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

Which Role for Muscle-Sparing Posterolateral Thoracotomy in the Treatment of Spontaneous Pneumothorax?

Objective  This study aims to show the place of muscle-sparing posterolateral thoracotomy in the treatment of spontaneous pneumothorax. Methods  It was a single-center study performed in the Department of Thoracic Surgery of Teaching hospital Hassan II of Fez for 8 years. We adopted the nosological definition, which classifies spontaneous pneumothorax into three categories. We included patients over 15 years of age with primary or secondary spontaneous pneumothorax operated by posterolateral thoracotomy without muscle section, and we analyzed the specific indications of this approach. It included 49 patients with primary or secondary spontaneous pneumothorax, operated by muscle-sparing posterolateral thoracotomy. Data were collected from regularly updated computer files of patients, entered by Excel 2013, and analyzed using SPSS.20 software. These data are: epidemiological, clinical, radiological, surgical exploration, surgical procedure, the result of the surgery and the evolution. Results  The average age was 42 years. Smoking was found in 61% of cases and pulmonary tuberculosis in 10% of cases. Thoracic computed tomography (CT) showed bullae and blebs in 31% of cases, pleural adhesions and pachypleuritis in 50% of cases, and hydropneumothorax with pachypleuritis in 37% of cases. There is a statistical correlation between pleuropulmonary decortication and pachypleuritis ( p  = 0.002) or hydropneumothorax ( p  = 0.001) on CT. Bullae and blebs resection was performed in 53% of cases and pleuropulmonary decortication in 63% of cases. A right pleuropneumonectomy was performed in one case. The follow-up was uneventful in 82% of cases. Conclusion  Muscle-sparing posterolateral thoracotomy remains the best approach and leads to good results.

Wedge resection and pleurodesis through single-incision videothoracoscopic transmediastinal approach for bilateral spontaneous pneumothorax

In general, in cases of bilateral primary pneumothorax, videoassisted thoracoscopic surgery procedures are performed sequentially on both sides. However, there are only a few reported cases of bullectomy through video-assisted thoracoscopic surgery using a transmediastinal approach for bilateral primary spontaneous pneumothorax. A 20-year-old male patient was admitted to our clinic with a right pneumothorax and developed a left pneumothorax four days later while he was under treatment. He underwent bilateral bullectomy and pleurodesis via a singleincision video-assisted thoracoscopic surgery in the supine position. The patient was discharged uneventfully within 72 h after the procedure. In conclusion, bilateral bullectomy and pleurodesis using single-incision transmediastinal access video-assisted thoracoscopic surgery may be good choices that are technically reliable and provide favorable surgical outcomes.

Primary Spontaneous Pneumothorax: Open Thoracotomy vs. Video-assisted Thoracoscopic Surgery: A Single-center Retrospective Cohort Study

Background

Primary spontaneous pneumothorax (PSP) is a spontaneous pneumothorax without underlying lung disease. The main goals of this study were to compare the outcomes of video-assisted thoracoscopic surgery (VATS) and open thoracotomy in patients with PSP.

Methods

The current study is a retrospective cohort study of patients who were admitted to the emergency department or general surgery ward at Dr. Masih Daneshvari Hospital (Tehran, Iran) with the diagnosis of PSP and underwent surgery by open or VATS approach from 2006 to 2012. The groups were compared in terms of the length of operation, the length of hospitalization, recurrence, and postoperative complications. Data were analyzed using SPSS version 18.0, and Student's t test, analysis of variance (ANOVA), Chi square, and Fisher's exact test were employed. P values less than 0.05 were considered statistically significant.

Results

PSP was diagnosed in 90 patients who underwent surgery. Open thoracotomy and VATS procedures were performed in 65 (72.2%) and 25 (27.8%) patients, respectively. VATS was converted to open in seven cases (7.7%). Recurrent pneumothorax was the most common surgical indication for PSP. There was no significant difference between the two groups in terms of mean age, sex, smoking, side of the involved lung, previous pneumothorax history, mean length of hospitalization for recurrence, post-operation bleeding, and failure of lung expansion. However, the length of surgery (P=0.011) and air leakage (P=0.048) significantly differed between the two groups.

Conclusion

When compared to open thoracotomy, VATS could be the primary treatment option in the surgical treatment of PSP due to the shorter length of surgery and decreased complications such as air leakage.

Simultaneous Bilateral Secondary Pneumothorax Complicating Osteosarcoma: A Case Report

Background:

The incidence of Simultaneous Bilateral Secondary Pneumothorax (SBSP) occurring as a complication of neoplasm is rare, only <1%. The lungs can be the site for spreading metastatic osteosarcoma.

Methods:

We investigated a 16-year-old female who was diagnosed with right distal femur osteosarcoma, pulmonary metastasis, and a rare SBSP complication. Pneumothorax was observed in both sites of pulmonary metastases and bronchopleural fistula by contrasting chest computed tomography.

Results:

This pneumothorax is the second one; the previous one was only on one side, before chemotherapy. 12 months after osteosarcoma was diagnosed and four months after SBSP occurred. The progression of osteosarcoma lesions was the cause of patient’s death. SBSP is the leading cause of severe complications in osteosarcoma.

Conclusion:

The clinician must perform diagnostic strategies for early detection of osteosarcoma and its proper management, which can reduce a patient’s suffering and impairment of the patient’s quality of life, thus decreasing morbidity and risk of mortality.

Retention of Bovie scratch pad radio-opaque marker during VATS Pleurodesis: case report

Background

Surgical intervention for spontaneous pneumothorax typically includes mechanical pleurodesis that frequently utilizes a Bovie scratch pad given its universal presence, low cost and ease of use. The pad is folded on itself after dividing it in half, allowing easier passage through the smaller incisions.

However, unintentional foreign body retention may occur during the course of an operation leading to reoperations or even worse complications. This case is reported to raise awareness that dividing the scratch pad may allow the embedded radio-opaque marker to fall out and become retained as a foreign body.

Case presentation

The patient is a 41 year-old female who presented with shortness of breath secondary to spontaneous pneumothorax. Chest CT scan showed apical blebs. The patient underwent video assisted thorascopic surgery (VATS) with bleb resection and mechanical pleurodesis using a divided and folded bovie scratch pad. Postoperative chest x-ray showed a retained foreign body. Reoperation confirmed this to be the radio-opaque marker of the scratch pad and was removed. The patient did well and was discharged the following day.

Conclusion

Dividing the bovie scratch pad may damage and “weaken” the product allowing the radio- opaque marker to fall out during its use for pleurodesis and should be discouraged. Recommendation is made of using the scratch pad as a whole and not dividing it.

Graphical abstract

Retained radio-opaque marker of bovie scratch pad during VATS mechanical pleurodesis.

Subxiphoid vs transthoracic approach thoracoscopic surgery for spontaneous pneumothorax: a propensity score-matched analysis

BACKGROUND

The transthoracic thoracoscopic surgery is currently accepted as a favorable technique for bullectomy for primary spontaneous pneumothorax. Recently, uniportal subxiphoid thoracoscopic surgery has been proposed as an alternative to conventional transthoracic thoracoscopic surgery.

METHODS

From November 2014 and January 2016, 127 consecutive patients who met the inclusion criteria were enrolled in this study. Among these patients, 32 were treated using subxipoid approach, whereas 95 were treated using transthoracic approach. Propensity score case-matching was performed to adjust for patient backgrounds.

RESULTS

The two groups of 32 pairs were well matched for baseline and surgical characteristics. Patients who underwent subxipoid approach had a longer operation time than transthoracic approach (p = 0.004). The subgroup analysis showed that the operation time for bilateral bullectomy was similar between the groups (p = 0.986). There were no differences between the groups with respect to the hospital stay after surgery, chest drain duration, the number of the staples used for the operation, and postoperative recurrence. However, the provoked arrhythmias events during surgery were significantly higher in the subxiphoid approach group (p = 0.011).

CONCLUSIONS

Although transthoracic thoracoscopic surgery for spontaneous pneumothorax is well established, uniportal subxiphoid thoracoscopic surgery may be a potentially alternative way to management of patients with spontaneous pneumothorax in selected cases, especially for bilateral surgery, but causions should be taked.

Unilateral single-port thoracoscopic surgery for bilateral pneumothorax or pulmonary bullae

BACKGROUND

Rapid rehabilitation surgery has become a widely accepted approach. Thoracic surgeons have attempted in many ways to make surgery less invasive. We combined tubeless technology, single-port technology and mediastinum approach for the treatment of simultaneous bilateral primary spontaneous pneumothorax(PSP)or pulmonary bullae. And we evaluated its therapeutic effect. This study aimed to investigate if tubeless single-port video-assisted thoracic surgery (Tubeless-SPVATS) via anterior mediastinum can be used as an alternative surgical treatment for bilateral lung diseases, especially for concurrent or contralateral recurrence PSP.

METHODS

From November 2014 to December 2016, 18 patients with simultaneous bilateral PSP or pulmonary bullae were treated with tubeless -SPVATS via anterior mediastinum. They were 13 males and 5 females with an average age of 20.2 ± 2.3 years (17 to 24 years). They all had preoperative chest CT and were diagnosed with simultaneous bilateral PSP or pulmonary bullae.

RESULTS

Fifteen patients underwent bilateral bullae resection with Tubeless-SPVATS via anterior mediastinum. Three patients underwent bilateral single-port video-assisted thoracic surgery. No thoracotomy was performed. No death and grade 3-4 mobidity were found. All the patients started eating 6 hours after surgery. The average operation time was 44.56±17.8min. The patients were discharged 3. 5±1.0 days postoperatively.

CONCLUSIONS

Tubeless-SPVATS via anterior mediastinum is a safe and feasible treatment for patients with simultaneous bilateral PSP or pulmonary bullae. However,contralateral thoracic is not explored fully enough. And when contralateral lung bullae are located near the hilum, endoscopic linear stapler cannot be easily used to conduct suture. Thus, the recurrence rate after performing Tubeless-SPVATS may be increased compared to performing thoracotomy. However, compared to bilateral thoracic surgery, this method reduced postoperative pain. And it took significantly less time than bilateral thoracic surgery. Thus, this method has some clinic value.

Efficacy of treatments in primary spontaneous pneumothorax: A systematic review and network meta-analysis of randomized clinical trials

BACKGROUND

Primary spontaneous pneumothorax (PSP) remains a significant global health problem. Despite general agreement, an official algorithm for the management of PSP still does not exist.

OBJECTIVES

Evaluating the efficacy of all available treatments in PSP.

METHODS

A systematic search of 12 electronic databases was performed to identify all randomized controlled trials (RCTs) of any treatments in PSP. The primary endpoint was recurrence incidence; secondary were an immediate success, complication and hospitalization days. All available outcomes were included in frequentist network meta-analysis.

RESULTS

4262 patients of 29 RCTs were included. In patients with first episode of PSP, video-assisted thoracoscopic surgery (VATS), tube drainage and aspiration had no significant difference regarding recurrence. Chemical pleurodesis significantly reduced the recurrent incidence of 46% compared with aspiration and 54% compared with tube drainage. VATS and aspiration significantly decreased hospitalization days compared with tube drainage. In patients with recurrent or persistent PSP, thoracotomy with mechanical pleurodesis has a higher rank than VATS with or without pleurodesis in preventing recurrence, with no significant difference. VATS alone significantly reduced complications compared with all others treatments, except thoracotomy with abrasion.

CONCLUSIONS

Aspiration and tube drainage have no significant difference in treating patients with first episode of PSP regarding recurrence. Aspiration reduced hospitalization days when compared with tube drainage. Thoracotomy with mechanical pleurodesis and VATS with or without pleurodesis are not significantly different in preventing recurrence in patients with recurrent or persistent PSP. VATS alone reduced complications compared with others treatments except for thoracotomy with abrasion.

High Nrf2 expression in alveolar type I pneumocytes is associated with low recurrences in primary spontaneous pneumothorax

Recurrent primary spontaneous pneumothorax (PSP) is a troublesome problem and a major concern for the patients. This study examined whether nuclear factor erythroid 2-related factor 2 (Nrf2) expression in alveolar type I pneumocytes was associated with the clinical manifestations of PSP patients including disease recurrence. Eighty-eight PSP patients who were managed with needlescopic video-assisted thoracoscopic surgery (NVATS) were included in this study. Immunohistochemistry (IHC) was assessed to determine Nrf2 expression in resected lung tissues and the results were correlated with clinicopathological characteristics by the chi-square or the Fisher's exact test. The prognostic value of Nrf2 for overall recurrence was evaluated by univariate and multivariable Cox regression model. The expression of Nrf2 was observed in type I pneumocytes of lung tissues from PSP patients by IHC. We found that low Nrf2 expression in PSP patients, especially in young (age ≤ 20, p = 0.033) and body mass index (BMI) ≥18 kg/m² (p = 0.019) groups, was significantly correlated with PSP recurrence. In the univariate and multivariate analyses, high Nrf2 expression was a significant protective factor for overall recurrence in PSP patients (univariate: p = 0.026; multivariate: p = 0.004). The expression level of Nrf2 in alveolar type I pneumocytes was a potential factor involved in PSP recurrence. Our findings suggest that elevated Nrf2 expression in PSP patients may be a promising way for reducing PSP recurrence.

Barbed suture material technique for wound closure and concomitant tube placement in uniportal VATS for pneumothorax

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) is an alternative modality for treatment of primary spontaneous pneumothorax (PSP) with its less invasiveness and acceptable surgical outcomes. However, a few reports have been introduced for wound management to achieve better cosmetic wound healing and for placement of the chest tube in uniportal VATS. Thus, we aimed to evaluate the feasibility of our novel method for wound closure and concomitant tube placement using continuous barbed suture material in uniportal VATS for PSP.

METHODS

Between July 2012 and December 2015, consecutive 31 patients (22 males) underwent uniportal VATS to treat PSP. Bilateral approaches were performed in four patients, thus total 35 cases were enrolled. We divided them into two groups with one group of 17 (48.5%) cases (group A), using barbed absorbable wound closure device for knotless continuous wound closure and subsequent chest tube anchoring, and the other group of 18 (51.4%) cases (group B), using conventional suture anchoring after skin closure using absorbable suture device. Postoperative surgical outcomes were compared to assess the feasibility of this technique.

RESULTS

Demographic data demonstrate no significant difference in both groups. There was no significant difference in length of hospital stay (3.7±1.2 vs. 4.1±1.2 days, P=0.267) and in median chest tube indwelling time (2.4±0.9 vs. 3.1±1.2 days, P=0.066), respectively. Operation time in group A was shorter than in group B but there was no significant difference (41.7±11.8 vs. 45.6±16.0 minutes, P=0.415). There was neither conversion to two or three port VATS in all cases. In group A, all chest tubes were removed with concomitant sealing the tube removal site by pulling the thread. Residual knots do not exist that stitch out procedure is not required. There was no wound complication in both groups during the median follow-up period of 18 months.

CONCLUSIONS

Knotless, barbed suture material technique for continuous wound closure with concomitant chest tube placement achieved equivocal outcomes in comparison to the conventional suture anchoring method. We suggest this simple technique for wound closure and easy tube removal with cosmetic wound healing in uniportal VATS for PSP.

Mid-Term Outcomes of Single-Port versus Conventional Three-Port Video-Assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax

Background

The benefits of video-assisted thoracoscopic surgery (VATS) have been demonstrated over the past decades; as a result, VATS has become the gold-standard treatment for primary spontaneous pneumothorax (PSP). Due to improvements in surgical technique and equipment, single-port VATS (s-VATS) is emerging as an alternative approach to conventional three-port VATS (t-VATS). The aim of this study was to evaluate s-VATS as a treatment for PSP by comparing operative outcomes and recurrence rates for s-VATS versus t-VATS.

Methods

Between March 2013 and December 2015, VATS for PSP was performed in 146 patients in Kyungpook National University Hospital. We retrospectively reviewed the medical records of these patients.

Results

The mean follow-up duration was 13.4±6.5 months in the s-VATS group and 28.7±3.9 months in the t-VATS group. Operative time (p<0.001), the number of staples used for the operation (p=0.001), duration of drainage (p=0.001), and duration of the postoperative stay (p<0.001) were significantly lower in the s-VATS group than in the t-VATS group. There was no difference in the overall recurrence-free survival rate between the s-VATS and t-VATS groups.

Conclusion

No significant differences in operative outcomes and recurrence rates were found between s-VATS and t-VATS for PSP. Therefore, we cautiously suggest that s-VATS may be an appropriate alternative to t-VATS in the treatment of PSP.

Is it possible to standardize the treatment of primary spontaneous pneumothorax? Part 2: surgical methods of treatment

The present report provides a detailed description of the surgical methods for primary spontaneous pneumothorax (PSP) treatment, from open surgery (thoracotomy) to minimally invasive procedures (video-assisted thoracoscopic surgery - VATS). It describes the methods of preventing pneumothorax recurrence, including partial or complete resection of the parietal pleura and chemical pleurodesis with VATS. The pros and cons of each method are presented. The paper also discusses new techniques for diagnosing pneumothorax, such as fluorescein-enhanced autofluorescence thoracoscopy (FEAT) and infrared thoracoscopy. Finally, the authors propose their own algorithm for the treatment of PSP.

Correlation of matrix metalloproteinase-2 and -9 expression with recurrences in primary spontaneous pneumothorax patients

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a common benign disorder. However, unpredictable recurrence is a major concern for most patients. The aim of the present study was to assess the role of matrix metalloproteinase-2 (MMP-2) and MMP-9 in alveolar macrophages of patients with PSP and its relationship with recurrence.

METHODS

Ninety-two patients who received needlescopic video-assisted thoracoscopic surgery (NVATS) wedge resection of lung with identifiable blebs for PSP were enrolled for the study. Immunohistochemistry was performed to evaluate the expression of MMP-2 and MMP-9 in lung tissues of patients with PSP. The result was correlated with clinicopathological variables and recurrence rates by the chi-square test. The value of MMP-2 and MMP-9 for overall recurrence was evaluated by univariate and multivariable Cox regression analyses.

RESULTS

The MMP-2 and MMP-9 staining was predominantly observed in alveolar macrophages of patients with PSP. We found that MMP-2 (recurrence: P<0.001; smoking status: P=0.029) and MMP-9 (recurrence: P=0.001; smoking status: P=0.045) expression in PSP, especially male patients, was significantly correlated with recurrence and smoking status. In the multivariate analyses, MMP-2 [hazard ratio (HR) =2.83; 95% confidence interval (CI): 1.37-5.85, P=0.005) and MMP-9 (HR =2.25; 95% CI: 1.19-4.24, P=0.013) were statistically significant risk factors for overall recurrence in PSP patients.

CONCLUSIONS

High expression levels of MMP-2 and MMP-9 showed a positive correlation with recurrence in PSP patients. Further studies are required to test whether inhibition of MMP-2 and MMP-9 expression renders a promising approach for reducing the risk of PSP recurrence in the future.

Evaluation of Spontaneous Pneumothorax Surgeries: A 16-Year Experience in Japan

Background. Video-assisted thoracoscopic surgery is the surgical procedure of choice for spontaneous pneumothorax due to its noninvasiveness and convenience. A higher recurrence rate with thoracoscopic bullectomy (TB) than that after traditional thoracotomy (TT) led us to adopt thoracoscopic double-loop ligation (TLL) as our standard procedure in 1998. This study compares the effectiveness and safety of these 3 operative procedures. Methods. Patients who underwent their first surgery for spontaneous pneumothorax at our hospital between January 1994 and December 2010 were included. Patients with a history of surgery for spontaneous pneumothorax, those with special clinical conditions such as lymphangioleiomyomatosis, or those with catamenial, traumatic, or iatrogenic pneumothorax were excluded. Results. A total of 777 males (14-91 years old; 814 pneumothorax sides), and 96 females (16-78 years old; 99 pneumothorax sides) were included in the study. TT was performed in 137 patients (143 sides), TB in 106 patients (112 sides), and TLL in 630 patients (658 sides). The postoperative recurrence rates were 3.5%, 16.1%, and 5.3% in the TT, TB, and TLL groups, respectively (p < 0.0001). Mean blood loss and operating time were lowest for TLL. Conclusions. The results suggest that TLL should be the surgical procedure of choice for spontaneous pneumothorax.

The Presence of a Reticulated Trabecula-Like Structure Increases the Risk for the Recurrence of Primary Spontaneous Pneumothorax after Thoracoscopic Bullectomy

INTRODUCTION

Deteriorated alveolar structure at the base of blebs and bullae is known as the reticulated trabecula-like structure. Its clinical significance in primary spontaneous pneumothorax (PSP) remains unclear. This study aimed to investigate the impact of the structure on recurrence of PSP after video-assisted thoracoscopic surgery (VATS) bullectomy.

METHODS

Between April 2010 and March 2014, 80 cases of PSP in 76 patients who underwent VATS bullectomy using endoscopic staplers were included. The staple line was covered with polyglycolic acid sheets and fibrin glue. Cases were assigned to a normal alveolar structure (NAS) group (n = 54) and a reticulated trabecula-like structure (RT) group (n = 26) based on the histological analysis. Factors associated with recurrence were analysed using logistic regression.

RESULTS

The reticulated trabecula-like structure was significantly related to apical lung blebs. The recurrence rate of PSP was significantly higher in the RT group than in the NAS group (38.5% vs. 3.7%; P <0.001). On multivariate analysis, the reticulated trabecula-like structure was an independent factor for recurrence of PSP after VATS bullectomy.

CONCLUSION

The change of alveolar structure at the base of apical lung blebs would increase the risk for recurrence of PSP after VATS bullectomy.

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.

Role of computed tomographic scanning prior to thoracoscopic surgery for primary spontaneous pneumothorax

BACKGROUND/PURPOSE

The role computed tomography (CT) performed prior to thoracoscopic surgery for primary spontaneous pneumothorax (PSP) remains unclear.

METHODS

We retrospectively reviewed medical records of all patients who underwent thoracoscopic surgery for PSP during 2008-2012. Patients were stratified into two groups: CT group (patients who received preoperative CT scanning) and control group (patients who did not receive preoperative scanning). Short-term postoperative results and long-term pneumothorax recurrence rates were compared.

RESULTS

A total of 298 patients were studied. Preoperative CT scanning was performed in 140 of them. The duration of operation, incidence of bullae formation, number of excised specimens, rate of complications, and postoperative hospital stay were similar between the two groups. After a mean follow-up of 20 months, the recurrence rates were 8.6% (12/140) in the CT group and 5.7% (9/158) in the control group (p = 0.371). In the CT group, five patients had unexpected pulmonary findings and three of them (60%) developed pneumothorax recurrence, the rate of which was significantly higher than that in patients without unexpected pulmonary findings (9/135, 6.7%, p = 0.004). Unexpected pulmonary lesions were more commonly noted in females (4/19, 21.1%) than in males (1/121, 0.8%; p < 0.001).

CONCLUSION

Preoperative CT scanning was not associated with better results after thoracoscopic surgery for PSP and is, therefore, not justified as a routine examination prior to the operation. In female patients, however, preoperative CT scanning might be needed because these patients tended to have a higher incidence of unexpected pulmonary lesions, which were associated with a higher rate of recurrence.

Video-assisted thoracoscopic surgery for postoperative recurrent primary spontaneous pneumothorax

OBJECTIVES

Postoperative recurrent primary spontaneous pneumothorax (PSP) is a troublesome complication and an important issue to be discussed. This study is to determine whether Re-video assisted thoracoscopic surgery (VATS) should be performed for postoperative recurrent PSP (PORP).

MATERIALS AND METHODS

Patients who had underwent needlescopic VATS for PSP between Jan. 2007 and Dec. 2011 were reviewed.

RESULTS

VATS was initially performed on 239 patients with PSP in total. Eleven patients were found to have PORP during a follow-up period of 36.95 months. Nine patients received Re-VATS and only two patients receiving conservative treatment had no further recurrence. No conversion to thoracotomy, blood transfusion and prolong air leak were recorded.

CONCLUSIONS

Even for smaller size cases, Re-VATS, which is technically feasible, safe and effective with better cosmetics and minor postoperative pain, should be a strong contender as priority treatment.

Bilateral bullectomy through uniportal video-assisted thoracoscopic surgery combined with contralateral access to the anterior mediastinum

OBJECTIVE:

Video-assisted thoracoscopic surgery (VATS) has been a surgical intervention of choice for the treatment of spontaneous pneumothorax (SP) with lung bulla. Our objective was to introduce a uniportal VATS approach for simultaneous bilateral bullectomy and to evaluate its therapeutic efficacy.

METHODS:

Between May of 2011 and January of 2012, five patients underwent bilateral bullectomy conducted using this approach. All of the patients presented with bilateral SP. Preoperative HRCT revealed that all of the patients had bilateral apical bullae. We reviewed the surgical indications, surgical procedures, and outcomes.

RESULTS:

All of the patients were successfully submitted to this approach for bilateral bullectomy, and there were no intraoperative complications. The median time to chest tube removal was 4.2 days, and the median length of the postoperative hospital stay was 5.2 days. The median postoperative follow-up period was 11.2 months. One patient experienced recurrence of left SP three weeks after the surgery and underwent pleural abrasion.

CONCLUSIONS:

Bilateral bullectomy through uniportal VATS combined with contralateral access to the anterior mediastinum is technically reliable and provides favorable surgical outcomes for patients with bilateral SP who develop bilateral apical bullae. However, among other requirements, this surgical procedure demands that surgeons be experienced in VATS and that the appropriate thoracoscopic instruments are available.

Spontaneous contralateral pneumothorax in a patient with low Body Mass Index

Spontaneous pneumothorax is most common in adolescents and young adults. Some of them develop contralateral pneumothorax. In this paper, we report the case of a patient with spontaneous contralateral pneumothorax, whose body mass index (BMI) was 18.8 kg/m2. For either chest physicians or thoracic surgeons, follow up with recognition of increased risk of the contralateral pneumothorax is important especially in patients with contralateral bullous lesions and low BMI.

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 management of pneumothorax in patients with anorexia nervosa: A case report and review of the literature

Of the many body systems adversely affected by severe anorexia nervosa (AN), the pulmonary system is relatively spared. However, in the face of severe malnutrition of AN, the lung may undergo architectural changes that adversely affect its integrity and healing capacity. We report herein a case of a pneumothorax in a patient with severe AN, in which standard approaches to manage the pneumothorax were unsuccessful. Despite prolonged tube thoracostomy drainage, and subsequent thoracoscopic pleuredesis, the patient continued to have an air leak and non-resolution of her pneumothorax. We review the literature and discuss alternative approaches in this patient population.

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.

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.

Pneumothorax: an update

Pneumothorax is a relatively common clinical problem which can occur in individuals of any age. Irrespective of aetiology (primary, or secondary to antecedent lung disorders or injury), immediate management depends on the extent of cardiorespiratory impairment, degree of symptoms and size of pneumothorax. Guidelines have been produced which outline appropriate strategies in the care of patients with a pneumothorax, while the emergence of video-assisted thoracoscopic surgery has created a more accessible and successful tool by which to prevent recurrence in selected individuals. This evidence based review highlights current practices involved in the management of patients with a pneumothorax.

Pneumothorax: an update

Pneumothorax is a relatively common clinical problem which can occur in individuals of any age. Irrespective of aetiology (primary, or secondary to antecedent lung disorders or injury), immediate management depends on the extent of cardiorespiratory impairment, degree of symptoms and size of pneumothorax. Guidelines have been produced which outline appropriate strategies in the care of patients with a pneumothorax, while the emergence of video-assisted thoracoscopic surgery has created a more accessible and successful tool by which to prevent recurrence in selected individuals. This evidence based review highlights current practices involved in the management of patients with a pneumothorax.