An apical symphysial technique using a wide absorbable mesh placed on the apex for primary spontaneous pneumothorax

Safety assessment of poly-ε-caprolactone in the treatment of primary spontaneous pneumothorax

Background/purpose

Biomaterial-based implants are gaining traction as an option for pleurodesis treatment, yet the search for the best biomaterial or the most suitable shape to handle spontaneous pneumothorax continues. This forward-looking research assessed the use of a poly-ε-caprolactone membrane for its safety when applied as a sclerosant in pleurodesis procedures in human patients.

Methods

From July 2017 to February 2018, we conducted a Phase I trial in which 10 patients with primary spontaneous pneumothorax were treated using video-assisted thoracoscopic surgery with a poly-ε-caprolactone membrane. These procedures encompassed bleb resection and mechanical pleurodesis through parietal pleura scrubbing. After resection, a 150 × 150 mm poly-ε-caprolactone membrane was applied to the apex. The primary outcome measures were the adverse events and laboratory outcomes.

Results

After surgery, we observed no cardiopulmonary-related adverse events or indications of systemic inflammation. Furthermore, no episodes of hypothermia or hyperthermia occurred. Chest radiographs showed no evident pneumonitis or effusion associated with tissue reactions. The average follow-up duration was 31.7 ± 17.7 months, during which two patients exhibited recurrence.

Conclusion

This study is the first to show the biocompatibility of poly-ε-caprolactone in humans, suggesting its potential as a treatment option for patients with primary spontaneous pneumothorax. Despite the relatively small number of patients, we maintain confidence in the reliability and safety profile of the PCL membrane, bolstered by its previously established efficacy in applications involving other organs. Phase II and phase III clinical studies are needed to support these observations.

Efficacy of mesh coverage in surgical bullectomy for primary spontaneous pneumothorax: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis.

METHODS

A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model.

RESULTS

23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12-0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = -0.74 days, 95% CI -0.28 to -1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14-1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71-2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant.

CONCLUSION

The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials.

The effect of polyglycolic acid sheet in preventing postoperative recurrent pneumothorax: a prospective cohort study

BACKGROUND

Primary spontaneous pneumothorax occasionally relapses, even after bullectomy; therefore, coverage of the bullectomy staple line for pleural reinforcement is common in Japan. However, the appropriate covering materials have not yet been determined.

METHODS

This was a longitudinal prospective cohort study. Data were available for patients aged < 40 years with primary spontaneous pneumothorax who underwent their first thoracoscopic bullectomy between July 2015 and June 2021. We used oxidized regenerated cellulose (ORC) sheets from July 2015 to June 2018, and polyglycolic acid (PGA) sheets from July 2018 to June 2021. The postoperative recurrence-free survival rate was evaluated. The characteristics of the recurrent cases (radiographic, intraoperative, and pathological findings) were also evaluated. The extent of pleural adhesions was classified into the following three groups: none, medium, or extensive.

RESULTS

A total of 187 patients were included in the study. There were 92 and 95 participants in the ORC and PGA sheet groups, respectively. The postoperative recurrence-free survival rates were significantly higher in the PGA sheet group than in the ORC sheet group (ORC group vs. PGA group, 82.9% vs. 95.4%, p = 0.031). In recurrent cases, there was a significant difference in terms of pleural adhesion (0.0% [12 of 12, none] vs. 100.0% [four of four, extensive], p < 0.001).

CONCLUSIONS

Compared with ORC sheets, PGA sheets are an effective material for preventing early recurrence of primary spontaneous pneumothorax. Strong local pleural adhesions potentially contribute to decreasing recurrence.

Current opinion and comparison of surgical procedures for the treatment of primary spontaneous pneumothorax

INTRODUCTION

Although three-port video-assisted thoracoscopic surgery (VATS) is the standard radical treatment for primary spontaneous pneumothorax (PSP), several issues need to be addressed as the postoperative recurrence rate remains relatively high. Although bullectomy is effective in preventing the postoperative recurrence of PSP, recurrent pneumothorax often occurs, requiring additional methods such as pleural covering with absorbable mesh sheets, surgical chemical pleurodesis, pleural abrasion, or pleurectomy. In addition, minimally invasive approaches that exceed three-port VATS are required according to the social demand. These approaches, such as uniportal VATS, reduced port surgery, and needlescopic surgery, have cosmetic merits, lower postoperative pain, and similar surgical results as three-port VATS.

AREAS COVERED

We focused on conventional and novel treatments for PSP in this article.

EXPERT OPINION

Effective methods that prevent postoperative recurrence and minimally invasive approaches will become popular in the near future.

Vicryl Mesh Coverage Reduced Recurrence After Bullectomy for Primary Spontaneous Pneumothorax

BACKGROUND

Although thoracoscopic stapled bullectomy is a standard procedure for primary spontaneous pneumothorax (PSP), the postoperative recurrence rate is high. We investigated whether using a Vicryl (Ethicon, Somerville, NJ) mesh to cover the staple line after bullectomy reduces the postoperative recurrence rate.

METHODS

Our single-blind, parallel-group, prospective, randomized controlled trial at 2 medical centers in Taiwan studied patients with PSP who were aged 15 to 50 years and required thoracoscopic bullectomy. On the day of operation, patients were randomly assigned (1:1) to receive Vicryl mesh (mesh group) or not (control group) after thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion. Randomization was achieved using computer-generated random numbers in sealed envelopes. Our primary end point was the pneumothorax recurrence rate within 1 year after the operation (clinicaltrials.gov number, NCT01848860.) RESULTS: Between June 2013 and March 2016, 102 patients were assigned to the mesh group and 102 to the control group. Within 1 year after operation, recurrent pneumothorax was diagnosed in 3 patients (2.9%) in the mesh group compared with 16 (15.7%) in the control group (P = .005). The short-term postoperative results and hospitalization duration were comparable between the groups.

CONCLUSIONS

For thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion, the use of a Vicryl mesh to cover the staple line is effective for reducing the postoperative recurrence of pneumothorax. Vicryl mesh coverage can be considered an optimal adjunct to the standard surgical procedure for PSP.

Polyglycolic acid mesh for preventing post-thoracoscopic bullectomy recurrence

PURPOSE

Thoracoscopic bullectomy is a common treatment modality for spontaneous pneumothorax but can result in a high frequency of postoperative recurrent pneumothorax in young patients. This retrospective study compared the recurrence rate of pneumothorax following conventional thoracoscopic bullectomy to that following bullectomy using a low-density polyglycolic acid mesh to cover the staple line.

METHODS

Group A comprised 237 patients who experienced 294 episodes of pneumothorax and underwent thoracoscopic bullectomy alone, and Group B comprised 130 patients who experienced 155 episodes of pneumothorax and underwent bullectomy with polyglycolic acid mesh used to cover the visceral pleura. To compare the postoperative inflammatory response between the two groups, we measured three inflammatory parameters: highest body temperature after surgery, C-reactive protein level on postoperative day 3, and change in eosinophil count from the day before the surgery to postoperative day 3.

RESULTS

The recurrence rate was significantly lower in Group B than in Group A (2.6% vs. 24.8%, P < 0.000001). All three inflammatory parameters were significantly higher in Group B than in Group A.

CONCLUSIONS

Using a polyglycolic acid mesh covering after thoracoscopic bullectomy resulted in acceptable long-term results (recurrence rate: 2.6%). This method was associated with a slightly elevated inflammatory response.

Clinicopathological significance of staple line coverage with an oxidized regenerated cellulose sheet after bullectomy for primary spontaneous pneumothorax

BACKGROUND

Oxidized regenerated cellulose (ORC) sheet, in surgery of primary spontaneous pneumothorax, is used to reinforce the visceral pleura around the staple line coverage aiming to prevent a postoperative recurrence. We evaluated the effect of ORC on recurrence within 2 years after surgery.

METHODS

A total of 201 patients aged < 40 years who underwent bullectomy for primary spontaneous pneumothorax at our institution were retrospectively reviewed. They were classified into an ORC sheet coverage group (ORC group, n = 100) and a non-coverage group (n-ORC group, n = 101). Two-year recurrence-free survival rates are assessed between the two groups with associated analysis of radiographical and operative findings.

RESULTS

ORC had no effect on the recurrence rate. CT images and re-operative findings showed regenerated bullae in 19 and 14 patients, close to staple lines in 14 and 11 patients, respectively. White pleural thickening within the covered area was observed in all patients of the ORC group. Pathological findings also showed pleural thickening in eight patients and bulla regeneration under pleural thickening in six patients.

CONCLUSIONS

Coverage with an ORC sheet after bullectomy did not prevent the regeneration of bullae and postoperative recurrence, regardless of exerting a reinforcement effect on the visceral pleura histologically.

New options for pneumothorax management

Introduction: Pneumothorax is defined as the presence of air in the pleural space. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is classified as primary or secondary. There are substantial inconsistencies in international guidelines for the treatment of pneumothorax. Moreover, many geographical variations exist in daily clinical practice.Areas covered: In this article, we focus on novel treatment modalities for this significant health problem in young adults.Expert opinion: In part, these discrepancies have been caused by the lack of high-quality trials or evidence. Currently, the pathophysiological mechanisms underlying pneumothorax are better understood and have implications for clinical management. Studies have demonstrated that the judicious use of pleurodesis can decrease its rate of recurrence, both in surgical and nonsurgical patients.

Comparison of additional minocycline versus iodopovidone pleurodesis during video-assisted thoracoscopic bleb resection for primary spontaneous pneumothorax: a propensity score-matched analysis

Background

The optimal chemical agent for additional pleurodesis during video-assisted thoracoscopic surgery (VATS) bleb resection in primary spontaneous pneumothorax (PSP) remains controversial. We compared the efficacy and safety of iodopovidone with those of minocycline for additional chemical pleurodesis during VATS bleb resection.

Methods

Of 332 patients who underwent VATS bleb resection, 299 patients diagnosed with PSP were enrolled in this study. The patients were divided into two groups according to the chemical agents used for additional pleurodesis (iodopovidone versus minocycline). Propensity score matching was performed on the basis of the preoperative clinical parameters. Postoperative complications, chest tube indwelling time, postoperative hospital stay, and recurrence rate were compared between the two groups.

Results

The median duration of follow-up was 14 months (range, 1-94 months). After propensity score matching, 94 patients from the iodopovidone group and 94 patients from the minocycline group were matched. The perioperative outcomes, including fever, prolonged air-leak, prolonged-effusion, postoperative bed-side pleurodesis, and rehospitalization because of complications, were not significantly different between the two groups. However, the amount of drainage during the first two postoperative days, duration of chest tube indwelling, and duration of hospitalization were significantly shorter in the minocycline group (P<0.001).

Conclusions

This study confirmed the safety of both minocycline and iodopovidone for additional pleurodesis. However, we carefully recommend minocycline over iodopovidone for pleurodesis because of faster postoperative recovery.

Pneumothorax in teenagers: reducing recurrence through resection of superior segment of lower lobe

Background

Spontaneous pneumothorax in young patients is characterized by a high recurrence rate. We retrospectively investigated causes of recurrence and effective surgical methods to improve this statistic, in particular through resection of the superior segment of the lower lung lobe (S6a).

Methods

From April 2011 to September 2017, we performed 146 operations for 126 lateral side pneumothoraces in patients 20 years of age or younger (105 males and 7 females, mean age 17.2 years) at our institution. Two groups-one with patients who underwent both apical bullectomy and S6a resection (the S6a group), and the other with patients who underwent only apical bullectomy with apical reinforcement using an absorbable mesh sheet (the AB group)-were statistically compared in terms of recurrence rate.

Results

A significant difference was found between the S6a group and the AB group in terms of the number of S6a recurrences (0 vs. 8 cases, respectively; P=0.025), although there was no significant difference between the two groups in terms of the total recurrence rate (16.1% vs.18.6%, respectively). Pathological examination revealed that 55 of the 56 (98.2%) S6a specimens already contained asymptomatic, non-ruptured bullae or microscopic bullous lesions at the time of the initial operation.

Conclusions

In addition to the apex, the S6a often involves lesions responsible for pneumothorax recurrence. To reduce this recurrence in teenage patients, we suggest that S6a resection be concomitantly performed in the initial operation-even if there are no macroscopically visible blebs on the S6a.

Association between postoperative bulla neogenesis at the staple line and resected lung weight for primary spontaneous pneumothorax: a retrospective study using the inverse-probability of treatment weighted method in patients grouped according to age

BACKGROUND

Bullectomy using autosutures is the standard procedure in patients with primary spontaneous pneumothorax (PSP). However, postoperative bulla neogenesis (POBN) along the staple line is relatively common and promotes PSP recurrence. We have previously reported the relationship between POBN and resected lung weight (LW). However, recently published data indicate that young patients with PSP have a high postoperative recurrence rate. Therefore, we evaluated the relationship between POBN and LW in PSP patients, subdivided according to age.

METHODS

Between February 2011 and April 2016, 96 lung-resection sites in 67 patients who underwent bullectomy were evaluated. Patients were subdivided into two groups by age: Y group (<25 years, 56 sites) and O group (≥25 years, 40 sites). We used the inverse-probability of treatment weighted (IPTW) method to adjust for the heterogeneity in their backgrounds. POBN was diagnosed by computed tomography.

RESULTS

Cox regression analysis for the O group indicated that LW ≥3.0 g was a significant risk factor for POBN (P=0.049). For the Y group, no association between lung weight and POBN was observed.

CONCLUSIONS

A LW ≥3.0 g is a significant risk factor for POBN in individuals aged ≥25 years.

Optimal surgical technique in spontaneous pneumothorax: a systematic review and meta-analysis

BACKGROUND

Numerous thoracoscopic techniques have been used in the management of primary spontaneous pneumothorax (PSP), including wedge resection, pleurectomy, pleural abrasion, chemical pleurodesis, and staple line covering. The purpose of this systematic review was to compare outcomes for the most commonly reported techniques.

MATERIALS AND METHODS

A systematic literature search looking at pneumothorax recurrence rate, length of stay, and chest tube duration after surgery was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database.

RESULTS

Fifty-one unique studies comprised of 6907 patients published between January 1988 and June 2015 were identified. Heterogeneity among effect sizes was significant for all outcomes. The lowest recurrence rates were observed in the wedge resection + chemical pleurodesis (1.7%; 95% confidence interval [CI], 1.0%-2.7%) and the wedge resection + pleural abrasion + chemical pleurodesis (2.8%; 95% CI, 1.7%-4.7%) groups. The shortest chest tube duration and length of stay were observed in the wedge resection + staple line covering ± other group (2.1 d; 95% CI, 1.4-2.9 and 3.3 d; 95% CI, 2.6-4.0, respectively).

CONCLUSIONS

The variability in reported outcomes and the lack of published multicenter randomized controlled trials highlights a need for more robust investigations into the optimal surgical technique in the management of PSP. Based on the limited quality studies available, this systematic review favors wedge resection + chemical pleurodesis and wedge resection + pleural abrasion + chemical pleurodesis in terms of recurrence rate after surgery for PSP.

Thoracoscopic modified pleural tent for spontaneous pneumothorax

OBJECTIVES

We developed a modified pleural tent (m-tent) procedure and used it in our hospital in almost 30 consecutive patients with spontaneous pneumothorax. The objective of this study was to clarify the feasibility and effectiveness of a thoracoscopic m-tent for the treatment of spontaneous pneumothorax.

METHODS

From July 2013 to November 2014, 107 patients with spontaneous pneumothorax were treated in our institution. Eighty-nine of these patients were analysed retrospectively. The inclusion criteria for thoracoscopic m-tent for spontaneous pneumothorax were multiple and widespread bullae, postoperative relapse and secondary spontaneous pneumothorax. The surgical procedures were usually performed through three ports. After bullectomy, an m-tent is made to strip the parietal pleura off the chest wall from about the level of the fourth or fifth rib to the apex, and two or three ligations are then applied to fix the pleural tent and lung parenchyma. Patients in whom an m-tent was not indicated underwent bullectomy plus coverage using absorbable materials.

RESULTS

Twenty-seven patients underwent bullectomy plus m-tent (m-tent group) and 62 underwent bullectomy plus coverage over a staple line using an absorbable material such as a polyglycolic acid sheet or nitrocellulose sheet (coverage group). No severe postoperative complications were observed in either group. The m-tent and coverage groups showed significant differences in operation time (129 vs 86 min, mean), haemorrhage (12.8 vs 7.2 ml), postoperative hospital stay (3.7 vs 2.9 days) and postoperative painkiller intake (8.6 vs 6.8 days). Recurrence was observed in 1 (3.7%) and 2 patients (3.2%), respectively.

CONCLUSIONS

The thoracoscopic m-tent procedure requires a longer operation, a longer hospital stay and greater painkiller intake. However, these differences are acceptable, and an m-tent should be considered as an option for pleural reinforcement in spontaneous pneumothorax, especially in patients who are complicated with severe pulmonary emphysema, widespread bullae or recurrent pneumothorax.

Staple Line Coverage with a Polyglycolic Acid Patch and Fibrin Glue without Pleural Abrasion after Thoracoscopic Bullectomy for Primary Spontaneous Pneumothorax

Background

This study was conducted to determine the efficacy of staple line coverage using a polyglycolic acid patch and fibrin glue without pleural abrasion to prevent recurrent postoperative pneumothorax.

Methods

A retrospective analysis was carried out of 116 operations performed between January 2011 and April 2013. During this period, staple lines were covered with a polyglycolic acid patch and fibrin glue in 58 cases (group A), while 58 cases underwent thoracoscopic bullectomy only (group B).

Results

The median follow-up period was 33 months (range, 22 to 55 months). The duration of chest tube drainage was shorter in group A (group A 2.7±1.2 day vs. group B 3.9±2.3 day, p=0.001). Prolonged postoperative air leakage occurred more frequently in group B than in group A (43% vs. 19%, p=0.005). The postoperative recurrence rate of pneumothorax was significantly lower in group A (8.6%) than in group B (24.1%) (p=0.043). The total cost of treatment during the follow-up period, including the cost for the treatment of postoperative recurrent pneumothorax, was not significantly different between the two groups (p=0.43).

Conclusion

Without pleural abrasion, staple line coverage with a medium-sized polyglycolic acid patch and fibrin glue after thoracoscopic bullectomy for primary spontaneous pneumothorax is a useful technique that can reduce the duration of postoperative pleural drainage and the postoperative recurrence rate of pneumothorax.

Air leakage on the postoperative day: powerful factor of postoperative recurrence after thoracoscopic bullectomy

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a relatively common disorder in young patients. Although various surgical techniques have been introduced, recurrence after video-assisted thoracoscopic surgery (VATS) remains high. The aim of study was to identify the risk factors for postoperative recurrence after thoracoscopic bullectomy in the spontaneous pneumothorax.

METHODS

From January 2011 through March 2013, two hundreds and thirty two patients underwent surgery because of pneumothorax. Patients with a secondary pneumothorax, as well as cases of single port surgery, an open procedure, additional pleural procedure (pleurectomy, pleural abrasion) or lack of medical records were excluded. The records of 147 patients with PSP undergoing 3-port video-assisted thoracoscopic bullectomy with staple line coverage using an absorbable polyglycolic acid (PGA) sheet were retrospectively reviewed.

RESULTS

The median age was 19 years (range, 11-34 years) with male predominance (87.8%). Median postoperative hospital stay was 3 days (range, 1-10 days) without mortality. Complications were developed in five patients. A total of 24 patients showed postoperative recurrence (16.3%). Younger age less than 17 years old and immediate postoperative air leakage were risk factors for postoperative recurrence after thoracoscopic bullectomy by multivariate analysis.

CONCLUSIONS

Immediate postoperative air leakage was the risk factor for postoperative recurrence. However, further study will be required for the correlation of air leakage with recurrence.

Covering the staple line with a polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax prevents postoperative recurrent pneumothorax

BACKGROUND

Postoperative recurrent pneumothorax (PORP) can arise after surgery for primary spontaneous pneumothorax (PSP) that is recurrent or involves prolonged air leakage. In this study, which included 265 patients (279 cases) with PSP who underwent surgery at our department, the percentage of patients that did not experience PORP was compared between a group that underwent bullectomy alone (group A) and a group in which the staple line and the surrounding visceral pleura were covered with a PGA sheet after bullectomy (group B) in order to study the utility of PGA sheets for preventing PORP.

METHODS

Among the patients with PSP who underwent surgery, the cases of 92 patients (98 cases) from Group A and 173 patients (181 cases) from Group B were reviewed retrospectively. The incidence rates of PORP in these two groups were statistically analyzed in addition to the associations between PORP and age, gender, the affected side, height, body weight, height/weight ratio, smoking habits, or the surgical procedure.

RESULTS

In total, 96.7% of the patients in group B did not suffer PORP, which was significantly higher than the equivalent figure for group A (83.7%, log-rank test: P=0.0003). Moreover, among the examined parameters, only covering the staple line with a PGA sheet was found to be an independent prognostic factor (Cox regression: P=0.0003; HR =0.212; 95% CI, 0.082-0.547).

CONCLUSIONS

It was revealed that when bullectomy is performed in patients with PSP, wide coverage of the staple line and the surrounding visceral pleura with a PGA sheet significantly reduces the risk of PORP.

Video-assisted thoracic surgery for pneumothorax: republication of a systematic review and a proposal by the guideline committee of the Japanese association for chest surgery 2014

OBJECTIVE

The purpose of this consensus conference was to determine whether video-assisted thoracic surgery (VATS) improves clinical outcomes compared with conventional thoracotomy in patients undergoing surgery for pneumothorax, and to outline evidence-based recommendations for the use of VATS.

METHODS

Before the consensus conference, the best available evidence was reviewed, with systematic reviews, randomized trials, and nonrandomized trials all taken into consideration in descending order of validity and importance. At the consensus conference, evidence-based interpretative statements were created, and consensus processes were used to determine the ensuing recommendations. The Medical Information Network Distribution Service in Japan (Minds) system was used to label the levels of evidence for the references and the classes of recommendations.

RESULTS AND RECOMMENDATIONS

The consensus panel agreed upon the following statements and recommendations for patients with pneumothorax undergoing surgery: 1. VATS is broadly indicated as surgery for pneumothorax. 2. VATS is judged to be less invasive, as it results in minimal postoperative pain, the periods of chest tube placement and hospitalization are short, and it shows a trend toward early realization of social integration. 3. There is no difference in terms of safety and complications between VATS and open thoracotomy. 4. As it is anticipated that VATS will result in a higher recurrence rate than open thoracotomy, it may be desirable to add a supplemental procedure during surgery. In summary, VATS can be recommended as pneumothorax surgery (Recommendation grade: Level B).

A new method to detect air leakage in a patient with pneumothorax using saline solution and multidetector-row spiral CT scan

BACKGROUND

The purpose of this study was to establish a new CT scan method to show signs of air leakage and to detect the point of the lung leak in patients with spontaneous pneumothorax by using saline solution and phonation.

METHODS

Eleven patients with spontaneous pneumothorax who had a chest tube placed and underwent an operation because of continuing air leakage were studied. After a plain chest CT scan was performed, 0.9% saline was injected into the affected pleural cavity. A CT scan was acquired again while the patient vocalized continuously. The CT images were evaluated by two thoracic surgeons. All patients underwent video-assisted thoracoscopic surgery to confirm their points of leakage and were treated for spontaneous pneumothorax.

RESULTS

Bubble shadows were seen in nine of 11 cases. In seven of those nine cases, multiple bubbles formed foam or wave shadows. These cases had a small pleural fistula. In the other two cases with a large fistula, air-fluid level in bulla and ground-glass attenuation areas were seen in the pulmonary parenchyma. In all 11 cases, some air-leakage signs were seen on CT scan, and a culprit lesion was presumed to exist by analyzing CT imaging findings and confirming with a surgical air-leak test.

CONCLUSIONS

With a saline injection and vocalization, CT scan could demonstrate air-leak signs in patients with spontaneous pneumothorax. This method does not require contrast medium, special instruments, or high skill and, thus, is a novel and useful examination to detect the culprit lesion in pneumothorax.

Surgery for secondary spontaneous pneumothorax

PURPOSE OF REVIEW

Secondary spontaneous pneumothorax (SSP) can occur in patients who are suffering from diffuse lung disease. The main cause of SSP is chronic obstructive pulmonary disease (COPD). In contrast to primary spontaneous pneumothorax, SSP is a potentially life-threatening condition because patients with SSP also have limited cardiopulmonary reserve. Prompt diagnosis and treatment of SSP are mandatory. In this review, thoracoscopy, a less invasive surgical treatment for SSP, is discussed from the viewpoint of postoperative morbidity, mortality, and recurrence of SSP.

RECENT FINDINGS

A meta-analysis showed that postoperative recurrence of pneumothorax is more frequently observed following thoracoscopy than following open thoracotomy. Recent studies on thoracoscopic surgery for SSP have shown that the rate of postoperative morbidity is still high (15-27.7%) and thoracoscopy is sometimes replaced with open thoracotomy because of dense pleural adhesion or inability to maintain one-lung ventilation during surgery. However, many thoracic surgeons prefer to perform thoracoscopic surgery for SSP because it is less invasive than open thoracotomy. Techniques for bullectomy and pleurodesis are currently being adapted to decrease the recurrence rate of pneumothorax.

SUMMARY

Thoracoscopic surgery for the treatment of SSP should be less invasive to reduce postoperative morbidity, and it should also be more effective to reduce the recurrence of pneumothorax.