Latest treatments for spontaneous pneumothorax

In vivo comparative assessments on pleural adhesive effects of three commercially available sealants

Objective

Surgical sealant, which is used for the reinforcement of suture lines, has been widely used in lung-resection surgeries with the aim of reducing postoperative morbidity; however, it may exacerbate surgical-site adhesion, creating the risks of restrictive thoracic movement and a difficult entrance for redo operation. We aimed to assess the pleural adhesive effects of 3 frequently used surgical sealants, (1) fibrin glue (fibrin), (2) a composite of polyethylene glycol and human serum albumin (PEG/HSA), and (3) bioabsorbable polyglycolic acid felt (PGA), in an in vivo setting.

Methods

Eighty-one rats were randomly assigned to 3 experimental groups-fibrin, PEG/HSA, and PGA. After intrapleural application of the sealants, the extent and severity of adhesion and inflammation were quantitatively compared among the 3 groups at 2, 4, and 8 weeks.

Results

The scores for both the extent and severity of adhesion were significantly greater in the PGA group than the other 2 groups throughout postoperative period (P < .001 for all). Although both scores in the PES/HSA and fibrin groups were 0 at 2 weeks, the fibrin group showed significantly greater scores than the PES/HSA group thereafter (P < .001 for all). Trends in inflammation scores were similar of those of adhesion scores, favoring the PES/HSA group followed by the fibrin group (P < .001 for all).

Conclusions

Among 3 commonly used sealants, PEA/HSA showed least degree of adhesion/inflammation compared with fibrin and PGA, whereas PGA demonstrated greatest degrees of adhesion/inflammation throughout a postoperative course of 8 weeks in an in vivo model.

Novel insights into causal associations of body mass index or height with pneumothorax: a two-sample Mendelian randomization study

Background

Observational studies have reported an association between body mass index (BMI) as well as height and the risk of pneumothorax. However, it has long been unclear whether BMI or height are causally associated with pneumothorax.

Methods

Genetic summary data for BMI, height and pneumothorax were retrieved from multiple independent large genome-wide association studies (GWAS). A series of quality control steps were conducted to select instruments. Four independent two-sample Mendelian randomization (MR) analyzes were performed to adequately assess the causal relationship between BMI or height on pneumothorax, and the robustness of the results was assessed by a series of sensitivity analyzes.

Results

Height increased the risk of pneumothorax with an OR of 1.5181 (95%CI 1.3092-1.7604; p = 3.28e-08); there was no evidence of a causal effect of BMI on the risk of pneumothorax with an OR of 0.8979 (95%CI 0.7417-1.0869; p = 0.269). Height increased the risk of spontaneous pneumothorax with an OR of 1.0010 (95%CI 1.0002-1.0018; p = 0.012); the results showed no significant causal relationship between BMI and spontaneous pneumothorax either with an OR of 0.9992 (95%CI 0.9983-1.0002; p = 0.112).

Conclusion

Our results supported a genetic association between height and pneumothorax. We found that height increased the risk of pneumothorax. However, no evidence was found to suggest a causal relationship between BMI and pneumothorax risk. The relationship between BMI and pneumothorax requires further in-depth analysis.

A comparative study of surgical outcomes for secondary spontaneous pneumothorax and the postoperative survival prognostic factor: interstitial vs. non-interstitial pneumonia

PURPOSE

To investigate the surgical outcomes and postoperative survival prognostic factors of intractable secondary spontaneous pneumothorax.

METHODS

A total of 95 patients who underwent thoracoscopic surgery for intractable secondary spontaneous pneumothorax between April 2010 and March 2020 were included in this study. These patients were classified into interstitial pneumonia and non-interstitial pneumonia groups, and a comparative study was performed on surgical outcomes and postoperative survival prognostic factors.

RESULTS

There was no difference in the 1-year overall survival rate between the two groups. However, the 3-year overall survival rate was significantly lower in the interstitial pneumonia group than in the non-interstitial pneumonia group. The differences in short-term surgical outcomes (persistent air leakage, postoperative complications, etc.) were not significant between the two groups. Univariate analysis revealed that the drainage period, the development of postoperative complications, and recurrence were significant independent postoperative survival prognostic factors for all cases. Postoperative complications were the only associated postoperative survival prognostic factor for interstitial pneumonia pneumothorax in the multivariate analysis.

CONCLUSION

The development of postoperative complications can cause poor postoperative survival prognosis of intractable secondary spontaneous pneumothorax due to interstitial pneumonia.

Talc slurry pleurodesis in patients with secondary intractable pneumothorax: A phase 2 study

BACKGROUND

Secondary pneumothorax, which occurs most commonly in the elderly, is caused by underlying diseases. Cardiac dysfunction and other organ inefficiencies may render surgical repair impossible. Such non-operative and poor-risk cases are targets for pleurodesis, which involves the instillation of chemicals or irritants to the thoracic cavity through injection, bronchoscopic bronchial occlusion, or other procedures. Sterile graded talc has been used for pleurodesis mainly in Europe and the United States; however, only a few studies and case series investigating this topic have been published. This study evaluates the efficacy and safety of talc slurry pleurodesis.

METHODS

Patients with inoperable secondary intractable pneumothorax, who were not candidates for surgical repair, were recruited. Four grams of sterilized talc was suspended in 50 mL of physiological saline and injected through a tube into the pleural cavity. Additional 50 mL of saline was subsequently injected through the same channel to clean the residual saline in the injection tube. Another additional talc instillation was allowed to control persistent air leakage. The primary endpoint was the proportion of drainage tube removal within 30 days after talc pleurodesis.

RESULTS

Thirty-one patients were included in this study. In 23 out of 28 patients, the drainage tube could be removed within 30 days of talc instillation (82.1 %, 95 % CI = 63.1-93.9), exceeding the threshold of 36.0 % (p < 0.0001). The most common event was pain (11/28 patients, 39.3 %).

CONCLUSIONS

Talc slurry pleurodesis is effective for intractable secondary pneumothorax, with minor side effects.

Surgery for Secondary Spontaneous Pneumothorax with Chronic Lung Diseases

PURPOSES

Secondary spontaneous pneumothorax (SSP) is occasionally observed in elderly patients suffering from diffuse lung diseases. The purpose of this study was to analyze the outcomes of surgical treatment of SSP patients with chronic lung diseases.

METHODS

In total, 242 patients who underwent surgery for spontaneous pneumothorax at Chiba University Hospital from January 2006 to October 2016 were included in this study. The patients' records were reviewed retrospectively for data on their background, surgical treatment, morbidity, mortality, and recurrence.

RESULTS

Of the spontaneous pneumothorax cohort, primary spontaneous pneumothorax (PSP) accounted for 144 patients. Among the 98 patients with SSP, 57 cases were caused by chronic obstructive pulmonary disease (COPD) and 21 were caused by interstitial pneumonia (IP). The postoperative complication rate was 19.3% in the COPD group, 42.9% in the IP group, and 11.1% in the PSP group. The recurrence rate was 5.3% in the COPD group, 28.6% in the IP group, and 21.5% in the PSP group.

CONCLUSIONS

The morbidity and recurrence were comparable between PSP and SSP cases with COPD, whereas these values were unfavorable in SSP cases with IP compared with PSP ones. Surgical intervention should be carefully considered in SSP patients with IP.

Influence of meteorological factors on development of spontaneous pneumothorax

This study investigated the correlation between spontaneous pneumothorax (SP) and meteorological factors during different seasons. Patients who visited emergency rooms (ERs) in large cities in Korea and were discharged with SP from 2014 to 2016 were included in this study. Data on temperature, air pressure, and wind speed for each region were collected to obtain each factor's daily maximum, minimum, average, and changes. Days with more than 1 case of SP per million were referred to as pneumothorax days (PD) and those with less than 1 case of SP per million were referred to as non-pneumothorax days (NPD). The environmental factors were assessed on the same day (Day 0), 1 day prior (Day-1), and 2 days prior (Day-2) to PD and NPD per season. A total of 17,846 patients were included in this study. During winter, 4080 patients with SP visited the ERs of large cities with low population densities. The maximum temperature (0.16°C vs 0.76°C, 0.04°C vs 0.87°C, and 0.09°C vs 0.91°C), change in temperature (0.24°C vs 0.90°C, 0.38°C vs 0.81°C, and 0.41°C vs 0.83°C), average atmospheric pressure (0.16 vs 0.52 hPa, 0.25 vs 0.42 hPa, 0.34 vs 0.40 hPa), and maximum atmospheric pressure (0.15 vs 0.53 hPa, 0.28 vs 0.49 hPa, 0.33 vs 0.71 hPa) were greater for Day 0, Day-1, and Day-2, respectively, in PD than in NPD. Meanwhile, the average (0.31 vs 0.48 m/s, 0.28 vs 0.46 m/s, 0.20 vs 0.40 m/s), minimum (0.20 vs 0.31 m/s, 0.18 vs 0.25 m/s, 0.16 vs 0.25 m/s), and maximum (0.44 vs 0.67 m/s, 0.36 vs 0.71 m/s, 0.26 vs 0.58 m/s) wind speeds were slower, and the changes in wind speed (0.44 vs 0.67 m/s, 0.36 vs 0.71 m/s, 0.16 vs 0.25 m/s) were lower for all 3 days in PD than in NPD. High average and change in temperature, slow and unchanging wind speed, and high average and maximum atmospheric pressure were associated with SP. Since many findings of this study were contradictory to previous studies, it is assumed that the interaction of various factors affects SP.

Correlative analysis of lung CT findings in patients with Birt–Hogg–Dubé Syndrome and the occurrence of spontaneous pneumothorax: a preliminary study

Background

The diagnosis of patients with Birt–Hogg–Dubé (BHD) syndrome is always delayed (even for more than 10 years). Improving the understanding and diagnosis of this disease is vital for clinicians and radiologists. In this study we presented the chest computed tomography (CT) findings of BHD syndrome and offered suggestions for BHD cases with spontaneous pneumothorax.

Methods

Twenty-six BHD patients from 11 families (10 men, 16 women; mean age: 46 ± 12 years, 20–68 years) were included. The clinical features of the patients included pneumothorax, renal lesions, and skin lesions. Twenty-three patients underwent chest CT imaging. The cyst condition of each patient derived from reconstructed chest CT imaging was recorded, including the cyst number, size, volume, pattern, and distribution.

Results

Pneumothorax occurred in 54% (14/26) of patients. Among them, 43% (6/14) had pneumothorax more than twice. However, typical skin and renal lesions were absent. Four patients had renal hamartoma. CT showed that 23 (100%) patients had lung cysts. Pulmonary cysts were bilateral and multiple, round, irregular, or willow-like. And 93.6% of the large cysts (long-axis diameter ≥ 20 mm) were under the pleura, and near the mediastinum and spine. The long-axis diameter, short-axis diameter and volume of the largest cysts were associated with the occurrence of pneumothorax (all P < 0.05).

Conclusions

Chest CT imaging can reveal some characteristic features of BHD syndrome. The occurrence of pneumothorax in BHD patients is closely related to their pulmonary cystic lesions.

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.

Reduced risk of recurrent pneumothorax for sirolimus therapy after surgical pleural covering of entire lung in lymphangioleiomyomatosis

Background

Patients with lymphangioleiomyomatosis (LAM) frequently experience pneumothorax. Although sirolimus is the standard therapy for LAM, its effect on pneumothorax is controversial. Recently, total pleural covering (TPC) and modified TPC (mTPC) were introduced as surgical treatment options for pneumothorax for patients with LAM. However, the effect of sirolimus on the recurrence of pneumothorax in patients who underwent the treatments is still uncertain. We hypothesized that some clinical factors including sirolimus treatment could predict postoperative recurrence of pneumothorax. In order to clarify this hypothesis, we retrospectively analyzed the clinical data from 18 consecutive patients with LAM who underwent 24 surgical pleural covering of entire lung (SPC) as 17 TPC and 7 mTPC against pneumothoraces from surgical database between January 2005 and January 2019, and we determined the predictors of postoperative recurrence.

Results

Of the 24 surgeries of SPC, 14 surgeries (58.3%) had a history of two or more ipsilateral pneumothoraces, and 11 surgeries (45.8%) had a history of ipsilateral pleural procedures before SPC. Sixteen surgeries (66.6%) in 12 patients received treatment of sirolimus after SPC (sirolimus group). With a median follow-up time of 69.0 months after SPC, four surgeries (16.6%) in three patients had a postoperative recurrence, and the 5-year recurrence-free survival (RFS) after SPC was 82.9%. In patients with postoperative recurrence, serum level of vascular endothelial growth factors D was significantly higher than that in those with non-recurrence (3260.5 vs. 892.7 pg/mL, p = 0.02), and the rate of sirolimus treatment in the recurrence group was significantly lower than that in the no-recurrence group (0 vs. 80%, p = 0.006). The log-rank test showed that the RFS of the sirolimus group (sirolimus use after SPC) was significantly better than that of the non-sirolimus group (p = 0.001), and no significant difference was observed for other factors.

Conclusion

We first reported sirolimus might effectively suppress the recurrence of pneumothoraces in LAM patients who received SPC. Sirolimus induction after SPC (TPC or mTPC) might be a feasible option for frequent pneumothorax in LAM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-02081-z.

Feasibility of application of an absorbable topical collagen hemostat sheet (INTEGRAN®) for prevention of postoperative recurrence of pneumothorax in youths

Background

Staple-line coverage is an effective method for prevention of postoperative recurrence of pneumothorax. However, the recurrence rate in young patients is still unsatisfactory using this method. Moreover, there is no consensus about the optimal material for use in this technique. To explore new material for this technique, we conducted this study to evaluate the safety of an absorbable topical collagen hemostat (INTEGRAN^®) for staple-line coverage in pneumothorax surgery in young patients.

Methods

A single-arm prospective interventional study was performed in 25 patients (age <25 years old) with primary spontaneous pneumothorax (PSP) who underwent wedge resection with staple-line coverage with INTEGRAN^® between 2017 and 2020. The rate of material-related adverse events (defined as a body temperature ≥38 ℃ continuing for ≥2 days, postoperative WBC >18,000/mm³ and/or CRP >15 mg/dL, or acute empyema within 30 postoperative days) was defined as the primary endpoint. The 1-year postoperative rates of recurrence and of new bullae around the staple-line were also measured.

Results

The median age was 19 years old. None of the patients had a body temperature ≥38 ℃ continuing for ≥2 days, extra-abnormal examination data, and acute empyema findings. At 1-year postoperatively, the recurrence rate was 12.0%, and the rate of new bullae around the staple-line was 16.7%.

Conclusions

This study showed the safety of use of INTEGRAN^® for staple-line coverage in pneumothorax surgery in young adults. The short-term recurrence rate was acceptable given the high-risk cohort examined in the study. A prospective randomized controlled study is needed for evaluation of the efficacy of INTEGRAN^® for prevention of recurrence of PSP.

Trial Registration

UMIN000026530 at UMIN Clinical Trials Registry

Correlation with spontaneous pneumothorax and weather change, especially warm front approaching

Background

Primary spontaneous pneumothorax (PSP) occurs more frequently in young, tall men, with approximately 10,000 times video-assisted thoracoscopic surgery (VATS) annually in Japan is undergoing for surgical treatment. The underlying mechanisms remain unclear, but several reports have suggested correlation with weather conditions. This study aimed to evaluate the relationship between onset of PSP and changes in weather.

Methods

We retrospectively analyzed data from 112 patients who underwent VATS for PSP in Iwate, Japan from 1 January 2010 to 14 June 2020. Of the 3,818 days in this study period, the day on which the patient became aware of symptoms was classified as the PSP onset day (n=112), and all others were classified as PSP non-onset day (n=3,706). Meteorological data were collected from airbase station using an online source for the same place and same time. Logistic regression modeling was used to obtain predicted risks for the onset of PSP with respect to weather conditions.

Results

Among the meteorological parameters, significant differences were mainly found at 2 days before onset for increasing average temperature [odds ratio (OR): 1.97, P=0.018], minimum temperature (OR: 1.97, P=0.018), average humidity (OR: 1.58, P=0.043), and decreased the sunshine time (OR: 2.26, P=0.012). No significant difference was observed in atrophic pressure at 2 days before onset.

Conclusions

Onset of PSP may correlate with the increased temperature and humidity, seen with an approaching of warm front.

Surgical treatment for secondary spontaneous pneumothorax: a risk factor analysis

PURPOSE

While surgery is an effective treatment for secondary spontaneous pneumothorax (SSP), it can be difficult, because affected patients are usually in a poor general condition. The present study investigated the risk factors of postoperative complications after surgery for SSP.

METHODS

Eighty-eight patients with SSP who underwent surgery from January 2006 to March 2018 were investigated. Clinical data were reviewed, and a multivariate analysis was performed.

RESULTS

Eighty-four patients (95%) were males, and the median patient age was 72 years. Underlying lung diseases were chronic obstructive pulmonary disease in 58 patients (65.9%), interstitial pneumonia in 26 (29.5%), and others in 4 (4.5%). Postoperative complications developed in 21 patients (24%). Hospital mortality/prolonged length of stay occurred in 6 patients (7%). A multivariate analysis showed that the preoperative performance status (performance status 0-2 vs. 3, hazard ratio: 6.570, 95% confidence interval: 1.980-21.800) was an independent predictor of postoperative complications.

CONCLUSION

Surgery for SSP contributed to early chest tube removal and favorable outcomes. However, rare fatal events occurred, and the patient performance status was a risk factor for postoperative complications. A careful evaluation of each patient's performance status is needed to determine the need for surgical intervention for SSP.

Effect of overhang and stiffness on accessibility of catheter tip to lung defects under surgical constraints

Background

Steering a catheter tip to a defective spot on a lung during fibrin glue application under pleurography (FGAP) constitutes a very challenging task. Accurate control of tip position/slope of steerable catheters is critical for providing glue to air-leaking defects on lung during FGAP. Steerable catheters are composed of multiple segments with different flexural rigidities and experience nonlinear deformation. Therefore, predicting tip position with accuracy is difficult. The purpose of this paper is to present a novel method that can accurately control the tip of the catheter, and thus enhance its target accessibility.

Methods

The tip position of a deflected steerable catheter can be accurately predicted using a simulation tool depicting the curvature of a bent catheter based on a mechanics of materials analysis. The proposed method utilizes the simulation tool to enhance the target accessibility of the catheter’s tip. This assists medical doctors to not only select the optimal catheter prior to operation, but also to steer the catheter to the defects effectively. Simulation reliability is tested by performing a catheter deflection experiment and measuring the tip position.

Results

The simulation result accurately predicts the location of the catheter tip with an error of less than 5 mm to the experimental results.

Conclusions

Controlling pull-wire tensions and overhang lengths based on simulation results substantially improves the target accessibility of the catheter tip.

Efficacy and Cost-Effectiveness of Portable Small-Bore Chest Tube (Thoracic Egg Catheter) in Spontaneous Pneumothorax

Background

Primary spontaneous pneumothorax is commonly treated with chest tube insertion, which requires hospitalization. In this study, we evaluated the efficacy, costs, and benefits of a portable small-bore chest tube (Thoracic Egg; Sumitomo Bakelite Co. Ltd., Tokyo, Japan) compared with a conventional chest tube.

Methods

We retrospectively analyzed all primary spontaneous pneumothorax patients who underwent treatment at Gangnam Severance Hospital between August 2014 and May 2018.

Results

A total of 279 patients were divided into 2 groups: the conventional group (n=236) and the Thoracic Egg group (n=43). Of the 236 patients in the conventional group, 100 were excluded because they underwent surgery during the study period. The efficacy and cost were compared between the 2 groups. There was no statistically significant difference between the groups regarding recurrence (conventional group, 36 patients [26.5%]; Thoracic Egg group, 15 patients [29.4%]; p=0.287). However, the Egg group had statistically significantly lower mean medical expenses than the conventional group (433,413 Korean won and 522,146 Korean won, respectively; p<0.001).

Conclusion

Although portable small-bore chest tubes may not be significantly more efficacious than conventional chest tubes, their use is significantly less expensive. We believe that the Thoracic Egg catheter could be a less costly alternative to conventional chest tube insertion.

Thoracoscopic surgery under local anesthesia for high-risk intractable secondary spontaneous pneumothorax

OBJECTIVES

To evaluate the outcomes of thoracoscopic surgery for intractable secondary spontaneous pneumothorax (SSP) under local anesthesia in high-risk patients and report intraoperative findings useful for identifying air leakage points.

METHODS

We analyzed outcomes of 14 consecutive thoracoscopic operations under local anesthesia for high-risk SSP from 2015 to 2019. Suspicious lesions were determined based on intraoperative direct or indirect detections. Direct detection involved identifying pleural fistulas or air bubbles. Indirect detection involved finding thin and transparent bullae without any other suspicious lesions. Identifications of culprit lesions were confirmed by arrest or significant decrease in air leakage after surgical repair. All surgical repairs were followed by immediate single pleurodesis for a definitive cure and prevention of recurrence. Success was defined as the removal of the thoracic tube by surgical repair combined with immediate postoperative single pleurodesis.

RESULTS

The main underlying pulmonary diseases were emphysema (n = 7), carcinoma (n = 3), interstitial pneumonia (IP) (n = 3), and nontuberculous mycobacterial infection (n = 1). A leakage point was identified in 13 cases (six on direct and seven on indirect detections). Success was achieved in nine cases (four on direct and five on indirect detections). Adverse events included one case of acute exacerbation of IP and one case of carbon dioxide narcosis.

CONCLUSION

Thoracoscopic surgery under local anesthesia can be the worthwhile definitive modality, among few remaining treatments, for highly fragile patients with SSP. Detecting air leakage directly and the presence of thin and transparent bullae without any other suspicious lesions can be clues for identifying culprit lesions.

Total pleural coverage followed by lung transplantation in patient with lymphangioleiomyomatosis

Tuberous sclerosis complex lymphangioleiomyomatosis (TSC-LAM) is a rare disease, which may develop an intractable pneumothorax. Chemical or mechanical pleurodesis is a general management to prevent recurrence of pneumothorax, rendering it difficult to later dissect the pleura and control intraoperative bleeding. Since total pleural coverage (TPC) alternative to pleurodesis has been firstly reported by Kurihara et al. (Jpn J Thorac Cardiovasc Surg 54:274, 2006), TPC was performed in case of a 46-year-old female with a secondary spontaneous pneumothorax caused by TSC-LAM and followed by lung transplantation. Final pathological report showed the reinforced visceral pleura in the absence of dense adhesions.

The three peaks in age distribution of females with pneumothorax: a nationwide database study in Japan

OBJECTIVES

Women are the minority among patients with spontaneous pneumothorax, but catamenial pneumothorax (CP) is unique to them. We aimed to clarify the clinical characteristics of female patients with spontaneous pneumothorax using a nationwide database.

METHODS

Medical records from the Japanese Diagnosis Procedure Combination database for inpatients with pneumothorax between July 2010 and March 2016 were retrospectively reviewed. Age, underlying diseases, body mass index, smoking status, laterality, number of hospitalizations and treatments were studied.

RESULTS

We identified 157 087 patients with pneumothorax, including 27 716 (17.6%) women and 129 371 (82.4%) men. The age distribution of female patients with pneumothorax had 3 peaks: 18 years, around 40 years and 80 years; male patients had 2 peaks: 18 years and 79 years. We identified 873 patients with CP; this number was not sufficient to account for the female-specific peak around 40 years. The characteristics of female patients of reproductive age were significantly different between those with and without CP. The patients with CP were older (average age: 37.9 ± 7.7 years vs 31.3 ± 11.5 years, P < 0.001), were right side dominant (right: 64.9%, left: 6.5%), had more hospitalizations (average number of hospitalizations: 1.6 ± 0.9 vs 1.3 ± 0.6, P < 0.001) and had more frequently undergone surgery (57.1% vs 37.3%, P < 0.001).

CONCLUSIONS

The age distribution of women with pneumothorax had 3 distinct peaks while that of men had 2. CP has different characteristics from other types of pneumothorax, thus requiring different treatment strategies for women of reproductive age.

Intractable pneumothorax due to rupture of subpleural rheumatoid nodules: a case report

Background

In rare cases, rheumatoid pleural nodules can rupture into the pleural cavity to cause pneumothorax or empyema. We report successful surgical treatment of a patient with an intractable secondary pneumothorax due to rupture of a subpleural rheumatoid nodule into the pleural cavity.

Case presentation

A 75-year-old man with a medical history of rheumatoid arthritis, acute coronary syndrome, and diabetes was admitted to our hospital because of left chest pain and dyspnea. A chest X-ray and chest computed tomography (CT) scan showed a left pneumothorax and several small subpleural nodules with cavitation. Repeated pleurodesis via a chest tube failed to improve the pneumothorax, so we decided to perform thoracoscopic surgery. Air leakage was detected in the left upper lobe where the subpleural nodule was visible on chest CT. Resection of the lesion successfully resulted in resolution of the air leakage. The final pathological diagnosis of the subpleural nodule was a pulmonary rheumatoid nodule. The patient has had no evidence of recurrence of pneumothorax after surgery.

Conclusions

We obtained a final pathological diagnosis of a rheumatoid nodule that caused an intractable pneumothorax. Pneumothorax associated with rupture of rheumatoid nodules in the subpleural cavitary is difficult to treat with thoracoscopic surgery as a second-line treatment.

A total pleural covering of absorbable cellulose mesh prevents pneumothorax recurrence in patients with Birt-Hogg-Dubé syndrome

Background

Birt-Hogg-Dubé syndrome (BHDS) is a recently recognized inherited multiple cystic lung disease causing recurrent pneumothoraces. Similarly to the lesions in patients with lymphangioleiomyomatosis (LAM), the pulmonary cysts are innumerable and widely dispersed and cannot all be removed. We recently described a total pleural covering (TPC) that covers the entire visceral pleura with oxidized regenerated cellulose (ORC) mesh. TPC successfully prevented the recurrence of pneumothorax in LAM patients. The purpose of this study was to evaluate the effect of an ORC pleural covering on pneumothorax recurrence in BHDS patients.

Results

This retrospective study enrolled a total of 81 pneumothorax patients with the diagnosis of BHDS who underwent 90 covering surgeries from January 2010 to August 2017 at Tamagawa Hospital. During the first half of the study period, a lower pleural covering (LPC) which covered the affected area with ORC mesh was mainly used to treat 38 pneumothoraces. During the second half of the study period, TPC was primarily performed for 52 pneumothoraces. All the thoracoscopic surgeries were successfully performed without serious complications (≥ Clavien-Dindo grade III). The median follow-up periods after LPC/TPC were 66/34 months, respectively. Pneumothorax recurrence rates after LPC at 2.5/5/7.5 years postoperatively were 5.4/12/42%, respectively; none of the patients who had underwent TPC developed postoperative pneumothorax recurrence (P = 0.032).

Conclusions

TPC might be an effective option for surgical treatment of intractable pneumothorax in patients with BHDS.

Electronic supplementary material

The online version of this article (10.1186/s13023-018-0790-x) contains supplementary material, which is available to authorized users.

Oxidized regenerated cellulose induces pleural thickening in patients with pneumothorax: possible involvement of the mesothelial-mesenchymal transition

PURPOSE

The pleural covering technique, i.e., wrapping a part of or the entire surface of the lung with oxidized regenerative cellulose (ORC), reinforces visceral pleura through pleural thickening for patients with pneumothorax and cystic lung diseases. However, it remains undetermined how ORC induces pleural thickening.

METHODS

A histopathological examination was performed for lung specimens from patients who had recurrent pneumothoraces after pleural covering and re-operation (n = 5). To evaluate the influence of ORC on the pleura in vitro, we used MeT-5A cells (a human pleural mesothelial cell line).

RESULTS

Pleural thickening was confirmed in all lung specimens examined. Three months after covering, the thickened pleura showed inflammatory cell infiltration, proliferation of myofibroblasts, and expression of fibronectin and TGF-β. However, after 1 year, those findings virtually disappeared, and the thickened pleura was composed mainly of abundant collagen. When MeT-5A cells were cultured in ORC-immersed medium, their morphology changed from a cobblestone to spindle-shaped appearance. The expression of E-cadherin decreased, whereas that of N-cadherin, α-smooth muscle actin, and fibronectin increased, suggesting mesothelial-mesenchymal transition (Meso-MT).

CONCLUSIONS

Our results suggest that Meso-MT may be involved as a mechanism of pleural thickening induced by pleural covering with ORC.

Primary and Secondary Spontaneous Pneumothorax: Prevalence, Clinical Features, and In-Hospital Mortality

Background. Optimal treatment practices and factors associated with in-hospital mortality in spontaneous pneumothorax (SP) are not fully understood. We evaluated prevalence, clinical characteristics, and in-hospital mortality among Japanese patients with primary or secondary SP (PSP/SSP). Methods. We retrospectively reviewed and stratified 938 instances of pneumothorax in 751 consecutive patients diagnosed with SP into the PSP and SSP groups. Factors associated with in-hospital mortality in SSP were identified by multiple logistic regression analysis. Results. In the SSP group (n = 327; 34.9%), patient age, requirement for emergency transport, and length of stay were greater (all, p < 0.001), while the prevalence of smoking (p = 0.023) and number of surgical interventions (p < 0.001) were lower compared to those in the PSP group (n = 611; 65.1%). Among the 16 in-hospital deceased patients, 12 (75.0%) received emergency transportation and 10 (62.5%) exhibited performance status (PS) of 3-4. In the SSP group, emergency transportation was an independent factor for in-hospital mortality (odds ratio 16.37; 95% confidence interval, 4.85–55.20; p < 0.001). Conclusions. The prevalence and clinical characteristics of PSP and SSP differ considerably. Patients with SSP receiving emergency transportation should receive careful attention.

Birt-Hogg-Dubé syndrome: a literature review and case study of a Chinese woman presenting a novel FLCN mutation

BACKGROUND

The Birt-Hogg-Dubé (BHD) syndrome is a very rare autosomal dominant form of genodermatosis caused by germline mutations in the folliculin (FLCN) gene, which is mapped to the p11.2 region in chromosome 17. BHD commonly presents cutaneous fibrofolliculomas, pulmonary cysts, renal cell carcinoma, and recurrent pneumothoraxes. The disease is easily ignored or misdiagnosed as pneumothorax, pulmonary lymphangiomyomatosis (LAM), or emphysema. Follow-up and guidelines for managing recurrent pneumothoraxes in these patients are lacking.

CASE PRESENTATION

We reported the case of a 56-year-old Chinese woman who presented skin lesions, multiple lung bubblae, recurrent pneumothoraxes, thyroid nodules, and pulmonary inflammatory pseudotumors (PITs). The patient had a family history of pneumothoraxes and renal tumor. The BHD diagnosis was confirmed by genetic testing, which revealed a novel FLCN mutation in exon 14. Furthermore, the patient underwent a bullectomy because of recurrent pneumothorax 6 years ago.

CONCLUSION

To our knowledge, the novel mutation in exon 14 and the manifestation of PIT in the present case have never been reported for BHD. The patient underwent a bullectomy previously with no relapse at the last follow-up before the preparation of this report, thereby suggesting that thoracotomy with bullectomy may be a possible therapeutic approach for some BHD patients with recurrent pneumothorax.

Birt-Hogg-Dubé syndrome: a case report and a review of the literature

Background: Birt-Hogg-Dubé syndrome (BHDS) is a rare autosomal dominant inherited syndrome caused by mutations in the folliculin coding gene (FLCN). The clinical manifestations of the syndrome involve the skin, lungs, and kidneys. Because of the rarity of the syndrome, guidelines for diagnosis and management of the patients with BHDS are lacking.

Objective: To present a case story and a review of the literature on BHDS in order to give an update on genetics, clinical manifestations, diagnosis, treatment, prognosis and follow-up strategies.

Design: Literature review and case story.

Results: A PubMed and Embase search identified 330 papers. BHDS is characterized by small benign tumors in the skin, spontaneous pneumothoraces caused by cysts in the lungs and a seven-fold increased risk of renal cancer. A case story of a young female patient presenting with pneumothorax and a family history of recurrent pneumothoraces in many relatives illustrates how the history and the diagnostic work up resulted in a diagnosis of BHDS.

Conclusion: BHDS is a rare inherited disorder. In patients with spontaneous pneumothorax or cystic lung disease without any obvious explanation, BHDS should be considered. Concomitant skin manifestations, a family history of familiar pneumothorax, renal cancers and skin manifestations supports the suspicion of BHDS. Early diagnosis is important in order to subject patients to systematic screening for renal cancers. A radiological surveillance strategy for renal cancer is proposed.

A Total Pleural Covering for Lymphangioleiomyomatosis Prevents Pneumothorax Recurrence

Background

Spontaneous pneumothorax is a major and frequently recurrent complication of lymphangioleiomyomatosis (LAM). Despite the customary use of pleurodesis to manage pnenumothorax, the recurrence rate remains high, and accompanying pleural adhesions cause serious bleeding during subsequent lung transplantation. Therefore, we have developed a technique of total pleural covering (TPC) for LAM to wrap the entire visceral pleura with sheets of oxidized regenerated cellulose (ORC) mesh, thereby reinforcing the affected visceral pleura and preventing recurrence.

Methods

Since January 2003, TPC has been applied during video-assisted thoracoscopic surgery for the treatment of LAM. The medical records of LAM patients who had TPC since that time and until August 2014 are reviewed.

Results

TPC was performed in 43 LAM patients (54 hemithoraces), 11 of whom required TPC bilaterally. Pneumothorax recurred in 14 hemithoraces (25.9%) from 11 patients (25.6%) after TPC. Kaplan-Meier estimates of recurrence-free hemithorax were 80.8% at 2.5 years, 71.7% at 5 years, 71.7% at 7.5 years, and 61.4% at 9 years. The recurrence-free probability was significantly better when 10 or more sheets of ORC mesh were utilized for TPC (P = 0.0018). TPC significantly reduced the frequency of pneumothorax: 0.544 ± 0.606 episode/month (mean ± SD) before TPC vs. 0.008 ± 0.019 after TPC (P<0.0001). Grade IIIa postoperative complications were found in 13 TPC surgeries (24.1%).

Conclusions

TPC successfully prevented the recurrence of pneumothorax in LAM, was minimally invasive and rarely caused restrictive ventilatory impairment.

The best time for surgery on a patient with recurrent pneumothorax and undetectable culprit lesions is at the exact time air leakage is discovered: a case report

Background

One cause of recurrent spontaneous pneumothorax includes overlooking bullae during a previous surgery for pneumothorax; and the identification of the culprit lesions is necessary for prevention of recurrence.

Case presentation

A 28-year-old man was referred to our hospital because of spontaneous right-sided pneumothorax. He underwent video-assisted thoracoscopic surgery, which did not reveal air leakage. The patient was subsequently seen at our hospital for 2 additional episodes of recurrent right-sided pneumothorax. At the third admission we observed intermittent air leakage while the patient was in the sitting position after chest drainage, and we performed surgery. An intraoperative submersion test showed air leakage dorsally from the pleural surface of S⁶ and a minute culprit lesion, which were not seen at the first operation and confirmed the leakage site. The area was ligated and coated with regenerated oxidized cellulose mesh and autologous blood.

Conclusion

In cases of pneumothorax with repeated recurrence, the best time to perform surgery on the patient with undetectable culprit lesion is the exact time that air leakage is observed.

Outpatient Treatment for Pneumothorax Using a Portable Small-Bore Chest Tube: A Clinical Report

Background

For treatment of pneumothorax in Korea, many institutions hospitalize the patient after chest tube insertion. In this study, a portable small-bore chest tube (Thoracic Egg; Sumitomo Bakelite Co. Ltd., Tokyo, Japan) was used for pneumothorax management in an outpatient clinic.

Methods

Between August 2014 and March 2015, 56 pneumothorax patients were treated using the Thoracic Egg.

Results

After Thoracic Egg insertion, 44 patients (78.6%) were discharged from the emergency room for follow-up in the outpatient clinic, and 12 patients (21.4%) were hospitalized. The mean duration of Thoracic Egg chest tube placement was 4.8 days, and the success rate was 73%; 20% of patients showed incomplete expansion and underwent video-assisted thoracoscopic surgery. For primary spontaneous pneumothorax patients, the success rate of the Thoracic Egg was 76.6% and for iatrogenic pneumothorax, it was 100%. There were 2 complications using the Thoracic Egg.

Conclusion

Outpatient treatment of pneumothorax using the Thoracic Egg could be a good treatment option for primary spontaneous and iatrogenic pneumothorax.

Pleural Covering Application for Recurrent Pneumothorax in a Patient with Birt-Hogg-Dubé Syndrome

Birt-Hogg-Dubé syndrome (BHDS) is a rare hereditary disease that presents with multiple lung cysts and recurrent pneumothorax. These cysts occupy predominantly the lower-medial zone of the lung field adjacent to the interlobar fissure, and some of them abut peripheral pulmonary vessels. For the surgical management of pneumothorax with BHDS, the conventional approach of resecting all subpleural cysts and bullae is not feasible. Thus, after handling several bullae by using a stapler or performing ligation as a standardized treatment, we applied to a pleural covering technique to thicken the affected visceral pleura and then to prevent recurrence of pneumothorax. We herein report the successful application of a pleural covering technique via thoracoscopic surgery to treat the recurrent pneumothorax of a 30-year-old man with BHDS. This technique is promising for the management of intractable pneumothorax secondary to BHDS.

Results of surgical treatment for secondary spontaneous pneumothorax according to underlying diseases

OBJECTIVES

The outcome of surgical treatment for secondary spontaneous pneumothorax (SSP) has rarely been investigated.

METHODS

We retrospectively reviewed 183 patients who underwent surgery for SSP. We categorized the patients into three groups according to underlying diseases: Group A (chronic obstructive pulmonary disease), Group B (interstitial pneumonia [IP]) and Group C (others). We defined treatment success as surgery without hospital mortality, postoperative complications, death within 6 months or ipsilateral recurrence of pneumothorax within 2 years. We assessed the risk factors for unsuccessful treatment using a Cox regression hazard model.

RESULTS

There were 123 patients in Group A, 20 in Group B and 40 in Group C. The hospital mortality rates were 2, 15 and 0% in Groups A, B and C, respectively. The hospital mortality, morbidity and pneumothorax recurrence rates in the IP group were higher than in the other groups. The 5-year overall survival rates were 78, 32 and 84% in Groups A, B and C, respectively; the prognosis of the IP group was significantly poorer. The treatment success rates were 86, 45 and 83% in Groups A, B and C, respectively. SSPs caused by IP and SSPs requiring open surgery were identified as the risk factors for unsuccessful treatment.

CONCLUSIONS

Surgery for SSP caused by underlying diseases other than IP yielded favourable results. However, a careful examination of surgical indication and a realistic disclosure for informed consent are required for patients with SSP caused by IP, because of the high treatment failure rate.

Partial pleural covering for intractable pneumothorax in patients with Birt-Hogg-Dubé Syndrome

BACKGROUND AND AIMS

Birt-Hogg-Dubé syndrome (BHD) is an inherited disorder associated with a germline mutation of the folliculin (FLCN) gene. Most patients with BHD have multiple pulmonary cysts, and are at high risk of repeated pneumothorax. Although an increasing number of patients are diagnosed with BHD by genetic testing, therapeutic approaches for intractable pneumothorax have not yet been described.

METHODS

We treated three patients who had repeated episodes of pneumothorax. All had multiple pulmonary cysts in the lower lobes, and two had a family history of pneumothorax. Video-assisted thoracic surgery was used to perform wedge resections and partial pleural covering of the cystic lesions. The partial pleural covering technique used sheets of polyglycolic acid felt or regenerative oxidized cellulose mesh. The resected tissues underwent histopathological evaluation, and peripheral blood leukocytes were tested for FLCN mutations.

RESULTS

The operative times were less than 2 h, and there were no complications. The resected cysts had histopathological features characteristic of BHD lung. All patients were found to have FLCN germline mutations; thus their repeated pneumothoraces were a manifestation of BHD. None of the patients developed respiratory problems after undergoing the partial pleural covering procedure, and they have all been well without pneumothorax for 30 months or more.

CONCLUSIONS

Partial pleural covering combined with resection of protruding cysts should be a safe and effective therapeutic approach for BHD patients with intractable pneumothorax. Further investigation is needed to establish a detailed protocol for treatment of pneumothorax that results in minimal functional impairment.

Preoperative saline-filled computed tomography thoracography for awake video-assisted thoracic surgery: report of three cases

Awake video-assisted thoracic surgery (VATS) is a therapeutic option for patients with intractable secondary spontaneous pneumothorax (SSP) complicated by impaired pulmonary function. The preoperative identification of air leak points is one of the keys to the success of this procedure. We describe how we performed saline-filled computed tomography (CT) thoracography to detect pleural fistulae in three patients with intractable SSP. Saline-filled CT thoracography showed bubble signs in two patients and an air-water level in bulla in one patient. The preoperative identification of air leak points resulted in successful awake VATS for all three patients. Our experience demonstrates that saline-filled CT thoracography is a useful diagnostic tool for SSP, especially when used in preparation for awake VATS when minimally invasive procedures are desirable.

Prevention of Polyglycolic Acid-Induced Peritoneal Adhesions Using Alginate in a Rat Model

Postoperative intra-abdominal or intrathoracic adhesions sometimes cause significant morbidity. We have designed three types of alginate-based treatments using strongly cross-linked (SL), weakly cross-linked (WL), and non-cross-linked (NL) alginate with calcium gluconate. In rat experiments, we compared the antiadhesive effects of the three types of alginate-based treatments, fibrin glue treatment (a standard treatment), and no treatment against adhesions caused by polyglycolic acid (PGA) mesh (PGA-induced adhesions). The antiadhesive materials were set on the PGA sheet fixed on the parietal peritoneum of the abdomen. Fifty-six days later, the adhesions were evaluated macroscopically by the adhesion scores and microscopically by hematoxylin-eosin staining and immunostaining. We also tested the fibroblast growth on the surface of the antiadhesive materials in vitro. The antiadhesive effects of WL and NL were superior to the no treatment and fibrin glue treatment. A microscopic evaluation confirmed that the PGA sheet was covered by a peritoneal layer constructed of well-differentiated mesothelial cells, and the inflammation was most improved in the NL and WL. The fibroblast growth was inhibited most on the surfaces of the NL and WL. These results suggest that either the WL or NL treatments are suitable for preventing PGA-induced adhesions compared to SL or the conventional treatment.

Total pleural covering technique for intractable pneumothorax in patient with Ehlers-Danlos syndrome

We report a patient with vascular-type Ehlers-Danlos syndrome (vEDS) who developed pneumothorax and was treated with a total pleural covering technique (TPC). A 24-year-old man developed repeat pneumothorax with intermittent hemo-sputum. Based on unusual radiological manifestations of lung lesions and physical findings, EDS was suspected as an underlying cause of the pneumothorax. Surgical treatment was performed using a mediastinal fat pad and TPC, and no relapse was seen up to 2 years after surgery. TPC is a less invasive surgical approach for selected patients with vEDS. Accurate underlying diagnosis of vEDS and systemic evaluation of vascular complications are necessary before planning surgery.

Efficacy and long-term clinical outcome of bronchial occlusion with endobronchial Watanabe spigots for persistent air leaks

BACKGROUND

We reviewed our clinical experience and examined the efficacy and long-term outcome of bronchial occlusion with endobronchial Watanabe spigots (EWSs).

METHODS

We retrospectively reviewed the clinical charts of patients who had undergone endoscopic bronchial occlusion with EWSs between July 2002 and July 2004. The affected bronchi were identified by chest computed tomography, pleurography, and balloon occlusion test.

RESULTS

Of the 21 patients, 18 had underlying pulmonary complications, including chronic obstructive lung disease (n=14), cancer (n=4), pneumoconiosis (n=3), and pneumonia (n=1). Six (29%) achieved complete resolution and 12 (57%) experienced a reduction in air leaks after the first EWS insertion. Of the 12 patients with reduced air leaks, 10 subsequently underwent chemical pleurodesis and 5 (24%) achieved complete resolution after the procedure. A second EWS insertion procedure was performed for 8 patients: 2 achieved complete resolution and 5 achieved a further reduction in air leaks with complete resolution after chemical pleurodesis. Eighteen of the 21 patients were followed up at an outpatient clinic after discharge: 13 for more than 12 months and 4 for more than 84 months. During the follow-up period, most patients did not show any obvious pulmonary complications.

CONCLUSIONS

We showed that bronchial occlusion with EWSs was effective in stopping or reducing air leaks and that 86% of our patients finally achieved complete resolution, some when the occlusion was combined with chemical pleurodesis. The rate of complications was acceptable, even after long-term placement.

Pulmonary manifestations of Birt-Hogg-Dubé syndrome

Birt-Hogg-Dubé syndrome (BHD) is a rare, autosomal dominant disorder characterized by the development of hair follicle tumors, renal tumors and pulmonary cysts. BHD is caused by heterozygous, predominantly truncating mutations in the folliculin (FLCN) gene located on chromosome 17, which encodes a highly conserved tumor suppressor protein. Although management of renal tumors of low malignant potential is the primary focus of longitudinal care, pulmonary manifestations including cyst formation and spontaneous pneumothorax are among the most common manifestations in BHD. Due to the lack of awareness, there is commonly a delay in the pulmonary diagnosis of BHD and patients are frequently mislabeled as having chronic obstructive lung disease, emphysema or common bullae/blebs. A family history of pneumothorax is present in 35 % of patients with BHD. Certain imaging characteristics of the cysts, including size, basilar and peripheral predominance, perivascular and periseptal localization, and elliptical or lentiform shape can suggest the diagnosis of BHD based on inspection of the chest CT scan alone. Recurrent pneumothoraces are common and early pleurodesis is recommended. A better understanding of role of FLCN in pulmonary cyst formation and long term studies to define the natural history of the pulmonary manifestations of BHD are needed.

What is an appropriate material to use with a covering technique to prevent the recurrence of spontaneous pneumothorax?

BACKGROUND

The purpose of this retrospective study was to identify an appropriate material that can be used as a covering for patients with a spontaneous pneumothorax (SP). A total of 279 patients were studied over a period of eight years.

METHODS

The patient characteristics, surgical details and perioperative outcomes were analyzed. We compared the clinicopathological characteristics between recurrent and non-recurrent cases, and examined the associations with the material used for covering the SP, such as polyglycolic acid (PGA) sheets, a fibrinogen-based collagen fleece (TachoComb; TC) or regenerated oxidized cellulose mesh (ROCM).

RESULTS

The differences in the gender, smoking habits, lesion site, location, comorbidities, ipsilateral spontaneous pneumothorax (ISP), contralateral spontaneous pneumothorax (CSP) and surgery for ISP did not reach statistical significance between the patients treated with a covering of ROCM and those treated with PGA/TC, although the age of the patients was significantly different in these groups, with the ROCM group having younger patients (p = 0.024). The length of the operation was significantly shorter in the ROCM group (mean: 76.7 minutes) than in the PGA/TC cases (130.4 minutes, p = 0.015). Concerning the intraoperative factors, there were no significant differences with regard to the approach, buttress stapling, covering or surgeon. No postoperative recurrence was observed in this series. There were no significant differences in the perioperative outcomes. However, the drainage period was shorter in subjects who underwent covering with the ROCM (mean: 1.125 days) than with the PGA/TC (2.412 days, p = 0.030). Further, the hospital stay had a tendency to be shorter in subjects who underwent covering with ROCM than with PGA/TC.

CONCLUSIONS

ROCM might be superior to PGA/TC as a material for covering SP in terms of the length of the operation and the drainage period. ROCM might decrease the hospital stay and the postoperative recurrence. Prospective studies in a larger cohort of patients will be necessary to define the optimal surgical technique to suppress the recurrence of SP.

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.

The Effect of Additional Pleural Procedures onto Recurrence Rates on the Spontaneous Pneumothorax Surgery

Background

Spontaneous pneumothoraxes constituted 1/1000 hospital admissions. They are particularly one of life threatening health issues in combination with bilateral pneumothorax, tension pneumothorax, repertory failure or COPD.

Objectives

The cases of spontaneous pneumothorax represent a significant portion of the patients profile within the chest surgery clinics. The risk of recurrent pneumothorax in post thoracoscopy is between 2% and 14%, thus the subject of cure treatment and approach is still controversial. The cases were retrospectively treated due to spontaneous pneumothorax and their reasons, treatment approaches and results were comparatively examined with the literature.

Patients and Methods

The years between 2007 and 2010, according to our hospital clinic, outpatients and accident &amp; emergency admission records, 79 patients were admitted with a diagnosis of spontaneous pneumothorax; and the patients’ age, gender, symptoms, types of pneumothorax, surgical intervention and recurrence, average length of stay, mortality and complications were retrospectively evaluated.

Results

Seventy of all the patients (88.6%) were male and 9 of those (13.7%) were female. The mean age was calculated as 45.50 ± 21.07 (0-85). The patients were comprised of 41 (51.9%) with primary spontaneous pneumothorax and 38 (48.1%) with secondary spontaneous pneumothorax. 55 of the patients (69.6%) with the first attack, and 24 patients (30.4%) with post tube thoracotomy’s 2nd or 3rd pneumothorax attack were admitted. Those who were accepted with post tube thoracostomy’s 2nd or 3rd attack made up 2/3 of the secondary spontaneous pneumothorax patients. 57 of the patients (68.4%) were treated with the tube thoracostomy. The tube thoracostomy related complication was 6.3%, hemorrhage due to parenchymal damage and massive air leak were observed. An open surgical method to 22 of those patients and apical resection and apical pleurectomy + tetracycline pleurodesis to 16 of whom and bullae ligation and mechanical abrasion to 6 patients were applied. The recurrence of pneumothorax in post-surgery was not observed for 1-3 year period Complication was not detected .Mortality, one patient (1.3%) died in post tube thoracotomy, which was a stage 4 lung cancer patient.

Conclusions

Most cases for pneumothorax were consisted of the patients with the primary spontaneous pneumothorax; the patients with recurrent pneumothorax were comprised of secondary spontaneous pneumothorax patients and those of majority secondary spontaneous pneumothorax patients were observed with bullous emphysema profile. By looking at the pertinent literature, there are publications showing VATS with the recurrence rate ranging from 2% to 14% and post thoracotomy recurrence rate from 0% to 7%. We think that applying pleurectomy, mechanical abrasion and chemical pleurodesis additional to bullae ligation or apical resection in pneumothorax surgery will significantly reduce the recurrence rate.

Spontaneous pneumothorax with persistent air leakage and invasive procedures

OBJECTIVE

Prolonged air leaks in patients with spontaneous pneumothorax are not infrequent. The aim of this study was to assess the duration of air leaks and define the clinical variables associated with the therapeutic success of chest tube drainage for spontaneous pneumothorax.

METHODS

A total of 441 patients with spontaneous pneumothorax treated with chest tube drainage between 2008 and 2012 were retrospectively evaluated. The clinical differences between the patients successfully treated with drainage and those who required more invasive procedures were analyzed.

RESULTS

Invasive procedures, such as video-assisted thoracic surgery (n=121), fibrin glue administration through a chest tube (n=8) and pleurodesis with OK-432 (n=21), were performed in 34% (150/441) of the patients. The treatment rate of chest drainage alone was higher in the patients with initial pneumothorax (72%; 124/170) than in those with recurrent pneumothorax (62%; 167/271) (p=0.015). In addition, this rate was higher in the patients with moderate lung collapse (70%; 167/237) than in those with severe lung collapse (61%; 124/204) (p=0.032).

CONCLUSION

Patients with recurrent pneumothorax or severe lung collapse associated with prolonged air leakage are more likely to receive invasive procedures.

Surgical results of video-assisted thoracic surgery and risk factors for prolonged hospitalization for secondary pneumothorax in elderly patients

BACKGROUND

The treatment of secondary pneumothorax in elderly patients is difficult because of underlying diffuse lung injury and complex medical comorbidities. Such patients still have high morbidity rates, resulting in longer periods of hospitalization.

METHODS

To examine the results of video-assisted thoracic surgery for elderly patients (aged 70 years or over) with secondary pneumothorax and investigate the risk factors for hospital stay longer than 7 days, we retrospectively analyzed the results obtained in such patients at our institution.

RESULTS

From among 73 patients who entered this study, 7 patients (9.6%) had postoperative complications. Video-assisted thoracic surgery could treat pneumothorax in 71 patients, except for the 2 who died in hospital. The median postoperative drainage and hospital stay periods were 2 days (1-40 days) and 5 days (2-51 days). Patients with interstitial pneumonitis, pulmonary infection and low total protein or sodium levels were the risk factors for hospital stay longer than 7 days.

CONCLUSIONS

VATS is a safe and effective procedure for secondary pneumothorax in elderly patients. Patients with interstitial pneumonitis, pulmonary infection, and hyponutrition state were the risk factors for postoperative hospital stay prolongation.

Intrathoracic irrigation with arbekacin for methicillin-resistant Staphylococcus aureus empyema following lung resection

OBJECTIVES

Empyema is a well-known complication following lung resection. In particular, empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) is difficult to treat. Here, we present our experience of MRSA empyema treated with local irrigation using arbekacin.

METHODS

Six patients consisted of 4 males and 2 females with an average age of 65.7 years. They developed MRSA empyema following lung resection and were treated at our institution between 2007 and 2011. Cases comprised four primary and one metastatic lung cancer, and 1 patient was a living lung transplantation donor. The surgical procedure consisted of four lobectomies, one segmentectomy and one wedge resection. After diagnosis of MRSA empyema, anti-MRSA drugs were administered intravenously in all cases. In addition, arbekacin irrigation at a dose of 100 mg dissolved in saline was performed after irrigation with saline only.

RESULTS

The average number of postoperative days for the diagnosis of MRSA empyema was 13 (range 4-19). The period of irrigation ranged from 6 to 46 days. Arbekacin irrigation did not induce nephrotoxicity or other complications, and no bacteria resistant to arbekacin was detected in the thoracic cavity. We re-operated on 1 case because he had pulmonary fistula and severe wound infection. At the time of removing the thoracic catheter, MRSA in the pleural effusion disappeared completely in 3 patients. The period until MRSA concentration in the pleural effusion became negative after starting arbekacin irrigation ranged from 4 to 9 days. In the remaining cases, in which MRSA did not disappear, the catheter was removed because of no inflammatory reaction after stopping irrigation and clamping the catheters. All patients were discharged from our institution without thoracic catheterization and no patients had relapsed during the follow-up period ranging from 6 to 44 months.

CONCLUSIONS

Irrigation of the thoracic cavity with arbekacin proved to be an effective, safe and readily available method for treating MRSA empyema following lung resection.

Evaluation of simple aspiration therapy in the initial treatment for primary spontaneous pneumothorax

OBJECTIVE

A retrospective evaluation of the effectiveness of simple aspiration therapy in primary spontaneous pneumothorax was carried out.

METHODS

We enrolled 143 patients with mild and moderate primary spontaneous pneumothorax between June 2006 and October 2010. Clinical backgrounds and therapeutic results from 92 patients that underwent simple aspiration therapy were assessed.

RESULTS

All patients were treated safely without any serious complications. With the exception of one patient with an unknown result, the initial success rate after three days was 72.5% (66 out of 91 patients). Chest X-ray analysis at the first medical examination showed that the success rate was significantly low in patients with a larger vertical rim between the apex and top of the lung and a higher collapsed area ratio; in particular, the success rate was markedly decreased in cases that exceeded 8 cm and 50%, respectively. No significant difference was observed in the aspiration volume, however, the success rate was lower when the aspiration volume was more than 1,500 mL. The recurrence rate at one year was 36.4% (24 out of 66 successfully treated patients).

CONCLUSION

Our results are nearly identical to previous reports from other countries and show that simple aspiration has proved to be a safe and effective therapy.

Successful treatment by fibrin glue sealant for pneumothorax with chronic GVHD resistant to autologous blood patch pleurodesis

Pneumothorax associated with chronic graft-versus-host disease (cGVHD) after stem cell transplantation is a rare complication. Autologous blood has been used successfully for pleurodesis, which was less toxic than chemical agents. However, when pneumothorax is resistant to pleurodesis, no other procedure is more effective and conservative. Here, we describe a case of myelodysplastic syndromes complicated with cGVHD-related pneumothorax. His pneumothorax has been resistant to pleurodesis using autologous blood and was treated successfully with fibrin glue sealant. In our limited experience, we believe the best success could be achieved when this method is used to treat persistent pneumothorax with cGVHD.

A total pleural covering technique in patients with intractable bilateral secondary spontaneous pneumothorax: Report of five cases

We herein present five cases of bilateral intractable secondary spontaneous pneumothorax associated with chronic severe lung diseases that were successfully treated with a modified form of a previously reported surgical procedure, the "total pleural covering technique," under video-assisted thoracic surgery. We performed the total pleural covering technique modified with a preceding coverage of air-leak points with polyglycolic acid sheets. In this series, the median length of surgery was 106 min (range: 67-220 min) on the unilateral side (10 sides). No significant surgical complications were observed, but one patient died on day 23 after the operation, due to respiratory insufficiency on the basis of the underlying lung disease. The remaining four patients have been followed up regularly (mean follow-up time: 23 months; range: 1-54 months) and there has been no recurrences of pneumothorax. We believe that the total pleural covering technique is a useful method; however, special attention should be paid to the underlying disease in order to identify patients who would be most likely to benefit from the procedure.

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.