Thoracoscopy for spontaneous pneumothorax

Pneumothorax in cystic fibrosis

Pneumothorax is recognized as a common and life-threatening complication in cystic fibrosis (CF) patients, especially in those who are infected with P. aeruginosa, B. cepacia or Aspergillus, need enteral feeding, are diagnosed as suffering from allergic bronchopulmonary aspergillosis (ABPA), developed massive hemoptysis, and their respiratory function is seriously compromised. Structural impairment and altered airflow dynamics in the lungs of CF patients are considered as the main predisposing factors, but also inhaled medications and non-invasive positive pressure ventilation (NIPPV) could increase the risk of pneumothorax. Clinical presentation could range from dramatic to very mild. Management of spontaneous pneumothorax occurring to patients with CF is essentially similar to that for non-CF patients. Therapeutic options include intercostal tube drainage, video-assisted thoracoscopic surgery (VATS), and medical or surgical pleurodesis. Pneumothorax increases both short- and long-term morbidity and mortality in CF patients and causes significant deterioration of their quality of life.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

New electroablation technique following the first-line stapling method for thoracoscopic treatment of primary spontaneous pneumothorax

STUDY OBJECTIVES

A new tip for the electroablation of pneumocysts was examined clinically as a second-line method for stapled resection of pneumocysts during video-assisted thoracoscopic surgery (VATS).

DESIGN

A trial to assess feasibility.

SETTINGS

National referral hospitals.

PATIENTS

One hundred seven patients were studied, of whom 99 patients were eligible for the study (85 men and 14 women; age range, 15 to 69 years; median age, 23 years), who had undergone VATS for primary spontaneous pneumothorax between July 1996 and June 1998. Apical pneumocysts were resected employing staplers, and residual pneumocysts, if present, were electroablated employing a new tip for the electrosurgery unit (ball shape, 8 mm in diameter, and made of stainless steel).

MEASUREMENTS AND RESULTS

Thirty-three patients (33%) underwent electroablation only for small (< 2 cm in diameter) pneumocysts (group S), and 11 patients (11%) underwent electroablation for large (>/= 2 cm in diameter) pneumocysts (group L). The remaining 55 patients (56%) did not undergo electroablation because there were no residual pneumocysts (group N). There were no complications during surgery. The duration of the operation was significantly shorter (about 20 min on average) for group N, but there was no significant difference in the amount of blood loss, the number of applied staples, the duration of drainage, and the duration of hospital stay. Group S achieved a 100% relapse-free rate (33 of 33 patients), group L achieved a 64% relapse-free rate (7 of 11 patients), and group N achieved an 89% relapse-free rate (49 of 55 patients) [group S vs group N, p = 0.08; group L vs group N, p = 0.001; and group S vs group L, p = 0.002].

CONCLUSION

Electroablation with the M-tip is feasible as a second-line method for the treatment of small pneumocysts following the stapling technique during VATS.

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

BACKGROUND

Due to the high recurrence rate in primary spontaneous pneumothorax (PSP), surgical therapy is currently a well-accepted method of treating this condition. There is no general agreement about the best time for surgical intervention (i.e., after the first or second episode) or the optimal surgical approach,--i.e., tube thoracocenteses, thoracotomy, or video-assisted thoracoscopy (VATS) with or without pleurectomy or pleurodesis. The aim of this study was to verify the efficacy of VATS and mechanical brush pleurodesis using a rotating electrical brush system.

METHODS

We treated 47 patients with PSP between June 1993 and June 1997. Follow-up ranged from 20 to 56 months. There were 38 male and nine female patients with a mean age of 26 years. Emergency thoracocenteses due to tension pneumothorax became necessary in three patients. All patients were treated by VATS and mechanical brush pleurodesis. Wedge resection was done if bullae or blebs were present (68.1%).

RESULTS

Operating time was 20-60 min (mean, 35). There were no intraoperative complications and no conversions to conventional surgery. In the first few postoperative days, postoperative pain was controlled with nonsteroidal antirheumatic drugs and additional morphines. Drainage time was 3-7 days (mean, 4). Hospitalization time was 4-8 days (mean, 5). The recurrence rate was 2.1% (one patient). No postoperative bleeding or wound infection occurred in any of our patients.

CONCLUSIONS

VATS combined with mechanical brush pleurodesis using the electrical brush system is a highly effective and safe treatment for patients with recurrent primary spontaneous pneumothorax.

Video assisted thoracic surgery for spontaneous pneumothorax

Images

Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases

OBJECTIVE

This article describes the technique and results for an initial series of 100 pneumothoraces treated by video-assisted thoracoscopy.

METHODS

From May 1991 to November 1994, 97 patients (78 male and 19 female patients) aged 37.2 +/- 17 years (range 14 to 92 years) underwent video-assisted thoracoscopy for treatment of spontaneous pneumothorax (primary in 75 patients, secondary in 22 patients).

RESULTS

The procedure was unilateral in 94 patients and bilateral in three patients (total 100 cases). Pleural bullae were resected with an endoscopic linear stapler; a lung biopsy was performed in the absence of any identifiable lesion. Pleurodesis was achieved by electrocoagulation of the pleura (n = 3), "patch" pleurectomy (n = 3), subtotal pleurectomy (n = 20), or pleural abrasion (n = 74), including conversion to standard thoracotomy in five. One of these five patients had primary pneumothorax and four had secondary pneumothorax. There were no postoperative deaths. A complication developed in 10 patients: five patients with a primary pneumothorax (6.6%) and five with a secondary pneumothorax (27.7%). The mean postoperative hospital stay was 8.25 +/- 3.2 days. Mean follow-up is 30 months (range 7 to 49 months). Pneumothorax recurred in 3% of patients, all of whom were operated on at the start of our experience. Three percent of the patients had chronic postoperative chest pain.

CONCLUSIONS

Video-assisted thoracoscopy is a valid alternative to open thoracotomy for the treatment of spontaneous primary pneumothorax. Its role for the management of secondary pneumothorax remains to be defined. In the long term, the efficacy of video-assisted thoracoscopic pleurodesis and surgeon experience should yield the same results as standard operative therapy.

[Videothoracoscopy in the surgical treatment of pneumothorax: report of 46 cases]

We report our 3-years experience with video-thoracoscopy for pneumothorax. Forty-six endoscopies (34 men, 12 women; mean age 27 +/- 9 years) were performed. Patients were under general anesthesia and intubation was selective. The conventional approach was used, with 3 incisions through which the camera and endoscopic instruments were inserted. Results were good in 39 (84.7%) patients. Pneumothorax recurred in 4 (8.7%) patients during the 3 years of follow-up. Thoracotomy was performed in 3 patients, because of lack of lung expansion in 1, persistent leak in another and encapsulated empyema in the third. Mean hospital stay after surgery was 7.3 days. Video-thoracoscopy can be considered a good therapeutic alternative to thoracotomy in the surgical treatment of patients with pneumothorax.

Safety and efficacy of video-assisted thoracic surgical techniques for the treatment of spontaneous pneumothorax

Video-assisted thoracic surgery has been widely used in the treatment of spontaneous pneumothorax despite a paucity of data regarding the relative safety and long-term efficacy for this procedure. We reviewed 113 consecutive patients (68 male and 45 female patients, aged 15 to 92 years, mean 35.1) who underwent 121 video-assisted thoracic surgical procedures during 119 hospitalizations from 1991 through 1993. Recurrent ipsilateral pneumothorax was the most frequent indication for surgery and occurred in 77 patients (65%). The most common method of management was stapling of an identified bleb in the lung, which was undertaken in 105 (87%) patients. No operative deaths occurred. Complications included an air leak lasting longer than 5 days in 10 (8%) patients, two of whom required second procedures for definitive management. No episodes of postoperative bleeding or empyema occurred. The postoperative stay ranged from 1 day to 39 days (median 3 days, average 4.3 days) and 99 patients (84%) were discharged within 5 days. Mean follow-up was 13.1 months and ranged from 1 to 34 months. Eleven patients (10%) were lost to follow-up. Ipsilateral pneumothorax recurred after five of 121 procedures (4.1%). Twelve perioperative parameters (age, gender, race, smoking history, site of pneumothorax, severity of pneumothorax, operative indications, number of blebs, site of blebs, bleb ablation, method of pleurodesis, and prolonged postoperative air leak) were entered into univariate and multivariate analysis to identify significant independent predictors of recurrence. The only independent predictor of recurrence was the failure to identify and ablate a bleb at operation, which resulted in a 23% recurrence rate versus a 1.8% rate in those with ablated blebs (p < 0.001). These data suggest that video-assisted thoracic surgery is a viable alternative to thoracotomy for the treatment of recurrent spontaneous pneumothorax. It results in a short hospital stay, low morbidity, high patient acceptance, and a low rate of recurrence.

Thoracoscopic surgery as a routine procedure for spontaneous pneumothorax. Results from 82 patients

A total of 82 consecutive patients with recurrent or persistent spontaneous pneumothorax were considered for thoracoscopic blebectomy or bullectomy and pleurodesis. The median age was 47 years, and 70% were men. All the patients were successfully treated using a video-assisted thoracoscopic technique. There were no deaths attributable to the procedure. Complications occurred in 6 patients (7.3%). Three patients (4%) with diffuse bullous lung disease had prolonged intubation (9, 11, and 12 days, respectively). Persistent air leaks lasting from 10 to 14 days occurred in 2 patients (3%). One patient had an endoloop slip from the lung parenchyma after a forceful sneeze 2 days after the operation. Air leak subsided after the second operation using a conventional suturing technique. Blebs or bullae were present in 69 patients (83%). These were ablated by endoscopic stapling (37 patients) and through thoracoscopic ligation using an endoloop technique (32 patients). In this group of patients, the median postoperative hospital stay was 5 days. Thirteen patients with air leaks and diffuse bullous lung disease received only talc insufflation thoracoscopically. All of them showed good lung expansion after the operation. There are no recurrences, with a mean follow-up of 22 months. These results suggest that thoracoscopic ablation of blebs or bullae and pleurodesis may be applicable to patients with spontaneous pneumothorax who require surgical intervention.

Video-assisted thoracic surgery. Current state of the art

OBJECTIVE

The author reviews the current state of the art of video-assisted thoracic surgery in the context of modern thoracic surgical practice.

SUMMARY BACKGROUND DATA

Thoracoscopy has been a part of thoracic surgical practice for many years, but was used mainly for diagnosis of pleural disease. The development of laparoscopic cholecystectomy awakened a new interest in this technique and led to the development of many new therapeutic and diagnostic applications of video-assisted thoracic surgery.

METHODS

Current literature and the author's personal experience with more than 500 cases are reviewed.

RESULTS

Video-assisted techniques have proven useful for the performance of a broad spectrum of thoracic surgical procedures. Patients may experience less pain and have a shorter hospital stay after a video-assisted procedure. Definitive proof of less morbidity when compared with the analagous open procedure remains to be determined. Patient acceptance has been high, and most thoracic surgeons use these techniques in their practice.

CONCLUSIONS

Video-assisted thoracic surgical procedures have made a significant impact on the practice of thoracic surgery. Advantages and disadvantages of specific procedures remain to be definitively determined. Surgeons have learned these techniques and have kept morbidity to acceptance levels during the learning phase. Where these techniques ultimately fit into the overall practice remains to be determined as more experience is gained.

Intrapleural talc for the prevention of recurrent pneumothorax

The ipsilateral recurrence rate after the first spontaneous pneumothorax treated with tube thoracostomy is reported to be between 23 percent and 52 percent. The incidence of recurrence after the first recurrence is substantially higher. Chemical pleurodesis has been attempted to decrease the recurrence rate. Tetracycline has been widely utilized, but parenteral tetracycline is no longer available. Therefore, alternative sclerosing agents have been used. Talc has been demonstrated to be effective in preventing recurrences and it has minimal long-term effects. This prospective study was designed to determine the efficacy of talc pleurodesis in patients with recurrent spontaneous pneumothorax. Eighteen patients admitted between May 1985 and March 1993 to the Department of Thoracic Surgery underwent thoracoscopy and were treated by tube thoracostomy with chemical pleurodesis. All the patients had had at least two pneumothoraces and six had had at least six pneumothoraces. Sterile asbestos-free talc, 2g, was aerosolized throughout the pleural surface. One or two chest tubes were inserted, left clamped for 2 h, and unclamped after this time. The tubes were removed when no air had escaped for 24 h. Only one (5.6 percent) patient had recurrence of the pneumothorax, and a second insufflation of talc resulted in no new recurrence after a follow-up of 10 months. The remaining 94.4 percent did not have recurrence of pneumothorax within an observation period of 38.5 +/- 28.1 months. The follow-up was more than 2 years for 66.7 percent with no recurrence and was more than 5 years for 33.3 percent. We conclude from these observations that the insufflation of 2 g of talc into the pleural space is a safe effective treatment for control of recurrent spontaneous pneumothorax.