Four-year experience with pleural abrasion using a rotating brush during video-assisted thoracoscopy

Pleurabrade: A Spiral Brush for Mechanical Pleurodesis and a Review of the Literature

Background  While the optimal treatment for primary spontaneous pneumothorax remains unclear, mechanical pleurodesis is a well-established treatment. The Pleurabrade is a spiral brush designed for mechanical pleurodesis during thoracoscopy. We present two patients who underwent mechanical pleurodesis with the Pleurabrade. Case Description  Two patients with spontaneous pneumothorax underwent operative intervention including mechanical pleurodesis with the Pleurabrade. Chest tubes were removed within 48 hours postoperatively and they were discharged home. Both patients remain recurrence free at 11 and 22 months, respectively. Conclusion  While further testing is needed, these case reports and operative video highlight the Pleurabrade as an efficient device for thoracoscopic mechanical pleurodesis.

Ablation of weak emphysematous visceral pleura by an ultrasonically activated device for spontaneous pneumothorax

Staple bullectomy is widely performed for the thoracoscopic treatment of spontaneous pneumothorax. When weak emphysematous change was observed to extend to the whole pleura around the localized bulla, weak emphysematous pleura always remain around the stapler after bullectomy. Such cases along with weak pleural surfaces around staplers belong to the groups at high risk of postoperative recurrence. We performed thoracoscopic ablation using an ultrasonically activated device (USAD) for such lesions and studied the efficacy. From April 2002 to December 2006, a total of 85 surgeries for spontaneous pneumothorax were performed in this hospital, of which 34 cases underwent ablation with a USAD for a weak pleural surface. No complications due to ablation were observed. Recurrence was observed in four subjects, but the cause of recurrence was the regeneration of a bulla outside the range of the ablation and was unrelated to the ablation itself. Moreover, significant white pleural thickening was observed at the ablation sites, demonstrating a stiffening effect of the weak visceral pleura. Ablation using a USAD is a safe and easy operative method, and it is an appropriate operative system as a stiffening procedure for a visceral pleura.

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

BACKGROUND

The outcome of thoracoscopic bullectomy for primary spontaneous pneumothorax (PSP) is not satisfactory. To reduce postoperative pneumothorax recurrence after thoracoscopic bullectomy, an effective and easy surgical method is required. We tried a new method using an absorbable mesh that covered the whole apical visceral pleura.

METHODS

A total of 157 sides of 143 patients who underwent stapled bullectomy under thoracoscopy for PSP were reviewed retrospectively. In the apical covering group (group A), a 15 x 15-cm(2) absorbable mesh sheet was placed on the apical visceral pleura with fibrin glue. Patients in group B underwent bullectomy alone. Cumulative postoperative recurrence was compared between the groups. Recurrent cases in group A were examined clinicopathologically.

RESULTS

Group A had 111 cases and group B had 46. There was no operative mortality. Postoperative recurrence occurred in 15 of 157 cases (9.6%): 4 in group A and 11 in group B. The cumulative postoperative 5-year recurrence rate was 3.6% in group A and 23.9% in group B (log-rank test, p = 0.013). In group A, local adhesion was seen at the apical pleurae, and inflammatory changes with foreign body giant cells were seen at the pleura covered with the mesh.

CONCLUSIONS

Placement of a wide absorbable mesh with fibrin glue at the apical visceral pleura significantly reduced postoperative recurrence after thoracoscopic bullectomy for PSP. The mesh was thought to act as a foreign body on the pleura and induce local inflammatory adhesion between the apical pleurae after bullectomy. This was an easy and effective symphysial procedure.

Surgical and other invasive approaches to recurrent pleural effusion with malignant etiology

With an increasing number of cancer survivors, the annual incidence of malignant pleural effusions has been rising in recent decades worldwide. Many patients with various forms of cancer develop malignant pleural effusions at some point in their life. Patients most commonly present with progressive dyspnea. These effusions are refractory and are associated with impaired quality of life for these patients. The main goals of management are evacuation of the pleural fluid and prevention of its re-accumulation. The therapy plan should consider the general health of the patients, their performance status, the presence of trapped lung, and the primary malignancy. However, there is no universally established, standard approach. Surgical options include thoracentesis, chest tube drainage, thoracoscopy followed by chemical and mechanical pleurodesis, Pleur-X catheter drainage, and pleurectomy. Chemical pleurodesis is the most common modality of therapy for patients with recurrent pleural effusion. For example, Talc is the most successful pleurodesis agent with similar equal to that of poudrage or slurry. Pleur-X catheter can reduce hospital stay and adds value to the treatment of patients with trapped lung, who are not appropriate candidates for pleurodesis. Furthermore, a mechanical pleurodesis has been shown to be effective particularly in pleural effusions with lower pH. This article reviews the surgical and other invasive options as well as their technical aspects in the management of recurrent malignant pleural effusions.

Mechanical Abrasion Improves Early Incorporation of Small Intestinal Submucosa

It has been shown that gross incorporation of porcine-derived small intestinal submucosa (SiS) is limited at 2 weeks. This study evaluates a technique for improving the early incorporation of implanted eight-ply SiS. Six pigs underwent implantation of SiS on the peritoneal surface using three techniques: suture fixation of stock-perforated SiS, suture fixation of manually perforated SiS, and suture fixation of stock-perforated SiS to mechanically abraded peritoneum. Gross incorporation was evaluated and random samples harvested for tensiometric analysis 2 weeks after implantation. SiS placed onto mechanically abraded peritoneum demonstrated significantly greater gross incorporation than both stock-perforated SiS (100% versus 42%, P = 0.015) and manually perforated SiS (100% versus 50%, P = 0.042). There was no difference in gross incorporation between stock and manually perforated SiS. Using tensiometric analysis, the force required to separate the peritoneum from the SiS implant was significantly greater for the SiS placed onto mechanically abraded peritoneum (4.4 ± 1.7 kg · f/cm2) than for both the stock-perforated SiS samples (1.0 ± 0.5 kg · f/cm2) and the needle-perforated SiS samples (1.4 ± 0.9 kg · f/cm2; P < 0.001). There was no difference between stock and manually perforated SiS at 2 weeks. Mechanical abrasion of the peritoneum before SiS onlay leads to improved gross incorporation 2 weeks after implantation in a porcine model of herniorrhaphy. Long-term studies and histologic analysis are needed to validate this method as a means for improving early incorporation of SiS.

Retrospective comparison of needle thoracoscopy and conventional thoracoscopic surgery to treat primary spontaneous pneumothorax

OBJECTIVE

To retrospectively compare needle video-thoracoscopic surgery (NVTS) with conventional video-thoracoscopic surgery (CVTS) for the treatment of primary spontaneous pneumothorax.

METHODS

The charts of 9 female and 66 male patients with onset of primary spontaneous pneumothorax between July 1999 and December 2005 were reviewed. Twenty-two patients in the NVTS group were treated with NVTS, using a needle-shaped thoracoscope and instruments (3-mm in diameter), and assisted by one 10-mm standard port, whereas 53 patients in the CVTS group were treated using conventional endoscopic devices with a 10-mm thoracoscope. All patients underwent endoscopic stapling to excise blebs if identified. Postoperative wound pain was scored using a numerical pain scale.

RESULTS

Neither group experienced mortality or any major morbidity during mean follow-up of 80.5 months. In the NVTS and CVTS groups, intraoperative blood loss (11.4+/-14.8 and 17.4+/-18.1 mL respectively, P=0.174), and mean operative times (75.5+/-38.5 and 92.2+/-33.1 min, respectively, P=0.062) did not differ significantly. Mean durations of pleural drainage (0.6+/-1.0 and 2.6+/-2.3 d, respectively, P<0.01), and postoperative hospital stay (2.3+/-1.4 and 4.4+/-2.5 d, respectively, P<0.01) were less in the needle video-thorascopic surgery group. The degree of postoperative wound pain did not differ significantly between the 2 groups. There were 3 cases of persistent postoperative air leakage in both groups, which required further approaches to check for unrecognized blebs. There was no recurrence of pneumothorax in the NVTS group, and 3.6% recurrence rate in the CVTS group.

CONCLUSIONS

Needle thoracoscopy seems to be a safe alternative to treat primary spontaneous pneumothorax.

Video assisted thoracic surgery in the management of spontaneous pneumothorax: the current status

Over the past decade, video assisted thoracic surgery (VATS) has changed the way spontaneous pneumothorax (SP) is managed. Benefits of VATS include less postoperative pain, shorter hospital stay, and attenuated postoperative inflammatory response are evident compared with open thoracic procedures. Furthermore, the increasing acceptance by patients and referring physicians is testament to its success. Recent studies and the authors decade of experience in management of SP by VATS show that it is quick, safe, and effective, with recurrence rates generally comparable to open procedures, with some exceptions. However, selecting the correct procedure and patient, as well as knowing the limitations of the surgeons and techniques are paramount for success. Even to this day, there are considerable variations in the treatment of SP and large scale controlled studies are needed to better define timing of surgery and the role of the different procedures in the treatment and prevention of SP.

Additional minocycline pleurodesis after thoracoscopic surgery for primary spontaneous pneumothorax

RATIONALE

Ipsilateral recurrence rates of spontaneous pneumothorax after video-assisted thoracoscopic surgery are higher than rates after open thoracotomy.

OBJECTIVES

This study was conducted to determine whether additional minocycline pleurodesis would be effective in diminishing recurrence after video-assisted thoracoscopic surgery treatment of primary spontaneous pneumothorax.

METHODS

Between June 2001 and February 2004, 202 patients with primary spontaneous pneumothorax were treated by conventional or needlescopic video-assisted thoracoscopic surgery. The procedures included resection of blebs and mechanical pleurodesis by scrubbing the parietal pleura. After the operation, patients were randomly assigned to additional minocycline pleurodesis (103 patients) or to observation (99 patients).

MAIN RESULTS

Patients in the minocycline group had higher intensity chest pain and required a higher accumulated dose of meperidine. Short-term results showed that the two groups had comparable chest drainage duration, postoperative hospital stay, and complication rates. Patients in the minocycline group demonstrated a trend of decreased rate of prolonged air leaks (1.9 vs. 6.1%, p = 0.100). After a mean follow-up of 29 mo (12-47 mo), recurrent ipsilateral pneumothorax was noted in two patients in the minocycline group and eight patients in the observation group (p = 0.044 by the Kaplan-Meier method and log-rank test). Postoperative long-term residual chest pain and pulmonary function were comparable in both groups.

CONCLUSIONS

Although associated with intense immediate chest pain, additional minocycline pleurodesis is a safe and convenient procedure that can reduce the rate of ipsilateral recurrence after thoracoscopic treatment for primary spontaneous pneumothorax.

Prospective comparison between endosuturing and endostapling in treating primary spontaneous pneumothorax

OBJECTIVE

Direct management of ruptured pulmonary blebs remains the definitive treatment for spontaneous pneumothorax. We compared endosuturing and endostapling performed via thoracoscopy to determine if suture closure of the blebs without resection was sufficient to treat primary spontaneous pneumothorax.

METHODS

Nine female and forty-nine male prospective patients were prospectively enrolled into two groups between July 1999 and May 2003. The patients in the suturing group were treated with an endoscopic suturing technique to close existing blebs. Patients in the stapling group underwent endoscopic stapling to excise the blebs. Only three ports were needed for each procedure.

RESULTS

Neither group experienced mortality or any major morbidity. There were no significant clinical differences between the suturing and stapling groups. The intra-operative blood loss was not significantly different (32.9+/-53.9 and 13.6+/-21.8 mL, respectively, P = 0.079). The duration of pleural drainage was not statistically significant (2.7+/-1.2 and 2.3+/-2.0 days, respectively, P = 0.369). The length of postoperative hospital stay was also not statistically significant (4.2+/-1.5 and 3.8+/-2.4 days, respectively, P = 0.386). However, the operative time was significantly longer in the suturing group (135.0+/-53.8 and 89.0+/-35.6 minutes, respectively, P < 0.05). In each group, there were two cases of recurrence during the 21.5+/-12.1 month followup period, all of which recovered well after retreatment.

CONCLUSIONS

We believe that this is the first prospective study on thoracoscopic suture closure of blebs. By imbricating and buttressing the blebs without resection, the endosuturing method represents an effective way to treat primary spontaneous pneumothorax.

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.

Thoracoscopic treatment of bullous emphysema in 3 dogs

OBJECTIVE

To report thorascopic partial lobectomy for treatment of bullous emphysema in dogs.

STUDY DESIGN

Prospective clinical study.

ANIMALS

Three dogs with spontaneous pneumothorax.

METHODS

Thoracoscopy without pulmonary exclusion was used to identify bulla. The thorascope was introduced into the thorax lateral to the xyphoid process, and instrument portals were made at different levels along the thoracic wall between the third and tenth intercostal spaces. The thorascope was passed through the mediastinum to view the opposite pleural cavity. After identification of bullae, the affected lung was excised using an endoscopic stapler, and the incision line was checked for air leakage. Thoracic drains were used for air aspiration for 2 days after surgery.

RESULTS

Bullae were confirmed histologically as emphysematous lesions. Lung inflation did not interfere with identification of bullae or with surgery. All dogs had full recovery without recurrence for 18 to 29 months after surgery.

CONCLUSIONS

Identification and ablation of bulla can be performed thoracoscopically without pulmonary exclusion in dogs.

CLINICAL RELEVANCE

Thoracoscopy offers several advantages compared with thoracotomy for treatment and diagnosis of idiopathic pneumothorax, including ease of identification of bullae and reduced postoperative pain and morbidity.

[Spontaneous pneumothorax: pleurodesis with an iodo-povidone hydroalcoholic solution]

OBJECTIVE

To analyze the efficacy of an iodo-povidone hydroalcoholic solution for the chemical pleurodesis of spontaneous pneumothorax.

MATERIAL AND METHOD

A descriptive, retrospective study of 81 patients with spontaneous pneumothorax. The patients were treated by video-assisted thoracoscopy and chemical pleurodesis with an iodo-povidone hydroalcoholic solution at the thoracic surgery unit of Hospital de la Santa Creu i Sant Pau in Barcelona (Spain) between January 1993 and December 1999.

RESULTS

Eighty-one patients, 59 men (73%) and 22 women (27%), between 14 and 82 years old (mean age 33 years) were treated. Pneumothorax was most often on the right side (43 cases, 53%). The main indications for surgery were recurrence (52 cases, 64%) and persistent air leaks (25 cases, 31%). All were treated by video-assisted thoracoscopy, with resection of the pulmonary parenchyma in 30 cases (37%) and pleural instillation of the iodo-povidone hydroalcoholic solution as the irritant in all cases. Air leaks were observed during early postoperative recovery in 10 patients (12.3%), self-limited fever in 5 (6.1%) and infection of drainage openings in 2 (2.4%). During the postoperative follow-up period of 6 to 67 months (mean 24 months), 5 recurrences (6.1%) were seen.

CONCLUSIONS

An iodo-povidone hydroalcoholic solution is easy to apply by video-assisted thoracoscopy and is highly effective for pleurodesis in cases of spontaneous pneumothorax.

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

BACKGROUND

Bullectomy for primary spontaneous pneumothorax has been associated with high postoperative recurrence rates when video-assisted thoracoscopic surgery (VATS) has been used rather than thoracotomy. The aim of this study was to evaluate the efficacy and identify the disadvantages, if any, of adding pleurodesis to VATS bullectomy to prevent recurrent pneumothorax.

METHODS

Fifty-three patients who underwent VATS bullectomy with additional pleurodesis for pneumothorax after November 1996 and 50 who underwent VATS bullectomy alone before October 1996 were compared retrospectively in terms of intraoperative factors and postoperative chest pain, pulmonary function, and pneumothorax recurrent rates. Pleurodesis was achieved by electrocauterizing the upper surface of the parietal pleura in a patchy fashion.

RESULTS

There were no significant differences between the additional pleurodesis group and the bullectomy alone group in terms of age, sex, operating time, intraoperative bleeding, number of resected bullae, duration of chest drainage, or volume of fluid drained. Postoperative chest pain and pulmonary function were also similar in both groups. A recurrent pneumothorax occurred in one patient (1.9%) in the additional pleurodesis group; this recurrence rate was significantly lower than that for the bullectomy alone group (eight patients, 16%; p = 0.029). Although the mean postoperative follow-up period was considerably shorter in the additional pleurodesis group (38 months [range, 26-49]) than in the bullectomy alone group (63 months [range, 50-72] ), eight (89%) of all nine recurrences occurred within 26 months of surgery-i.e., within the minimum follow-up period for the additional pleurodesis group.

CONCLUSIONS

Pleurodesis is a minimally invasive technique that is effective in preventing postoperative recurrences of pneumothorax when added to VATS bullectomy. Additional pleurodesis has no disadvantages vs bullectomy alone in terms of worsening postoperative chest pain or pulmonary function.

Thoracoscopic management of primary spontaneous pneumothorax

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is the preferred option for the surgical management of primary spontaneous pneumothorax (PSP).

AIMS

To evaluate the role of thoracoscopic blebectomy with and without chemical pleurodesis.

METHODS

A retrospective study was performed on 113 consecutive cases carried out in one unit. RESULTS; One hundred and thirteen VATS procedures were performed on 108 patients. The mean age was 23 years (range 14-45). The male to female ratio was 82:26. Recurrent pneumothorax was the indication for surgery in 80%. Conversion to an open procedure was required in 10 cases (9%), most commonly due to severe adhesions. Successful endoscopic blebectomy was performed in 98 cases (87%), 48 of which had an additional chemical pleurodesis. Follow-up is currently to a mean of 28 months. Recurrence has occurred in eight cases, including only three in the group managed with additional chemical pleurodesis (6.25%).

CONCLUSION

VATS with blebectomy and chemical pleurodesis is a safe and effective procedure in the management of PSP.