| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1996;61:1510-1512
© 1996 The Society of Thoracic Surgeons
Department of Thoracic and Cardiovascular Surgery, Ewha Womans University, Mokdong and Dongdaemoon Hospital, Seoul, Republic of Korea
Accepted for publication February 5, 1996.
 |
Abstract |
|---|
 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
|---|
Methods. Sixty-six patients, aged 13 to 81 years, with recurrent, persistent or contralateral spontaneous pneumothorax were involved in this study. Thirty-six patients were treated by VATS and 30 by TAMT. The operating time, the amount of analgesics used on the first postoperative day, the duration of the indwelling chest tube, and the number of recurrences after operation were compared. The follow-up periods of both procedures were from 6 to 24 months.
Results. Of the 66 patients, 64 were male and 2 were female. The duration of operation, from start of skin incision to insertion of chest tube, was 91.2 ± 36.8 minutes in VATS and 86.3 ± 40.9 minutes in TAMT (p = 0.6061). The amount of analgesics (keptoprofen) used was 1.9 ± 2.3 ampules in VATS and 2.1 ± 2.9 ampules in TAMT (p = 0.0883). The duration of indwelling chest tube was 5.0 ± 4.0 days in VATS and 4.3 ± 2.1 days in TAMT (p = 0.3707). The number of recurrences after operation was 4 in VATS and none in TAMT.
Conclusions. There were no advantages of VATS over TAMT for management of recurrent, persistent, or contralateral spontaneous pneumothorax in regard to the operating time, the amount of analgesics used on the first postoperative day, the duration of the indwelling chest tube, and the number of postoperative recurrences in patients with apical bullae.
|
Introduction |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
|
Patients and Methods |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
Preoperative study included chest radiography and computed tomography of the chest for complete localization of the apical bullae in patients who were suspected of having secondary pneumothorax. Preoperative pulmonary function test was not carried out because we thought the result would be meaningless due to pain from the indwelling chest tube or air leakage through the tube. Video-assisted thoracic surgery was performed by one surgeon (K.H.K.) and TAMT by two surgeons (K.H.K. and S.S.C.).
Operative Procedures of VATS
Under general anesthesia the patients were intubated with a double-lumen endotracheal tube. The patients were prepared and draped as for thoracotomy. Contralateral single-lung ventilation was started and three 1.5-cm skin incisions were made; only two skin incisions were made for the patients who already had an inserted chest tube, and the chest tube insertion site was used for a port. A 10-mm videothoracoscope (Karl Storz, Tuttlingen, Germany) was introduced via a 12-mm trocar. Bullae were identified. They were grasped with the endobabcock and excised with a 30-mm Endo-GIA stapling device (United States Surgical Corp, Norwalk, CT). Mechanical pleurodesis was done by scrubbing the apical pleura with a sponge-on-a-stick. A 32F chest tube was inserted through the skin incision in the most dependent position.
Operative Procedures of TAMT
The anesthesia and preparation for the patients were the same as for VATS. However, the patient's arm was extended upward higher than for VATS and the axilla was exposed. A 5- to 7-cm skin incision was made along the lower margin of the axillary fold. The pleural cavity was entered through the third intercostal space between the latissimus dorsi and pectoralis major muscles. The intercostal space was widened by applying two small retractors. The bullae were clamped by the lung kelley clamp and divided, and the lung was sutured with chromic 3-0 catgut using continuous running sutures. Mechanical pleurodesis was done on the apical parietal pleura. A 32F chest tube was inserted through another stab wound at the seventh or eighth intercostal space.
Postoperative Care
All patients were extubated in the operating room and transferred to the general ward. Antibiotics were administered to all patients. Keptoprofen (nonsteroidal analgesic) was administered intramuscularly every 4 to 6 hours according to the patient's request, and oral analgesics (choline magnesium trisalicylate, acetaminophen, piroxicam, or a combination of these) were given from the first postoperative day until removal of the chest tube. The criteria for removal of the chest tube were no air leakage through the tube, no evidence of collapse of the lung on chest radiography, and less than 50 to 100 mL of drainage through the tube for 24 hours with minimal fluctuation of fluid level in the chest tube on coughing or deep breathing. All patients were discharged the day after removal of the chest tube.
Postoperative Assessment
The operating time, the amount of analgesics used on the postoperative first day, the duration of the chest tube indwelling, and the rate of recurrence after operation were assessed. The operating time was from the start of the skin incision to insertion of the chest tube. The amount of analgesics used was measured as the total ampules of ketoprofen (ampule-100 mg or 2 mL) on the first postoperative day. The follow-up chest roentgenogram was done in the outpatient division after discharge at intervals of 1 week, 3 weeks, and 3 months, and then the patients were followed up with telephone communication for this study 6 to 24 months postoperatively. The recurrence was proved by chest radiography during the follow-up period.
Statistical analysis was done by Student's t test. The statistical significance of differences between two groups was accepted for any p value less than 0.05.
|
Results |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
. Of the 66 patients, 64 were male and only 2 were female; age ranged from 13 to 81 years. Sixty-two patients were diagnosed as having primary SP and 4 had secondary SP. The indications for operation were recurrent SP in 50, persistent in 12, and contralateral in 4 patients. Thirty-six patients were treated by VATS and 30 by TAMT. The duration of operation was 91.2 ± 36.8 minutes in VATS and 86.3 ± 40.9 minutes in TAMT (p = 0.6061). The amount of analgesics used was 1.9 ± 2.3 ampules in VATS and 2.1 ± 2.9 ampules in TAMT (p = 0.0883). The duration of chest tube indwelling was 5.0 ± 4.0 days in VATS and 4.3 ± 2.1 days in TAMT (p = 0.3707). No cases were converted from VATS to thoracotomy or TAMT to full thoracotomy. There were no complications such as bleeding, empyema, or myocardial infarction after operation. There were no lost cases during the follow-up period. There were 4 recurrences after VATS and none after TAMT. Three cases that recurred 1 week, 5 months, and 6 months later were treated conservatively. The remaining case recurred at 2 weeks after VATS and was treated by limited posterolateral thoracotomy; the cause of the recurrence was the remaining bulla. There were no differences in clinical results between the two groups. However, the TAMT group showed less operating time and a shorter chest tube indwelling period, although these were not statistically significant.
|
|
Comment |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
The bullae are usually located on the apical portion of the upper lobe in patients with SP. They are easily approached through TAMT. The reports by Deslauriers and associates [9], Chung and colleagues [10], and Murray and associates [11] showed excellent results by this approach. We compared the two procedures, and our results showed no advantages of VATS over TAMT.
We think TAMT has advantages when compared with VATS. First, the cost of TAMT is less than that of VATS because it does not require any special instruments and disposables. Molin and associates [12] reported the operating room cost for VATS was significantly greater than that of limited thoracotomy in patients undergoing lung biopsy for interstitial lung disease despite the use of nondisposable equipment. In the Republic of Korea our medical insurance association has put a limit on covering the cost of disposables used; they are paid for in part by the patients. Thus the cost of VATS is higher than that of TAMT. Second, TAMT is cosmetically excellent. The small incision on the axilla is hidden when the arm is in the neutral position. The scars of VATS, however, are usually visible directly, although they are small. Third, although the pain caused by TAMT is a problem in the postoperative period because TAMT causes pain from incisional trauma and from spreading the intercostal space by rib spreaders, the use of analgesics after TAMT and VATS is similar. We did not study chronic pain in the late postoperative period, but we think the pain would be similar to that of VATS as suggested by Landreneau and associates' [13] study of chronic pain.
However, TAMT has a limitation in exposing the operative fields. If the bullae are not located on the apical part of the upper lobe, bullectomy is difficult through TAMT. In contrast, VATS has almost no limitation in exposing the lesions on the middle or lower lobe. Before performing TAMT, therefore, careful case selection should be followed. Younger patients with primary SP usually have causes of SP on the upper lobe, and so routine chest radiography is enough for doing TAMT. Computed tomography of the chest is needed in older patients with secondary SP before doing TAMT to localize the bullae on the apical portion of the lung.
Our patient group was small in number, and the patients were not randomized to one or the other group. However, our cases were limited to young patients with primary pneumothorax or older patients with apical bullae that were comfirmed preoperatively by computed tomography of the chest. The choice for doing TAMT or VATS was decided by patients themselves. Two surgeons performed TAMT and one surgeon performed VATS. We think that the technical aspects of the two procedures were similar. We therefore think the operators' personal bias in choosing and doing the procedures was nearly eliminated.
In conclusion, there are no advantages of VATS over TAMT in the operating time, use of analgesics, duration of chest tube indwelling, and postoperative recurrence in managing SP with the apical bulla. We think the clinical results of TAMT are as good as those of VATS in managing SP when careful case selection is done.
|
Footnotes |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
|
References |
|---|
|
TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  K. M. Ryu, P. W. Seo, S. Park, and J.-W. Ryu Complete atelectasis of the lung in patients with primary spontaneous pneumothorax. Ann. Thorac. Surg., March 1, 2009; 87(3): 875 - 879. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Qureshi, A. Nugent, J. Hayat, M. Qureshi, and R. Norton Should surgical pleurectomy for spontaneous pneumothorax be always thoracoscopic? Interactive CardioVascular and Thoracic Surgery, August 1, 2008; 7(4): 569 - 572. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Yamada, K. Yoshino, and H. Inoue Simultaneous Bilateral Spontaneous Pneumothorax With Pleural Window Communicating With Bilateral Pleural Spaces Ann. Thorac. Surg., April 1, 2008; 85(4): 1434 - 1436. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K.-D. Cho, C.-B. Park, M.-S. Cho, U. Jin, D.-G. Cho, and C.-K. Kim Modification of Thoracoscopic Surgery for Spontaneous Pneumothorax Asian Cardiovasc Thorac Ann, December 1, 2006; 14(6): 472 - 475. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J-M. Tschopp, R. Rami-Porta, M. Noppen, and P. Astoul Management of spontaneous pneumothorax: state of the art. Eur. Respir. J., September 1, 2006; 28(3): 637 - 650. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. L. Freixinet, E. Canalis, G. Julia, P. Rodriguez, N. Santana, and F. R. de Castro Axillary thoracotomy versus videothoracoscopy for the treatment of primary spontaneous pneumothorax Ann. Thorac. Surg., August 1, 2004; 78(2): 417 - 420. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Gotoh, T. Okamoto, Y. Yamamoto, D. Liu, K. Kameyama, E. Hayashi, C.-L. Huang, and H. Yokomise Development of a canine model of pulmonary emphysema and imaging of the emphysematous lung with infrared thoracoscopy J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1916 - 1921. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Van Schil Cost analysis of video-assisted thoracic surgery versus thoracotomy: critical review Eur. Respir. J., November 1, 2003; 22(5): 735 - 738. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M Henry, T Arnold, and J Harvey BTS guidelines for the management of spontaneous pneumothorax Thorax, May 1, 2003; 58(90002): ii39 - 52. [Full Text]
|
|
|
|
|
|
J.-S. Chen, H.-H. Hsu, S.-W. Kuo, P.-R. Tsai, R. J. Chen, J.-M. Lee, and Y.-C. Lee Needlescopic versus conventional video-assisted thoracic surgery for primary spontaneous pneumothorax: a comparative study Ann. Thorac. Surg., April 1, 2003; 75(4): 1080 - 1085. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Lang-Lazdunski, O. Chapuis, P.-M. Bonnet, F. Pons, and R. Jancovici Videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax: long-term results Ann. Thorac. Surg., March 1, 2003; 75(3): 960 - 965. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Sawabata, M. Ikeda, A. Matsumura, H. Maeda, S. Miyoshi, and H. Matsuda New Electroablation Technique Following the First-Line Stapling Method for Thoracoscopic Treatment of Primary Spontaneous Pneumothorax Chest, January 1, 2002; 121(1): 251 - 255. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Torresini, M. Vaccarili, D. Divisi, and R. Crisci Is video-assisted thoracic surgery justified at first spontaneous pneumothorax? Eur. J. Cardiothorac. Surg., July 1, 2001; 20(1): 42 - 45. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. T. Kim, K. H. Kim, Y. H. Yoon, W. K. Baek, and H. K. Lim A 2-mm Videothoracoscopic Incision for Primary Spontaneous Pneumothorax Asian Cardiovasc Thorac Ann, March 1, 2001; 9(1): 27 - 30. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. H. Baumann, C. Strange, J. E. Heffner, R. Light, T. J. Kirby, J. Klein, J. D. Luketich, E. A. Panacek, and S. A. Sahn Management of Spontaneous Pneumothorax : An American College of Chest Physicians Delphi Consensus Statement Chest, February 1, 2001; 119(2): 590 - 602. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Lang-Lazdunski, X. de Kerangal, F. Pons, and R. Jancovici Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy Ann. Thorac. Surg., August 1, 2000; 70(2): 412 - 417. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. K. Ayed and H. J. Al-Din The Results of Thoracoscopic Surgery for Primary Spontaneous Pneumothorax Chest, July 1, 2000; 118(1): 235 - 238. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. A. Sahn and J. E. Heffner Spontaneous Pneumothorax N. Engl. J. Med., March 23, 2000; 342(12): 868 - 874. [Full Text] [PDF]
|
|
|
|
|
|
G. Massard, P. Thomas, and J.-M. Wihlm Minimally invasive management for first and recurrent pneumothorax Ann. Thorac. Surg., August 1, 1998; 66(2): 592 - 599. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Passlick, C. Born, K. Haussinger, and O. Thetter Efficiency of Video-Assisted Thoracic Surgery for Primary and Secondary Spontaneous Pneumothorax Ann. Thorac. Surg., February 1, 1998; 65(2): 324 - 327. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Nazari Psychological Implications in the Surgical Treatment of Pneumothorax Ann. Thorac. Surg., June 1, 1997; 63(6): 1830 - 1831. [Full Text]
|
|
|
|
|
|
R. M. Becker, K. H. Kim, and J. T. Kim Transaxillary Minithoracotomy for Spontaneous Pneumothorax Ann. Thorac. Surg., December 1, 1996; 62(6): 1887 - 1887. [Full Text]
|
|
|
|
|
|
A. P. C. Yim and K. H. Kim Transaxillary Minithoracotomy for Spontaneous Pneumothorax Ann. Thorac. Surg., December 1, 1996; 62(6): 1887 - 1888. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
