Video-assisted thoracoscopic surgery (VATS) for bilateral primary spontaneous pneumothorax

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee

INTRODUCTION

Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations.

METHODS

Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment.

CONCLUSIONS

The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention.

LEVEL OF EVIDENCE

Level 4.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

Use of Video-Assisted Thoracoscopic Surgery (VATS) in the Treatment of Primary Spontaneous Pneumothorax (PSP) in Children

INTRODUCTION

This study aims to review the primary spontaneous pneumothorax (PSP) patients we have treated and to discuss the results in terms of PSP treatment management and video-assisted thoracoscopic surgery (VATS) use in the light of the literature.

METHODS

The study was designed retrospectively and conducted at a tertiary referral university hospital between January 1, 2015 and May 1, 2021. Patients under the age of 18 years with a diagnosis of pneumothorax (PTX) were included in the study. Medical records were analyzed in terms of clinical characteristics, demographic data, findings from imaging data, procedures performed, and course of the disease at hospital. Patients with no evidence of PTX on radiologic imaging (direct postero-anterior chest X-ray (PACXR) or thoracic computed tomography (TCT)), incomplete medical records for follow-up, history of trauma, and neonatal PTX were excluded from the study.

RESULTS

The study was conducted on a total of 98 PTX cases in 69 patients, 61 (88.4%) males and eight (11.6%) females. The ages of the patients ranged between 13 and 17 years with a mean of 16.59 ± 0.95 years. While 48 (49%) PTX cases were treated with tube thoracostomy, 19 (19.4%) were treated with medical follow-up (nonsurgical treatment) and 31 (31.6%) were treated with VATS. A total of 31 VATS procedures were performed on 28 patients. The follow-up period after VATS ranged from tthree to 78 months, with a mean of 31.5 ± 20.3 months and a median of 28 months.

CONCLUSION

 Our retrospective study showed that TCT scanning did not provide additional benefit when PSP was detected on PACXR in patients presenting with chest pain and respiratory distress. According to the findings of our study, it was thought that the probability of undergoing an invasive procedure and surgical intervention increased as the percentage of PTX detected in PACXR increased. Tube thoracostomy may be required in a patient with PSP if PTX does not start to decrease and lung expansion does not increase after an average of 60 hours after the decision for medical follow-up, and if PTX is progressive in the follow-up. VATS can be performed on a patient with PSP when lung expansion does not increase after an average of 18 hours after tube thoracostomy, when PTX progresses, when air leakage continues for more than 10 days despite increased lung expansion, and when recurrent PTX occurs.

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.

A Case of Tension Pneumothorax After Diverticular Rupture During Diagnostic Colonoscopy

Colonoscopy is routinely used for the diagnosis and treatment of colorectal diseases. Bowel perforation is a rare but severe complication that significantly increases the morbidity and mortality. Tension pneumothorax is an uncommon complication of colonic perforation. We present a case of the successful treatment of a patient with tension pneumothorax, following colonoscopy, by using tube thoracostomy and Hartman-type resection of the rectosigmoid junction and proximal sigmoid. Surgeons, anesthesiologists, and endoscopists should consider the possibility of pneumothorax as a rare complication of colonoscopy. Early detection and urgent treatment is the key to successful management.

Comparison of single-stage and two-stage bilateral video-assisted thoracic surgery

OBJECTIVE

Single-stage sequential bilateral video-assisted thoracoscopic surgery (VATS) is a controversial procedure. In the present study, we retrospectively compared the outcomes of single-stage and two-stage VATS.

METHODS

This study involved patients who underwent single-stage sequential bilateral VATS (SS-VATS group) or two-stage VATS at a 3-month interval (TS-VATS group) for treatment of non-small cell lung cancer from 2010 to 2018. The major outcome was the comparison of intraoperative changes.

RESULTS

The inspiratory peak pressure was higher, the incidences of intraoperative hypoxia and unstable hemodynamics were higher, the surgical time was longer, and the durations of the intensive care unit stay and postoperative hospitalization were longer in the SS-VATS group than in the TS-VATS group. However, the chest tube duration, incidence of postoperative mechanical ventilation, and clinical complications were not different between the two groups.

CONCLUSIONS

Compared with two-stage VATS, single-stage sequential bilateral VATS can be performed for successful treatment of bilateral pulmonary lesions with a shorter total time and higher cost-effectiveness in terms of anesthesia and hospitalization but with a higher incidence of intraoperative adverse effects and a longer hospital stay.

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.

Simultaneous Bilateral Primary Spontaneous Pneumothorax: A Case Report and a Review of the Literature

Background

Simultaneous bilateral primary spontaneous pneumothorax (SBPSP) is an extremely rare and potentially fatal condition. Patients usually have no relevant medical conditions. Some cases, however, may have certain risk factors such as smoking, being young, and male gender. We reported a case of a healthy young male who presented with BPSP.

Case Presentation

A 21-year-old man with a past medical history of well-controlled intermittent asthma presented with acute worsening shortness of breath overnight. Chest X-ray performed showed bilateral large pneumothorax with significantly compressed mediastinum. Chest tubes were placed bilaterally with immediate clinical improvement. However, the chest tubes continued to have an air leak without full lungs expansion. Computed tomography scan without contrast of the chest revealed subpleural blebs in both upper lobes. The patient underwent bilateral video-assisted thoracoscopic surgery (VATS) with apical bleb resection, bilateral pleurectomy, and bilateral doxycycline pleurodesis. Biopsy of the apical blebs and parietal pleura of both lungs were negative for any atypical cells suspicious for malignancy or Langerhans cell histiocytosis. The patient had been doing well six months following surgery with no recurrence of pneumothorax.

Conclusion

SBPSP is a rare and urgent condition that requires prompt intervention. In a young patient without any underlying disease, surgical intervention, such as VATS, is relatively safe and can be considered early.

Simultaneous Bilateral Video-Assisted Thoracoscopic Surgery for the Treatment of Primary Spontaneous Pneumothorax

We determined the feasibility and clinical efficacy of simultaneous bilateral video-assisted thoracoscopic surgery (VATS) for treating primary spontaneous pneumothorax (PSP). We performed a retrospective analysis of the efficacy of simultaneous bilateral resection of pulmonary bullae using VATS in 21 PSP patients that were treated at our hospital from February 2010 to August 2013. We found bilateral bullae in all patients through the intraoperative exploration. Surgical procedures were successfully completed in all patients without conversion to thoracotomy. The mean time of surgery was 128.76 ± 13.82 min (range 100–150 min). Total amount of intraoperative bleeding was 80–200 ml. Total drainage of bilateral thoracic ducts was 200–500 ml at the 1st postoperative day with a mean drainage of 321.42 ± 82.66 ml. Bilateral thoracic ducts were removed 4–8 days postoperatively with a mean time of 4.7 days. The duration of postoperative hospitalization was 5–9 days with a mean duration of 7 days. No patient had serious complication(s) and all patients were discharged after full recovery. The patients were followed up for 6–18 months after the surgery and no relapse occurred. In conclusion, treating the unilateral PSP by simultaneous bilateral VATS is safe and effective. It reduces patients’ risk of second surgery and also minimizes patients’ suffering and costs incurred.

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.

Promoter methylation is not associated with FLCN irregulation in lung cyst lesions of primary spontaneous pneumothorax

Germline mutations in FLCN are responsible for ~10% of patients with primary spontaneous pneumothorax (PSP), characterized by multiple lung cysts in the middle/lower lobes and recurrent pneumothorax. These clinical features are also observed in a substantial portion of patients with sporadic PSP exhibiting no FLCN coding mutations. To assess the potential underlying mechanisms, 71 patients with PSP were selected, including 69 sporadic and 2 familial cases, who bared FLCN mutation‑like lung cysts, however, harbored no FLCN protein‑altering mutations. Notably, in a significant proportion of the patients, FLCN irregulation was observed at the transcript and protein levels. Genetic analyses of the cis‑regulatory region of FLCN were performed by sequencing and multiplex ligation‑dependent probe amplification assay. No inheritable DNA defect was detected, with the exception of a heterozygous deletion spanning the FLCN promoter, which was identified in a family with PSP. This mutation caused a reduction in the expression of FLCN in the lung cysts. Pedigree analysis demonstrated that haploinsufficiency of FLCN was pathogenic. To determine whether epigenetic mechanisms may be involved in the irregulation of FLCN, the promoter methylation status was measured in the remainder of the patients. No evidence of FLCN promoter methylation was demonstrated. The present study suggested that FLCN irregulation in lung cysts of PSP is not associated with promoter methylation.

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.

Video-thoracoscopic enucleation of esophageal leiomyoma

BACKGROUND

Leiomyoma is the most common benign tumor of the esophagus. Surgical enucleation is indicated in case of symptoms or an unclear diagnosis, and open thoracotomy has long been the standard approach for this procedure. However, enucleation through video assisted thoracoscopic surgery (VATS) has been developed as a preferred approach for most lesions in recent years.

METHOD

Herein we report our twelve patients (seven men and five women, with median age of 42 years) from 2001 to 2009, who underwent enucleation through VATS for esophageal leiomyomas, with a size from 1 to 8 cm in diameter (median: 5), and at different locations, from the thoracic outlet to near the diaphragmatic level of the thoracic esophagus. Intraoperative fiberoptic esophagoscopy was performed in two patients for localization by illumination. A right-sided approach was performed in eight cases (upper two thirds of esophagus) and the left-sided in another four cases (lower third of esophagus).

RESULT

The median operative time was 95 minutes (70 to 230 minutes). Four of them required small utility incisions (4-6 cm) for better exploration and manipulation. There were no major complications, such as death or empyema due to leaks from mucosal tears, and the presenting symptoms were improved during the follow-up period, from 12 to 98 months.

CONCLUSION

VATS can be considered as an initial approach for most patients with esophageal leiomyomas, even large in size, irregular in shape, or at unfavorable location. It is a safe, minimally invasive, and effective treatment. However, conversion to open thoracotomy should be required for the sake of clinical or technical concern.

Review: Diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) commonly occurs in tall, thin, adolescent men. Though the pathogenesis of PSP has been gradually uncovered, there is still a lack of consensus in the diagnostic approach and treatment strategies for this disorder. Herein, the literature is reviewed concerning mechanisms and personal clinical experience with PSP. The chest computed tomography (CT) has been more commonly used than before to help understand the pathogenesis of PSP and plan further management strategies. The development of video-assisted thoracoscopic surgery (VATS) has changed the profiles of management strategies of PSP due to its minimal invasiveness and high effectiveness for patients with these diseases.

Video-assisted thoracoscopic surgery (VATS) for the treatment of hepatic hydrothorax: report of twelve cases

BACKGROUND

Hepatic hydrothorax is defined as a significant pleural effusion in patients with liver cirrhosis and without underlying cardiopulmonary diseases. Treatment of hepatic hydrothorax remains a challenge at present.

METHODS

Herein we share our experiences in the treatment of 12 patients with hepatic hydrothorax by video-assisted thoracoscopic surgery (VATS). Repair of the diaphragmatic defects, or pleurodesis by focal pleurectomy, talc spray, mechanical abrasion, electro-cauterization or injection was administered intraoperatively, and tetracycline intrapleural injection was used postoperatively for patients with prolonged (>7 d) high-output (>300 ml/d) pleural effusion.

RESULTS

Out of the 12 patients, 8 (67%) had uneventful postoperative course and did not require tube for drainage more than 3 months after discharge. In 4 (33%) patients the pleural effusion still recurred after discharge due to end-stage cirrhosis with massive ascites.

CONCLUSION

We conclude that the repair of the diaphragmatic defect and pleurodesis through VATS could be an alternative of transjugular intrahepatic portal systemic shunt (TIPS) or a bridge to liver transplantation for patients with refractory hepatic hydrothorax. Pleurodesis with electrocauterization can be an alternative therapy if talc is unavailable.

Value of video-assisted thoracoscopic surgery in the diagnosis and treatment of pulmonary tuberculoma: 53 cases analysis and review of literature

Tuberculoma of the lung is one of manifestations in tuberculosis and usually presents as a solitary pulmonary nodule (SPN). It is difficult to differentiate tuberculoma from SPN by other benign or malignant diseases. At present, the crucial role of video-assisted thoracoscopic surgery (VATS) in diagnosis and treatment of pulmonary diseases has been well acknowledged. Here, we reported 53 patients undergoing VATS resection for tuberculomas in our series. No postoperative mortality was found and only two patients experienced prolonged air-leakage (>7 d) and two had minor wound infections that were recovered after anti-tuberculosis or antibiotic treatment. Anti-tuberculosis chemotherapy from 6 to 12 months was routinely used postoperatively. We conclude that VATS is a satisfactory tool for the diagnosis and treatment of tuberculoma and can also establish a reliable diagnosis for all patients with SPNs.