Video-assisted thoracoscopic surgery (VATS) in the management of spontaneous pneumothorax

SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax

This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group.

Videothoracoscopic approach to recurrence primary spontaneous pneumothorax: using of electrocoagulation in small bulla/blebs

OBJECTIVE

To evaluate the effectiveness of electrocoagulation of bullae/blebs and apical pleurectomy via videothoracoscopic approach.

METHODS

We reviewed 42 patients who underwent Videoassisted thoracoscopy (VATS) procedure for recurrence primary spontaneous pneumothorax (PSP) from 200022006. There were 30 male and 12 female patients with a median age of 30 years. The percentage of pneumothorax was calculated median of 60% (British Thoracic Society Guideline - 2003). Thirty-two (76.2%) bullae/blebs were observed with the median diameter of 15 mm (5-30).

RESULTS

Bulla ablation via cauterisation and apical pleurectomy was performed in 32 patients. Ten patients underwent only apical pleurectomy/abrasion because in this group there was not any either bulla or bleb could be found. The median duration of drainage time was 3 days. There was no mortality and complications occurred in five (11.9%) patients. Only two (4.76%) recurrence occurred during the 52 months (5 to 76) median follow-up period.

CONCLUSION

Videothoracoscopic bulla ablation with apical pleurectomy is a safe method for recurrence PSP. Especially, if the bulla or bleb is smaller than 20 mm the ablation via cauterisation reduces the expenses of VATS procedure by avoiding the use of stapler devices.

Novel method for bulla detection with video-assisted thoracoscopic surgery in patients with spontaneous pneumothorax

Detection of bullae is usually performed during lung inflation with an inspiratory hold in collaboration with anesthetists (conventional method). One cause leading to recurrent pneumothorax is failure to detect the position and extent of bullae under the conventional method. We herein present a novel method for detecting bullae under negative intrathoracic pressure, enabling exploration in the narrow cupola space without lung inflation.

[Pneumothorax]

The presence of free air in the pleural space, or pneumothorax, is a frequent condition in the clinical practice. The therapeutic approach of the pneumothorax depends on the clinical conditions of the patient, the magnitude of the disease and the presence or absence of underlying lung disease. In this chapter we emphasize the diagnostic and therapeutic guidelines for a rational approach of the pneumothorax.

Video assisted thoracoscopic bullectomy and acromycin pleurodesis: an effective treatment for spontaneous pneumothorax

The introduction of video assisted thoracoscopic surgery (VATS) has led to the development of several endoscopic options for the management of spontaneous pneumothorax. We describe here our experience in the management of primary spontaneous pneumothorax (SP). We carried out 58 VATS procedures on 55 patients during the period 1993-95. There were six conversions to open thoracotomy because of dense adhesions in five patients and a large apical bulla of 20 cm in one. These patients were excluded from the study. The remaining 49 patients underwent 52 VATS procedures. There were 37 males and 12 females with a median age of 23 (range: 15-71) years. The indications for surgery were persistent SP for more than 5 days in 21 (40%), and recurrent SP in 31 (60%). Twenty-six procedures (25 patients) consisted of bullectomy alone (group 1; 1/1/93-30/9/94) and the next 26 procedures (24 patients) included chemical pleurodesis with 2 g of Acromycin (Lederle) in 10 ml of 0.9 normal saline (group 2; 1/10/94-31/12/95). Both groups had a mean follow up of 38 months (range: 36-40). Mean postoperative chest drainage in group 2 (3.1 +/- 1.09) was significantly shorter than in group 1 (4.7 +/- 1.0). Group 2 patients also had a shorter hospital stay (4.8 /- 1.08 vs. 6.76 +/- 1.09). There were five (20%) recurrences in group 1 while only one (4%) occurred in group 2. In view of these results we recommend the routine use of Acromycin pleurodesis in addition to thoracoscopic bullectomy.

Video-assisted thoracoscopic surgery for spontaneous pneumothorax--a 7-year learning experience

OBJECTIVES

To determine the effect of increasing experience of video-assisted thoracoscopic surgery (VATS) in the treatment of spontaneous pneumothorax (SP) on clinical efficacy and surgical practice.

PATIENTS AND METHODS

A prospective study of 180 consecutive operations in 173 patients who underwent VATS for SP by a single surgeon during a 7 year period.

RESULTS

118 patients, mean age 32.1 years (range 13-63 years), were treated for primary spontaneous pneumothorax (PSP) while 55 patients, mean age 65.9 years (range 28-92 years), were treated for secondary spontaneous pneumothorax (SSP). All patients had VAT parietal pleurectomy combined in 162 (90%) patients with stapled bullectomy. At a current median experience of 2.0 years (range 0.4-6.8 years), 12 (6.6%) patients required reoperation for treatment failures within 12 months of surgery--9 patients within 30 days of VATS and 3 for late recurrent pneumothorax. Two patients (both with SSP) died within 30 days of surgery. When compared with PSP, VATS in SSP is characterized by an elderly, male predominance, a longer postoperative stay, a higher mortality rate and a lower rate of late recurrence. With increasing experience of the technique, there has been a significant decrease in treatment failures. In the treatment of PSP, both operating time and postoperative stay have decreased significantly with experience whilst the use of staple cartridges per patient has increased significantly with experience in both PSP and SSP.

CONCLUSION

There is a demonstrable 'learning curve' effect on the clinical efficacy and surgical practice of video assisted thoracoscopic surgery for spontaneous pneumothorax.