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

Pneumothorax and pneumomediastinum in children

Pneumothorax is a condition that describes the presence of air between the visceral and parietal pleura sheets and the consequent collapse of the lungs. The collapse of the lungs can be partial or total and can present in different clinical stages, such as a high-pressure pneumothorax that can cause a mediastinal shift. Pneumomediastinum is the presence of free air between the mediastinal tissues due to various causes. It can manifest spontaneously and be minimally symptomatic but can also develop due to severe complications. Its etiology includes numerous iatrogenic and traumatic factors. Although spontaneous pneumothorax and pneumomediastinum that develop in childhood are similar to adult patients, it is important to determine the appropriate treatment strategy in addition to the age group, the effectiveness of the treatment, the role of the applied treatment in reducing recurrence, and the etiologyoriented treatments if there is an underlying pathology.

Nonintubated versus intubated thoracoscopic bullectomy for primary spontaneous pneumothorax: A multicenter propensity-matched analysis

BACKGROUND

We aimed at comparing in a multicenter propensity-matched analysis, results of nonintubated versus intubated video-assisted thoracic surgery (VATS) bullectomy/blebectomy for primary spontaneous pneumothorax (PSP).

METHODS

Eleven Institutions participated in the study. A total of 208 patients underwent VATS bullectomy by intubated (IVATS) (N = 138) or nonintubated (NIVATS) (N = 70) anesthesia during 60 months. After propensity matching, 70 pairs of patients were compared. Anesthesia in NIVATS included intercostal (N = 61), paravertebral (N = 5) or thoracic epidural (N = 4) block and sedation with (N = 24) or without (N = 46) laryngeal mask under spontaneous ventilation. In the IVATS group, all patients underwent double-lumen-intubation and mechanical ventilation. Primary outcomes were morbidity and recurrence rates.

RESULTS

There was no difference in age (26.7 ± 8 vs 27.4 ± 9 years), body mass index (19.7 ± 2.6 vs 20.6 ± 2.5), and American Society of Anesthesiology score (2 vs 2). Main results show no difference both in morbidity (11.4% vs 12.8%; p = 0.79) and recurrence free rates (92.3% vs 91.4%; p = 0.49) between NIVATS and IVATS, respectively, whereas a difference favoring the NIVATS group was found in anesthesia time (p < 0.0001) and operative time (p < 0.0001), drainage time (p = 0.001), and hospital stay (p < 0.0001). There was no conversion to thoracotomy and no hospital mortality. One patient in the NIVATS group needed reoperation due to chest wall bleeding.

CONCLUSION

Results of this multicenter propensity-matched study have shown no intergroup difference in morbidity and recurrence rates whereas shorter operation room time and hospital stay favored the NIVATS group, suggesting a potential increase in the role of NIVATS in surgical management of PSP. Further prospective studies are warranted.

Chronic chest pain and paresthesia after video-assisted thoracoscopy for primary pneumothorax

Background

This study aims to identify clinical and surgical risk factors for chronic chest pain and paresthesia after video thoracoscopic surgery for primary spontaneous pneumothorax.

Methods

We retrospectively collected the data of 1,178 consecutive patients <40-years-old undergoing video thoracoscopic surgery for primary spontaneous pneumothorax in 9 Italian centers in 2007–2017. Cases with <2-month follow-up were excluded, leaving 920 patients [80% male; median age: 21 (IQR, 18–27) years] for statistical analysis. The following risk factors for chronic chest pain and chronic paresthesia were assessed by univariable and multivariable Cox regression model: age, gender, cannabis smoking, video thoracoscopy ports number, pleurodesis technique (partial pleurectomy/pleural electrocauterization/pleural abrasion/talc poudrage), chest tube size (24/28 F), postoperative chest tube stay.

Results

Blebs/bullae resection with pleurodesis was performed in 732 (80%) cases; pleurodesis alone in 188 (20%). During a median follow-up of 68 (IQR: 42–95) months, chronic chest pain developed in 8% of patients, chronic chest paresthesia in 22%; 0.5% of patients regularly assumed painkillers. Chronic chest pain was independently associated with partial pleurectomy/pleura abrasion (P<0.001) and postoperative chest tube stay (P=0.019). Chronic chest paresthesia was independently associated with pleurodesis by partial pleurectomy (P<0.001), chest tube stay (P=0.035) and 28 F chest tube (P<0.001).

Conclusions

After video thoracoscopic surgery for primary spontaneous pneumothorax, the incidence of chronic chest pain and paresthesia was significantly lower when pleurodesis was performed by pleural electrocauterization or talc poudrage, and chest tube was removed early. A 24 F chest tube was associated with lower risk of chronic chest paresthesia.

Recurrence of Spontaneous Pneumothorax Is Not Associated with Allegedly Risk-Prone Lifestyle Conduct

PURPOSE

Spontaneous pneumothorax (PNTX) is a common disease frequently operated at specialized thoracic surgery units. Videothoracoscopic surgery (VATS) has become the standard for treatment and recurrence prevention. While there is broad consensus regarding indications and techniques of PNTX surgery, postoperative risks and consecutive patient behavioral advice have not been sufficiently elucidated.

METHODS

Single-center cohort analysis of 641 patients operated for primary PNTX by VATS over 10 years. Putatively recurrence-prone lifestyle activities (smoking status, flying habits, and scuba diving) and actual occurrence of recurrences were correlated.

RESULTS

Follow-up rate was 46% (279/607 patients). Mean time interval between primary operation and follow-up was 61 (range: 5-177) months. In 10 patients (3.6%), a PNTX recurrence was observed. Regarding postoperative risk behavior reported at follow-up, 28% of patients were active smokers (15 ± 7 cigarettes/day), 59% traveled by plane repeatedly, and only two patients did scuba diving (0.7%). Low body-mass-index was associated with an increase in PNTX recurrence, whereas smoking, flying, and scuba diving could not be identified as risk factors.

CONCLUSION

In our study, none of the supposed "classic" lifestyle-associated risk factors for PNTX recurrence after VATS proved to be a significant threat. Postoperative patient behavior might not be constrained by overcautious medical advice.

Recurrence rate after thoracoscopic surgery for primary spontaneous pneumothorax

OBJECTIVES

There is an on-going discussion regarding the recurrence rate after surgery for primary spontaneous pneumothorax by video assisted thoracic surgery (VATS) or by thoracotomy access. This study aimed to describe the recurrence rate, and to identify a possible learning curve, following surgery for primary spontaneous pneumothorax by VATS.

DESIGN

All patients who underwent surgery for primary spontaneous pneumothorax by VATS at Karolinska University Hospital 2004-2013 were reviewed. Preoperative and operative characteristics were obtained from medical records. Patients were followed-up through telephone interviews or questionnaires and by review of medical records. The primary outcome of interest was time to recurrence of pneumothorax requiring intervention. Outcomes were compared between patients operated during 2004-June 2010 and July 2010-2013.

RESULTS

219 patients who underwent 234 consecutive procedures were included. The mean follow-up times were 6.3 and 2.9 years in the early and late period, respectively. The postoperative recurrence rate in the early period was 16% (11%-25%), 18% (12%-27%), and 18% (12%-27%), at 1, 3 and 5 years, compared to 1.7% (0.4%-6.8%), 7.6% (3.7%-15%), and 9.8% (4.8%-19%) at 1, 3 and 5 years, in the late period (p = 0.016).

CONCLUSIONS

We found that the recurrence rate after thoracoscopic surgery for primary spontaneous pneumothorax decreased significantly during the study period. Our results strongly suggest that thoracoscopic surgery for pneumothorax involve a substantial learning curve.

[Gas tamponade following intraoperative pneumothorax on a single lung: A case study]

Intraoperative pneumothorax is a rare complication with a high risk of cardiorespiratory arrest by gas tamponade especially on a single lung. We report the case of a female patient aged 53 years who benefited from a left pneumonectomy on pulmonary tuberculosis sequelae. The patient presented early postoperative anemia with a left hemothorax requiring an emergency thoracotomy. In perioperative, the patient had a gas tamponade following a pneumothorax of the remaining lung, and the fate has been avoided by an exsufflation. Intraoperative pneumothorax can occur due to lesions of the tracheobronchial airway, of the brachial plexus, the placement of a central venous catheter or barotrauma. The diagnosis of pneumothorax during unipulmonary ventilation is posed by the sudden onset of hypoxia associated with increased airway pressures and hypercapnia. The immediate life-saving procedure involves fine needle exsufflation before the placement of a chest tube. Prevention involves reducing the risk of barotrauma by infusing patients with low flow volumes and the proper use of positive airway pressure, knowing that despite protective ventilation, barotraumas risk still exists.

Study of poly-ɛ-caprolactone membranes for pleurodesis

BACKGROUND/PURPOSE

Pleurodesis with biomaterial membrane is an emerging treatment method for pneumothorax. However, the ideal one for the common disease is still under debate.

METHODS

We investigate the Poly-ε-caprolactone (PCL) membrane pleurodesis by using New Zealand White rabbits, which was sacrificed for examination one month later. Moreover, inflammation and fibrosis scoring were done under microscopic evaluation, as well as Western blot analysis in vitro and in vivo.

RESULTS

Gross evaluation of pleurodesis score revealed that dense PCL membrane produced moderate pleural adhesion, while porous PCL membrane exhibited significantly higher pleurodesis scores.

CONCLUSION

PCL membrane induced significant degree of adhesion, both within the abdomen and chest of the rabbits. The porous PCL membrane produces more intensive adhesion than dense one. Fibronectin plays an important role in the process of pleurodesis. Further study is required for the clinical application of the promising material.

Thoracoscopic modified pleural tent for spontaneous pneumothorax

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Video-assisted thoracic surgery and pneumothorax

Video-assisted thoracoscopic surgery (VATS) is a type of thoracic surgery performed using a small video camera that is introduced into the patient's chest via a scope. It is considered a minimally invasive technique where the surgeon is able to view the instruments that are being used along with the anatomy on which the surgeon is operating. The camera and instruments are inserted through separate holes in the chest wall also known as "ports", depending on the patient and problem there are surgeries with one port "uniport", two or three ports. These small ports have the advantage that fewer infections are observed. This allows for a faster recovery. Traditionally, thoracic surgery performed for diagnosis or treatment of chest conditions has required access to the chest through thoracotomy or sternotomy incisions. Vats minimally invasive technique has replaced in many cases thoracotomy or sternotomy. In our current review we will present this technique in detail.

Video-Assisted Thoracoscopic Pleurectomy in Spontaneous Pneumothorax Surgery

OBJECTIVES

Published experiences with thoracoscopic apical or total pleurectomy for patients with a pneumothorax are limited. We aimed to evaluate the long-term results and effectiveness of pleurectomy in our patients, that vast majority of whom underwent thoracoscopic apical or total pleurectomy.

MATERIAL AND METHODS

Between January 2001 and December 2010, in the Istanbul University Medical School Department of Thoracic Surgery, 67 patients, consisting of 52 patients with a primary spontaneous pneumothorax and 15 with a secondary spontaneous pneumothorax who underwent 72 processes of thoracoscopic resection of blebs or bullae and pleural symphysis, consisting of 43% total pleurectomy, 42% apical pleurectomy plus pleural abrasion, and 15% non-pleurectomy pleurodesis procedures due to prolonged air leak or recurrent spontaneous pneumothorax, were analyzed retrospectively. The applied pleural procedures were: 1. total pleurectomy 2. apical pleurectomy and pleural abrasion for the remaining parts and 3. non-pleurectomy pleurodesis procedures. The long-term outcomes of patients undergoing the three different pleural procedures were compared.

RESULTS

Total pleurectomy process, apical pleurectomy and abrasion process for remaining parietal pleura, and non-pleurectomy pleurodesis procedures were performed 31, 30, and 11 times, respectively. No recurrence was observed in the total pleurectomy group, 1 recurrence was observed for the apical pleurectomy plus pleural abrasion group, and 2 recurrences were observed for the non-pleurectomy group.

CONCLUSION

Video-assisted thoracoscopic pleurectomy is a safe and effective method in spontaneous pneumothorax surgery. Especially, total pleurectomy has efficient results in the prevention of recurrences.

The usefulness of two-port video-assisted thoracosopic surgery in low-risk patients with secondary spontaneous pneumothorax compared with open thoracotomy

BACKGROUND:

Secondary spontaneous pneumothorax is difficult to treat and has been thought to have high morbidity and mortality rate due to the underlying diseases and presence of comorbidities in the patients. However, early surgical intervention will be beneficial if it is tolerable by the patient. In the surgical approach for treating pneumothorax, video-assisted thoracoscopic surgery (VATS) may reduce the postoperative drainage period and hospital stay compared with open thoracotomy.

MATERIALS AND METHODS:

A retrospective review of the clinical data of 40 patients with secondary spontaneous pneumothorax who underwent open thoracotomy (n = 20) or two-port VATS (n = 20) between January 2008 and December 2012 was performed.

RESULTS:

Postoperative drainage period of open thoracotomy group and two-port VATS group was 9.85 ± 5.28 and 6.75 ± 2.45, respectively, with a significant inter-group difference. Postoperative hospital stay was 11.8 ± 5.12 in the open thoracotomy group and 8.25 ± 2.88 in the two-port VATS group, with a significant inter-group difference. Recurrence rate and postoperative complication rate were not significant between the two groups.

CONCLUSION:

In selected patients with secondary spontaneous pneumothorax treated with surgical approach, two-port VATS resulted in shorter postoperative drainage period and hospital stay compared with open thoracotomy.

VATS bullectomy and apical pleurectomy for spontaneous pneumothorax in a young patient with Swyer-James-Mc Leod syndrome: case report presentation and literature review focusing on surgically treated cases

BACKGROUND

Swyer-James-McLeod Syndrome (SJMS) is an uncommon, emphysematous disease characterized by radiologic hyperlucency of pulmonary parenchyma due to loss of the pulmonary vascular structure and to alveolar overdistension.

CASE REPORT

We herein describe a 15-year-old Caucasian patient with well-established SJMS since childhood who presented with spontaneous pneumothorax. Video-assisted thoracoscopic bullectomy with apical pleurectomy was performed. Since SJMS is considered an on-going inflammatory process, the patient one year after surgery exhibits excellent quality of life with no pneumothorax recurrence.

Chemical pleurodesis for spontaneous pneumothorax

Pneumothorax is defined as the presence of air in the pleural cavity. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is sub-divided into primary and secondary. The severity of pneumothorax could be varied from asymptomatic to hemodynamically compromised. Optimal management of this benign disease has been a matter of debate. In addition to evacuating air from the pleural space by simple aspiration or chest tube drainage, the management of spontaneous pneumothorax also focused on ceasing air leakage and preventing recurrences by surgical intervention or chemical pleurodesis. Chemical pleurodesis is a procedure to achieve symphysis between the two layers of pleura by sclerosing agents. In the current practice guidelines, chemical pleurodesis is reserved for patients unable or unwilling to receive surgery. Recent researches have found that chemical pleurodesis is also safe and effective in preventing pneumothorax recurrence in patients with the first episode of spontaneous pneumothorax or after thoracoscopic surgery and treating persistent air leakage after thoracoscopic surgery. In this article we aimed at exploring the role of chemical pleurodesis for spontaneous pneumothorax, including ceasing air leakage and preventing recurrence. The indications, choice of sclerosants, safety, effects, and possible side effects or complications of chemical pleurodesis are also reviewed here.

Thoracotomy versus VATS: is there an optimal approach to treating pneumothorax?

Introduction

The 2010 British Thoracic Society guidelines recommend that a weighted decision be made by clinicians with regard to surgical intervention for pneumothorax as the video assisted thoracoscopic surgery (VATS) approach is better tolerated by patients but carries a higher rate of recurrence (5% vs 1%).

Methods

Overall, 163 patients underwent surgical intervention for pneumothorax at our institution and data were collected prospectively for almost 7 years. Of these, 86 patients underwent VATS under a single surgeon with extensive VATS experience to compensate for the associated learning curve while 79 patients underwent an open procedure.

Results

There was no statistically significant difference in the recurrence rate between the open and the VATS group (1% vs 3.5%, p=1.0). The VATS group was superior to the open group in terms of reduced postoperative bleeding (7.5% vs 0%, p=0.01), reduced number of intensive care unit admissions (16% vs 0%, p<0.01) and a reduced adjusted length of stay (3 vs 5.5 days, p<0.01).

Conclusions

A comparable recurrence rate is attainable with a VATS approach once the learning curve is surpassed and a reduction in morbidity is an additional merit.

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.

Single-incision thoracoscopic surgery for primary spontaneous pneumothorax using the SILS port compared with conventional three-port surgery

BACKGROUND

Single-incision thoracoscopic surgery (SITS) is postulated to cause less incisional pain, less paresthesia, and less wound scarring than the conventional three-port approach. The difficulties performing the technique have prevented it from being widely accepted. This study shows how the authors overcame the difficulties by using the SILS port and proved it to be a safe and useful procedure for the treatment of primary spontaneous pneumothorax (PSP).

METHODS

The same surgeon operated on all the patients using the three-port technique (n = 13) and SITS (n = 27) under the same procedural and management policy. The two groups were retrospectively compared in terms of operation time, postoperative complications, hospital stay, pain score, residual paresthesia, satisfaction regarding the wound scar, and surgical material cost.

RESULTS

The mean age, sex ratio, and previous pneumothorax episodes were similar between the two groups. The uniport and three-port groups did not differ statistically in terms of mean operation time (74.6 ± 22.8 vs 72.4 ± 20.2 min; p = 0.77), hospital stay (2.3 ± 0.7 vs 2.5 ± 0.8 days; p = 0.72), visual analog pain scale (on the day of surgery: 4.1 ± 1.7 vs 4.8 ± 2.2, p = 0.26; on day 1: 3.2 ± 1.4 vs 2.8 ± 1.4, p = 0.33; on day 2: 2.7 ± 1.0 vs 2.6 ± 1.1, p = 0.61), or total surgical material cost (US$1,810 ± $320 vs $1,741 ± $329; p = 0.58). However, the uniport group had a lower incidence of paresthesia than the three-port group (33.3 vs 76.9%; p = 0.01) and showed a higher satisfaction rate regarding wound scarring (70.4 vs 30.7%; p = 0.03).

CONCLUSIONS

Compared with the three-port approach, SITS using the SILS port in PSP patients proved to be a safe and feasible procedure that can be clinically implemented without additional economic burden or operation time. Additionally, SITS showed better cosmesis with minimized neurologic sequelae, which contributed to higher satisfaction among patients. Progress in uniport instruments and surgical experience will lead to wider applications of SITS.

Thoracoscopic pleurodesis for primary spontaneous pneumothorax with high recurrence risk: a prospective randomized trial

OBJECTIVE

To compare the efficacy and safety between apical pleurectomy and pleural abrasion with minocycline in primary spontaneous pneumothorax (PSP) with high recurrence risk.

BACKGROUND

The optimal thoracoscopic pleurodesis procedure for PSP with high recurrence risk remains controversial.

METHODS

Between January 2006 and May 2009, a total of 369 patients with spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery. After stapled bullectomy, 160 patients with no identifiable bleb or multiple blebs (≥3) were randomly chosen to undergo apical pleurectomy (pleurectomy group, 80 patients) or pleural abrasion with minocycline (abrasion/minocycline group, 80 patients).

RESULTS

Patients in the pleurectomy group had a longer operation duration (mean, 81.4 minutes vs 55.8 minutes, P < 0.001), a greater amount of operation bleeding (mean, 29.4 mL vs 13.2 mL, P = 0.025), and a greater amount of postoperative chest drainage (mean, 287.4 mL vs 195.8 mL, P = 0.040). Patients in the abrasion/minocycline group had a higher intensity of chest pain and required more frequent meperidine injections. Hemothorax occurred in 3 pleurectomy patients (3.8%). The short-term results showed that the 2 groups had comparable durations of postoperative chest drainage, durations of postoperative hospital stay, and complication rates. After a mean follow-up of 26.1 months, recurrent ipsilateral pneumothorax occurred in 3 patients (3.8%) in the pleurectomy group and 3 patients (3.8%) in the abrasion/minocycline group. Postoperative long-term residual chest pain and pulmonary function were comparable in both groups.

CONCLUSIONS

: Pleural abrasion with minocycline pleurodesis is as effective as apical pleurectomy and either technique is appropriate for treating PSP patients with high recurrence risk. This trial was registered at http://www.clinicaltrials.gov (ID: NCT00270751).

Comparison of needlescopic and conventional video-assisted thoracic surgery for primary spontaneous pneumothorax

Whether the outcome of primary spontaneous pneumothorax (PSP) when treated with needlescopic video-assisted thoracic surgery is positive is still under scrutiny. The present study was conducted to compare the needlescopic approach with the conventional approach. One-hundred and six patients with primary spontaneous pneumothorax who had undergone needlescopic video-assisted thoracic surgery (NVATS) between May 2006 and August 2008 were reviewed. Their age, gender, smoking status, BMI, side of attack, operative indications, operative time, intraoperative blood loss, postoperative length of stay, postoperative pain in visual analog scale (VAS), postoperative recurrence and follow-up period were recorded. These data were compared with those of 89 patients with PSP who had undergone conventional video-assisted thoracic surgery (CVATS) between June 2002 and April 2006. The operative time was shorter (NVATS: 82.36 ± 35.58 min, CVATS: 99.78 ± 35.74 min; p = 0.008) and intraoperative blood loss was less (NVATS: 16.67 ± 25.90 ml, CVATS: 24.36 ± 26.86 ml; p = 0.04) for the NVATS group. The postoperative pain in VAS was significantly less in NVATS. No major complication or mortality was found in either group. For treatment of primary spontaneous pneumothorax, NVATS is a safe and effective option. Further, it has the added benefit of less pain and improved cosmetics.

The feasibility of axial and coronal combined imaging using multi-detector row computed tomography for the diagnosis and treatment of a primary spontaneous pneumothorax

BACKGROUND

The preoperative detection of emphysema like changes (ELCs) is necessary for the successful treatment of pneumothorax. High resolution computed tomography (HRCT) has been used for the preoperative detection of ELCs. However, the traditional HRCT method uses only the axial view, which is perpendicular to the distribution of ELCs. This is not an ideal diagnostic method for the evaluation of ELCs.

METHODS

Forty-eight patients with pneumothorax had multi-detector computed tomography (MDCT) reconstruction using the coronal view. ELCs were evaluated in the axial and coronal view by a radiologist. A surgeon performed intra-operative examinations of the ELCs. The sensitivity of the different views was compared.

RESULTS

The detection sensitivity was 74.4% (70/94) for the axial view and 91.5% (86/94) for the axial-coronal combined view. The intra-operative detection rate was 95.7% (90/94). The preoperative detection of ELCs on the axial-coronal combined view was significantly higher than on the conventional axial view alone (p < 0.01).

CONCLUSIONS

Evaluation of ELCs on the axial and coronal combined HRCT improved the sensitivity of preoperative detection of ELCs compared to the conventional single axial HRCT. This increased sensitivity will help decrease the recurrence with VATS.

Surgery for secondary spontaneous pneumothorax

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Management of complications of minimally invasive thoracic surgery

Minimally invasive thoracic surgery (MITS) has become part of the modern thoracic surgeon's armamentarium. Its applications include diagnostic and therapeutic procedures, and over the past one and a half decades, the scope of MITS has undergone rapid evolution. The role of MITS is well established in the management of pleural and mediastinal conditions, and it is beginning to move beyond diagnostic procedures for lung parenchyma conditions, to gain acceptance as a viable option for primary lung cancer treatment. However MITS poses technical challenges that are quite different from the conventional open surgical procedures. After a brief review of the history of MITS, an overview of the scope of MITS is given. Important examples of diagnostic and therapeutic indications are then discussed, with special emphasis on the potential complications specific to MITS, and their prevention and management.

Is prophylactic treatment of contralateral blebs in patients with primary spontaneous pneumothorax indicated?

OBJECTIVES

More than 50% of patients with primary spontaneous pneumothorax have contralateral blebs/bullae, and about a quarter will develop a contralateral pneumothorax. The purpose of this prospective study was to determine the need for elective treatment of asymptomatic contralateral blebs/bullae in patients presenting with primary spontaneous pneumothorax.

METHODS

From May 2006 through June 2008, results from 35 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs receiving unilateral video-assisted thoracic surgery, 35 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery, and 16 patients with ipsilateral primary spontaneous pneumothorax receiving bilateral video-assisted thoracic surgery for positive contralateral blebs were collected. Their demographic and operating data were also recorded.

RESULTS

There was no significant difference in age, gender, smoking percentage, body mass index (kg/m(2)), blood loss, and postoperative pain among groups. There was longer operative time and length of stay in group receiving bilateral surgery. Within the follow-up period of 16.68 +/- 9.91 months (median, 17.50), no recurrence on either lung was found in the group operated on both sides, while contralateral occurrence was found in 17.14% of the group with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery within the period of 18.15 +/- 8.07 months (median, 21).

CONCLUSION

The study showed that the preemptive video-assisted thoracic surgery for the contralateral blebs/bullae effectively prevented the contralateral occurrence.

Evidence-based management of paediatric primary spontaneous pneumothorax

The exact incidence of paediatric primary spontaneous pneumothorax (PSP) is unclear, although PSP incidence in the general population is between 6 and 18 per 100,000. PSP has been reported throughout the paediatric age range. A potential genetic predisposition for familial cases has been recently identified. Whilst there is universal consensus on the management of tension pneumothorax, lack of agreement and consistency exists across a wide range of management issues for other aspects of PSP management. Paediatric PSP may have a higher recurrence rate than adult PSP, and the presence of apical lung cysts or bullae is not predictive of recurrence. The decision for surgical intervention should be based on documented recurrence. There is a lack of paediatric evidence to guide management decisions, and extrapolation of predominantly adult data to younger age groups should not be encouraged. Given the relatively low apparent incidence, a multicentre approach to future research is required in order to generate the evidence required for informed management of PSP in children.

Thoracoscopic bullectomy for primary spontaneous pneumothorax in pediatric patients

INTRODUCTION

Primary spontaneous pneumothorax is a condition that carries significant morbidities and mortalities if not managed properly. Thoracotomy with bullectomy has been the treatment of choice for persistent air leak or recurrence after initial chest drain insertion. With the advancement in minimal invasive surgery, the thoracoscopic approach can dramatically reduce the complications of open thoracotomy. We review our experience in managing spontaneous pneumothorax in children using thoracoscopy.

MATERIALS AND METHODS

The medical records of all patients who were discharged with the diagnosis of spontaneous pneumothorax from 1997 to 2007 were reviewed. The demographic data and management were noted. For those patients who underwent thoracoscopic surgery, the intra-operative findings, post-operative outcomes and complications were compared.

RESULTS

A total of 15 patients with spontaneous pneumothorax were identified. They all received chest drain insertion as the primary treatment modality. Nine patients, with mean age 16.1 +/- 0.9 years, failed the initial management and subsequently received thoracoscopic surgery with a mean interval of 7.6 +/- 2.5 days after initial chest drain insertion. Among these patients, bullae were found in seven patients (two patients had more than one bulla). The bullae were excised with mean operative time being 63.9 +/- 25.2 min. No conversion to thoracotomy was reported. All patients received paracetamol as pain control and there was no associated complication. No recurrence was found at follow-up till now.

CONCLUSION

This study confirms that the presence of bulla is commonly seen in patients with spontaneous pneumothorax who fail initial management. Thoracoscopic bullectomy, a safe and effective operation, should be offered to this group of patients.

Expectations and patient satisfaction related to the use of thoracotomy and video-assisted thoracoscopic surgery for treating recurrence of spontaneous primary pneumothorax

OBJECTIVE

To compare the outcomes of thoracotomy and video-assisted thoracoscopic surgery (VATS) in the treatment of recurrence of primary spontaneous pneumothorax.

METHODS

Medical records of patients presenting recurrence of primary spontaneous pneumothorax were retrospectively reviewed. Patients were divided into two groups: those who underwent conservative thoracotomy (n = 53, thoracotomy group); and those who underwent VATS (n = 47, VATS group).

RESULTS

Although there were no deaths in either group and the length of hospital stays was similar between the two, there was greater morbidity in the thoracotomy group. Patients in the thoracotomy group required more pain medication for longer periods than did those in the VATS group (p < 0.05). In the thoracotomy group, the rate of recurrence was 3%. Pain was classified as insignificant at one month after the operation by 68% of patients in the VATS group and by only 21% of those in the thoracotomy group (p < 0.05). At three years after the surgical procedure, 97% of the VATS group patients considered themselves completely recovered from the operation, compared with only 79% in the thoracotomy group (p < 0.05). Chronic or intermittent pain, requiring the use of analgesics more than once a month, was experienced by 90% of the thoracotomy group patients and 3% of the VATS group patients. In addition, 13% of the thoracotomy group patients required clinical pain management.

CONCLUSIONS

We recommend VATS as the first-line surgical treatment for patients with recurrent primary spontaneous pneumothorax.

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.

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.

Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage?

BACKGROUND

Simple aspiration is recommended as first-line treatment for all primary spontaneous pneumothoraces requiring intervention. However, the optimal salvage treatment remains unclear when simple aspiration is unsuccessful for controlling symptoms. In this study, the safety, efficacy, and estimated costs of video-assisted thoracoscopic surgery (VATS) and chest tube drainage (CTD) were compared.

METHODS

Between 2002 and 2007, 164 patients with a first episode of spontaneous pneumothorax were managed by simple aspiration. Among them, 52 patients underwent subsequent VATS (30 patients) or CTD (22 patients) due to unsuccessful aspiration. The demographic data and treatment outcomes of the two groups were collected through retrospective chart review.

RESULTS

Postoperative analgesics use did not differ between groups. Complications developed in 2 of the VATS group (6.7%) and 6 of the CTD group (27.3%), with mean hospital stays of 4.8 and 6.1 days, respectively (p = 0.034). Patients in the VATS group had lower rates of overall failure, although the rates of immediate failure were not significantly different. After a mean follow-up of 16 months, recurrent ipsilateral pneumothorax was noted in 1 VATS patient and 5 CTD individuals (p = 0.038). The estimated total costs per patient were $1,273 in the VATS group and $865 in the CTD group.

CONCLUSIONS

Although associated with higher costs, VATS rather than CTD is the preferred salvage treatment for unsuccessful aspiration of the first episode of primary spontaneous pneumothorax, because of shorter hospital stay and lower rates of overall failure and recurrence.

Patterns, Effects, and Thoracic Volume Changes of Thoracoscopic Pleurodesis in Rabbits

BACKGROUND

The ideal thoracoscopic pleurodesis method for preventing recurrence of spontaneous pneumothorax remains controversial. This study was conducted to compare the patterns, effects, and thoracic volume changes achieved using a variety of thoracoscopic procedures in rabbits.

MATERIALS AND METHODS

Thirty-six New Zealand White rabbits were randomly assigned to undergo the following thoracoscopic procedures in the left hemithorax: (a) parietal pleural abrasion; (b) minocycline instillation; (c) combination of abrasion and minocycline; or (d) examination alone. The rabbits were euthanatized 30 days after the operation to determine pleurodesis score, area of greatest adhesion, thoracic volume change, and histopathological findings.

RESULTS

Grossly, pleural abrasion produced moderate localized apical pleural symphysis with no obvious thoracic volume change. Minocycline instillation induced moderate generalized pleurodesis with a significant decrease in thoracic volume. The combination of abrasion and minocycline instillation produced the greatest generalized pleurodesis as well as a significant decrease in thoracic volume. On microscopic examination, the combination procedure produced the greatest inflammation and fibrosis of the visceral and parietal pleura. Increased intensity of pleurodesis score as well as pleural inflammation and fibrosis is associated with decreased thoracic volume.

CONCLUSIONS

Thoracoscopic pleurodesis achieved using pleural abrasion and minocycline instillation induced different patterns of pleurodesis, and a combination of each method generated a synergy and produced a better pleurodesis. However, as the generalization and intensity of the pleurodesis were inversely associated with thoracic volume, the optimal method should be determined on an individual basis according to the clinical situation.

Catamenial and Noncatamenial, Endometriosis-related or Nonendometriosis-related Pneumothorax Referred for Surgery

RATIONALE

Catamenial and endometriosis-related pneumothorax are considered relatively rare entities. Their clinical characteristics and outcome are incompletely known.

OBJECTIVES

To evaluate the frequencies, clinical characteristics, and outcomes of catamenial and endometriosis-related pneumothoraces occurring in women with no underlying lung disease referred for surgical treatment.

METHODS

Clinical files of all the women of reproductive age referred to our center during a 6-year period for surgical treatment of spontaneous pneumothorax were retrospectively reviewed. Catamenial pneumothorax (CP) was defined as recurrent pneumothorax occurring between the day before and within 72 hours after the onset of menses. All histologic slides were reviewed to confirm initial diagnoses.

MEASUREMENTS AND MAIN RESULTS

A total of 114 women underwent video-assisted thoracic surgery; 28 women (24.6%) had CP (right-sided in all but one), and diaphragmatic abnormalities (perforations and/or nodules) were observed in 22 of them. Diaphragmatic abnormalities were seen in 21 of 86 patients with non-CP. Histologic examination found endometriosis, mainly diaphragmatic, in 18 of 28 CPs and 11 of 86 non-CPs. A 6-month antigonadotropic treatment was prescribed postoperatively to women with either CP or endometriosis-related pneumothorax. Mean follow-up was 32.7 (+/-18.5) months. Recurrence rates in CP, non-CP but endometriosis-related, and non-CP non-endometriosis-related pneumothoraces were 32, 27, and 5.3%, respectively.

CONCLUSIONS

Our experience shows that (1) CP and/or endometriosis-related pneumothoraces account for an important percentage of spontaneous pneumothoraces referred for surgery, (2) diaphragmatic abnormalities seem to play a fundamental role in their pathogenesis, and (3) management is difficult because of the high recurrence rate.

Video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery is finding an ever-increasing role in the diagnosis and treatment of a wide range of thoracic disorders that previously required sternotomy or open thoracotomy. The potential advantages of video-assisted thoracoscopic surgery include less postoperative pain, fewer operative complications, shortened hospital stay and reduced costs. The following review examines the surgical and anesthetic considerations of video-assisted thoracoscopic surgery, with an emphasis on recently published articles.

The role of awake video-assisted thoracoscopic surgery in spontaneous pneumothorax

OBJECTIVE

We assessed in a randomized study the feasibility and efficacy of awake video-assisted thoracoscopic bullectomy with pleural abrasion to treat spontaneous pneumothorax.

METHODS

Between January 2001 and June 2005, a total of 43 patients with primary spontaneous pneumothorax were randomly assigned by computer to undergo video-assisted thoracoscopic bullectomy and pleural abrasion under sole thoracic epidural anesthesia or general anesthesia with single-lung ventilation (control group). Primary outcome measures included technical feasibility and patient satisfaction with anesthesia as scored into 4 grades (from 1, unsatisfactory, to 4, excellent). Secondary outcome measures included global operating room time, assessment of thoracic pain by visual analog pain scale, number of nursing care calls, hospital stay, and recurrences within 12 months.

RESULTS

In the awake group, technical feasibility was scored as excellent, good, and satisfactory in 8, 7, and 6 patients, respectively. Intergroup comparisons (awake versus control) showed that global operating room time (78.0 +/- 20.0 vs 105.0 +/- 15.0 minutes, P < .0001), perioperative visual analog pain scale score (2.0 +/- 3.0 vs 3.5 +/- 2.0, P = .005), nursing care calls (2.0 +/- 1 vs 3.0 +/- 3.0, P = .017), hospital stay (2.0 +/- 1.0 days vs 3.0 +/- 1.0 days, P < .0001), and overall costs (2540 euros +/- 352 euros vs 3550 euros +/- 435 euros, P < .0001) were significantly better in the awake group. In the awake group, 5 patients (23.8%) could be discharged within the first 24 postoperative hours. One patient in the awake group and 2 patients in the control group had recurrences within 12 months (difference not significant).

CONCLUSION

In our study, awake video-assisted thoracoscopic bullectomy with pleural abrasion proved easily feasible and resulted in shorter hospital stays and reduced procedure-related costs while providing equivalent outcome to procedures performed under general anesthesia.

Position of a chest tube at video-assisted thoracoscopic surgery for spontaneous pneumothorax

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is a good therapeutic option for young patients with primary spontaneous pneumothorax (PSP), but there sometimes exists unexpected prolonged hospital stay due to air leak after the operation.

OBJECTIVES

The goal of this retrospective study was to clarify if the position of the chest tube placed at VATS for PSP affected the periods of postoperative hospital stay.

METHODS

Seventy-one cases with PSP under age 40 who undertook VATS from January 1994 to February 2001 were examined for several factors. They were classified into two groups by the location of the tip of the chest tube placed at VATS as follows: upper medial pleural space (group I) and outside of there (group II).

RESULTS

Fifty-three of the 71 cases (75%) were classified in group I and 18 (25%) were in group II. Between the two groups, there were no differences as to preoperative characteristics of the patients and intraoperative findings of blebs or bullae. On the other hand, postoperative air leak-related complications were more frequent in group II than in group I (p=0.004). Mean postoperative hospital stay was 5.1+/-1.9 days in group I and 8.4+/-4.3 days in group II (p<0.0001).

CONCLUSIONS

Patients with the tip of the chest tube in the upper medial pleural space at VATS could be discharged earlier than the other patients. The chest tube placement is one of the important factors for the outcome of VATS for PSP.

Optimal Timing for Surgical Treatment to Prevent Recurrence of Spontaneous Pneumothorax

PURPOSE

Persistent air leakage and recurrence are the most common indications for the surgical treatment of spontaneous pneumothorax; however, the optimal timing for surgery is still unclear.

METHODS

The subjects of this study were 90 patients treated for either primary spontaneous pneumothorax (PSP; n = 58) or secondary spontaneous pneumothorax (SSP; n = 32). We compared the incidence of prolonged air leak, the rate of recurrence of pneumothorax, the time from the first episode of pneumothorax to recurrence, and the postoperative complications in the two groups. We also analyzed the recurrence rate after treatment with observation and tube drainage versus surgery.

RESULTS

Seventy-three patients were treated with tube thoracostomy or oxygen therapy for the first episode of pneumothorax. Surgery was performed in 32 patients; for the first episode of pneumothorax in 17 and for the second or third episode in 15. Postoperative complications developed in six (18.7%) patients and 24 of 73 patients who did not undergo thoracotomy suffered recurrence. The incidence of a second episode was 32.9% and the incidence of a third episode in the 18 patients who suffered recurrence after conservative treatment was 61.1%. None of the patients who underwent surgery suffered recurrence.

CONCLUSIONS

Tube thoracostomy is still the treatment of choice for first-time spontaneous pneumothorax. However, because the incidence of a third episode of pneumothorax after conservative treatment is high, surgical treatment should always be considered for patients with recurrence. In short, surgical intervention is safe and effective and minimizes the chance of recurrence of both PSP and SSP.

[Effectiveness and complications of video-assisted surgery for primary spontaneous pneumothorax]

OBJECTIVE

To assess the effectiveness and describe the complications of video-assisted thoracoscopic surgery (VATS) for the treatment of primary spontaneous pneumothorax.

PATIENTS AND METHODS

Between May 1997 and September 2003, our department scheduled 147 VATS procedures for spontaneous pneumothorax in 127 patients (102 men [80.5%]). The mean (SD) age for the series was 28.3 (11.6) years. Bullae and blebs were resected by endostapler and vigorous pleural abrasion was carried out. Vanderschueren staging was as follows: stage I, 10 (6.8%); stage II, 22 (15%); stage III, 71 (48.3%); and stage IV, 44 (29.9%). The procedure was indicated for the following reasons: third episode, 56 (38.1%); persistent air leak, 47 (32%); elective, 16 (10.9%); simultaneous bilateral pneumothorax, 28 (19%). VATS was performed on the right side only in 85 patients (57.8%), on the left in 62 (42.2%), and on both sides in 16 (11.6%).

RESULTS

A total of 137 of the 147 VATS procedures scheduled (93.2%) were performed, and there were no deaths. The rate of conversion to thoracotomy was 6.8%, and the overall rate of complications was 13.7%. Postoperative complications were due to bleeding in 5 cases (3.6%), air leak (>5 days) in 10 (7.2%), wound infection in 2 (1.4%), residual pneumothorax in 4 (2.9%), need to insert a new pleural drain in 3 (2.1%), and pleural empyema in 1 (0.7%). Two patients took oral analgesics for more than 30 days after the procedure. Pneumothorax recurred during follow-up in 7 patients (5.1%). No significant correlation was found between recurrence of pneumothorax after VATS and Vandeschueren stage, age, bilaterality of the procedure, indication, or days of postoperative drainage (P>.05).

CONCLUSIONS

VATS for resection of pleural lesions plus pleural abrasion is an efficacious and simple treatment for primary spontaneous pneumothorax regardless of intraoperative findings.

Video-Assisted Thoracoscopic Surgery for Recurrent Spontaneous Pneumothorax: The Long-term Benefit

BACKGROUND

Management of recurrent primary spontaneous pneumothorax by open surgery was considered the treatment of choice until recently. The major drawbacks of this management are the prolonged postoperative pain and cosmetic results. In the last decade, video-assisted thoracoscopic surgery (VATS) has replaced the routine use of open surgery. Most papers that compared limited open surgery to VATS addressed the early postoperative results, and studies that assessed the long-term results focused primarily on the rate of recurrence and pulmonary function tests. The aim of this study was to compare the outcome of minithoracotomy and VATS with emphasis on patients' long-term, subjective perspective and satisfaction.

METHODS

Medical records of patients with recurrent primary spontaneous pneumothorax were retrospectively reviewed. Patients who underwent surgical treatment by limited thoracotomy (63 patients) or VATS (58 patients) more than 3 years ago were enrolled. Hospital medical charts were used to compare the early postoperative results. Outpatient clinic records and a telephone questionnaire were employed to evaluate long-term results.

RESULTS

There was no mortality or major morbidity in either group, and hospitalization time was similar. Patients in the thoracotomy group needed significantly higher doses of narcotic analgesia for a longer period. There were two cases of recurrence in the VATS group (3%). Seventy-eight percent of patients in the VATS and 21% in the thoracotomy group classified their pain as insignificant a month following the operation (P < 0.05). Three years following surgery, 97% of the VATS group patients considered themselves completely recovered from the operation compared with only 79% in the thoracotomy group (P < 0.05). Nineteen percent of the thoracotomy group and 3% of the VATS group suffered from chronic or intermittent pain necessitating use of analgesics more than once a month. Thirteen percent of patients from the open procedure group required services from the pain clinic. Patients in the VATS group were, in general, much more satisfied with their operation and with the surgical scars compared with patients from the thoracotomy group.

CONCLUSION

We recommend video-assisted surgery as the first-line surgical treatment for patients with recurrent primary spontaneous pneumothorax. This recommendation is based on its somewhat favorable early postoperative course, the superior long-term outcome, and patient satisfaction.

Videothoracoscopic talc poudrage in primary spontaneous pneumothorax: A single-institution experience in 861 cases

OBJECTIVE

We sought to evaluate the outcome of 861 patients treated with videothoracoscopic talc poudrage for primary spontaneous pneumothorax.

METHODS

From September 1995 through January 2004, a total of 861 patients (578 male, 283 female, mean age 28.6 years) underwent videothoracoscopy for recurrent and complicated primary spontaneous pneumothorax. Patients were treated with videothoracoscopic talc poudrage only (group A: Vanderschueren's stage I, 196 patients; stage II, 112 patients) or videothoracoscopic talc poudrage plus stapling of the blebs/bullae (group B: stage III, 391 patients; stage IV 162 patients). Follow-up included clinical interview and chest radiography (805 patients). In 26 patients (follow-up longer than 5 years), respiratory function was investigated to determine residual volume and diffusing lung capacity.

RESULTS

No operative deaths occurred. No patient had adult respiratory distress syndrome. Postoperative complications occurred in 29 patients (3.36%). The conversion rate to an open procedure was 0.46% (4/861). After a mean follow-up of 52.5 months, 14 patients had recurrences (1.73%). The recurrence rate was 2.41% (7/290) in group A and 1.359% (7/515) in group B (chi2 value: 1.207389; P:.27; odds ratio: 0.56; 95% confidence interval: 0.20-1.62). Results of respiratory function tests were within normal ranges (80% or more of predictive value) in all 26 patients.

CONCLUSIONS

Videothoracoscopic talc poudrage achieves a high success rate in the treatment of primary spontaneous pneumothorax with a very low morbidity rate. Recurrences show a statistically significant relationship (P:.037) with smoking habits.