothorax in children: is there an optimal technique?

OBJECTIVE

Video-assisted thoracic surgery (VATS) for treatment of spontaneous pneumothorax refractory to nonoperative management was first reported in children by Rodgers in 1986 (Ann Surg. 1986; 204:677-680). Small series have shown success with apical blebectomy, mechanical or chemical (talc) pleurodesis, or combination techniques. We report the largest pediatric series of VATS for primary spontaneous pneumothorax (PSP) to date, to assess outcomes and compare techniques.

METHODS

Retrospective review of all children undergoing VATS for PSP between 1999 and 2007 at 2 university-affiliated hospitals by the same group of surgeons. Mann-Whitney U tests and chi(2) used (P < .05 = significant).

RESULTS

Thirty-two patients underwent 41 VATS procedures (32 initial-30 unilateral, 2 bilateral; 9 subsequent-7 contralateral, 2 ipsilateral recurrences). Mean age at presentation was 16.5 years (range, 13-20 years). Blebs were identified at the time of VATS in 95% of patients, but in 12.5%, they were on lower lobes. Mean duration of postoperative air leak was 2.7 days, postoperative hospital length of stay was 5.0 days, and postoperative chest tube duration was 5.1 days; 2 patients required Heimlich valves, which were managed at home. Five different surgical techniques were used as follows: blebectomy plus mechanical pleurodesis had the shortest length of stay (4.3 days) and need for chest tube drainage (4.1 days) but had a higher recurrence risk (6% major, 16% minor) than blebectomy plus chemical pleurodesis. The risk of requiring an additional VATS procedure (ipsilateral or contralateral) was 28%. Mean follow-up was 46 months.

CONCLUSIONS

Blebectomy plus either mechanical or chemical pleurodesis were both associated with acceptable outcomes. Blebectomy plus chemical pleurodesis appears to have less risk of ipsilateral recurrence but longer postoperative stay and chest tube drainage.

Videothoracoscopic surgical approach for spontaneous pneumothorax: review of the pertinent literature

Spontaneous pneumothorax is usually caused by the rupture of subpleural blebs/bullae in the underlying lung and is one of the most common elective applications of video-assisted thoracoscopic surgery (VATS). VATS has been used as an alternative to thoracotomy in the treatment of spontaneous pneumothorax. Recurrent pneumothorax and persistent air leakage are quite often indications for spontaneous pneumothorax, and bilateral spontaneous pneumothorax is also considered to be an indication for surgical intervention. The goals of surgical intervention are to eliminate intrapleural air collection and prevent recurrence. Diverse procedures have been reported in the surgical treatment for spontaneous pneumothorax. We review the literature regarding the VATS approach for spontaneous pneumothorax.

The Prevalence of Blebs or Bullae Among Young Healthy Adults

BACKGROUND

To determine the prevalence of blebs or bullae using thoracoscopy in young healthy adults, and to compare patient characteristics among those with and without blebs.

METHODS

Bilateral thoracoscopic evaluation of the lungs was performed in healthy individuals who were referred for thoracoscopic thoracic sympathectomy for essential hyperhidrosis. Participants were enrolled into a registry and followed for up to 9 years.

RESULTS

Analysis was performed on 250 consecutive cases. Blebs were observed in 15 of 250 individuals (6%; male, n = 6; female, n = 9; mean age, 25.3 years; range, 15 to 51 years). Individuals with blebs had a significantly lower body mass index (BMI) [mean +/- SD, 20.7 +/- 2.4 kg/m(2) vs 22.7 +/- 3.4 kg/m(2); p = 0.027] when compared to individuals without blebs, whereas all other parameters were similar. Blebs were most prevalent among slim individuals (BMI < 22 kg/m(2)) who smoked (odds ratio, 5.9; 95% confidence interval, 1.19 to 29.20).

CONCLUSION

Blebs were identified thoracoscopically in 6% of young healthy adults with no underlying lung disease. Low BMI in combination with smoking may have an important role in the development of pleural blebs in healthy young adults; however, these changes may not be responsible for future spontaneous pneumothoraces.

Staple line reinforcement with fleece-coated fibrin glue (TachoComb) after thoracoscopic bullectomy for the treatment of spontaneous pneumothorax

BACKGROUND

We investigated the cause of pneumothorax recurrence after thoracoscopic surgery and the effectiveness of staple line reinforcement with fleece-coated fibrin glue (TachoComb) in the prevention of postoperative pneumothorax recurrence.

METHODS

From April 3, 1992 to the end of December 2005, thoracoscopic bullectomy was performed on 499 patients of primary spontaneous pneumothorax. The causes of recurrence were investigated on 39 patients on the basis of surgical observations, preoperative chest computed tomography, and so on. The most common cause was new bulla formation (37 cases), 19 of which were apparently related to the staple line (within 1 cm of the staple lines) and 15 of which were not related to the staple line. After 2000, we stopped using forceps to grasp lungs and we have reinforced the staple line by applying fleece-coated fibrin glue.

RESULTS

The staple line reinforced with fleece-coated fibrin glue, or sprayed with fibrin glue solution and the untreated group (bullectomy only with staples) were compared, and the recurrence rates were 1.22%, 7.25%, and 10.00%, respectively (P = 0.0006021).

CONCLUSIONS

The recurrence rate after thoracoscopic bullectomy with fleece-coated fibrin glue was significantly lowered and we consider this procedure to be the treatment of choice for the management of spontaneous pneumothorax.

Predictors of general complications after video-assisted thoracoscopic surgical procedures

BACKGROUND

The video-assisted thoracoscopic approach has become the preferred method for many procedures due to the reduced trauma, complication rate and morbidity. The aim of this study was a risk evaluation of patients undergoing video-assisted thoracoscopic surgery (VATS) procedures.

METHODS

Between 1991 and 2004, 1,008 patients were included in this single-center retrospective analysis. Risk assessment was performed using univariate and multivariate analysis.

RESULTS

Multivariate analysis revealed that patient age (p = 0.003), the duration of the VATS procedure (p = 0.008), redo-VATS (p < 0.001) and conversion to open thoracotomy (p < 0.001) correlated significantly with the incidence of complications. Patients with immune deficiency following organ transplantation had the highest complication rate at 31.7%, which was significantly higher than for patients with either benign disease (p = 0.010) or malignant disease (p = 0.019).

CONCLUSIONS

VATS is a safe procedure, but extra caution is recommended for patients with a higher risk profile (age, redo-VATS, immune deficiency).

Video-assisted thoracic surgery--the past, present status and the future

Video-assisted thoracic surgery (VATS) has developed very rapidly in these two decades, and has replaced conventional open thoracotomy as a standard procedure for some simple thoracic operations as well as an option or a complementary procedure for some other more complex operations. In this paper we will review its development history, the present status and the future perspectives.

Pneumothorax

Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, definitive measures to prevent recurrence are recommended after the first recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-related pneumothoraces have CT findings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax.

Effects of timing of thoracoscopic surgery for primary spontaneous pneumothorax on prognosis and costs

BACKGROUND

Primary spontaneous pneumothorax recurs frequently. Timing of video-assisted thoracoscopic surgery to prevent recurrence is controversial and long-term costs remain inconclusive.

METHODS

We constructed a Markov model to assess the effect of different timings for surgery on health status, costs, and cost effectiveness from the payers' perspective in Japan.

RESULTS

During 1-year follow-up, the proportions of patients who underwent surgery after the first and second drainage were 46% and 36%, respectively. Average 1-year cost for surgery at the first episode was highest (U.S. dollars 6556), followed by the second (U.S. dollars 2988) and the third (U.S. dollars 2532). Incremental cost for surgery at the first episode compared with the second and that at the second episode compared with the third were U.S. dollars 30564 and U.S. dollars 29915 per quality-adjusted life year, respectively. Sensitivity analyses showed utility and length of hospital stay for surgery have the strongest effect on incremental cost.

CONCLUSIONS

Thoracoscopic surgery at the first episode significantly increased costs, but could be acceptable from a cost-effectiveness perspective.

Traitement actuel du pneumothorax primaire et secondaire

INTRODUCTION

The treatment of a primary or secondary spontaneous pneumothorax remains controversial and many therapeutic options exist. In the event of a first episode of pneumothorax, should the patient be treated by observation, aspiration or thoracic drainage? For patients undergoing a thoracoscopic intervention for a spontaneous pneumothorax which is the best technique to treat the lung and parietal pleura? What are the results of thoracoscopy compared to thoracotomy and are the costs comparable?

PERSPECTIVES

The optimal treatment for a first episode of pneumothorax remains to be determined. As there are only a limited number of patients in the published randomised controlled studies only grade B or C recommendations can be given. This is also true for the treatment of the lung and parietal pleura during a thoracoscopic intervention. Most authors advise that an apical pleurectomy is performed. With regard to results and cost of thoracoscopy compared to thoracotomy, conflicting results have been published and definite conclusions cannot be drawn.

CONCLUSION

As large randomised prospective studies are not available regarding the treatment of pneumothorax only grade B or C recommendations can be given.

Staple line coverage with absorbable mesh after thoracoscopic bullectomy for spontaneous pneumothorax

BACKGROUND

Thoracoscopic simple bullectomy for primary spontaneous pneumothorax (PSP) has a relatively high postoperative recurrence rate and sometimes results in postoperative air leakage. One of the reasons for postoperative recurrence is the regrowth of bullae around the staple line. Therefore, reinforcement of the visceral pleura around the staple line is a reasonable way to prevent postoperative air leaks and recurrence. This study was done to determine the efficacy in preventing postoperative air leak and recurrent pneumothorax of widely covering the staple line with absorbable mesh after thoracoscopic bullectomy.

METHODS

Wide coverage of the staple line with absorbable mesh was performed on 114 patients with PSP. These patients were retrospectively compared with 126 patients who underwent thoracoscopic simple bullectomy alone.

RESULTS

The postoperative duration of chest drainage in the coverage group (mean, 1 day; range, 0-5) was significantly shorter than that in the simple bullectomy group (mean, 3 days; range 0-20). A prolonged air leak (>7 days) occurred in six patients in the simple bullectomy group, but there were no such leaks in the coverage group. Recurrent pneumothorax occurred in three patients (2.6%) in the coverage group and 12 patients (9.5%) in the simple bullectomy group.

CONCLUSION

Wide coverage of the staple line with absorbable mesh is effective in preventing postoperative air leak and in decreasing the recurrence rates of PSP.

Pathogenesis and Treatment of Primary Spontaneous Pneumothorax: An Overview

The exact pathogenesis of primary spontaneous pneumothorax (PSP) remains unknown. Furthermore, various specialists including pulmonologists, surgeons, emergency care physicians, radiologists and others are known to treat this disorder in clinical practice. As a consequence, guidelines on the management of PSP are scarce, and differences in treatment approaches persist. In this paper, evidence on the pathogenesis and on various treatment techniques and strategies is reviewed. An algorithmic treatment approach is proposed.

Management of primary spontaneous pneumothorax

The optimal management of primary spontaneous pneumothorax remains the subject of considerable controversy. During the last few years, however, interesting new data on pathogenesis and various treatment techniques have been published, which have led to the publication of some interesting and thought-provoking opinion articles. The author reviews the latest developments in pneumothorax pathophysiology and management.