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Ann Thorac Surg 1996;61:1641-1645
© 1996 The Society of Thoracic Surgeons
Department of Thoracic Surgery, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
Accepted for publication February 15, 1996.
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods. A series of 163 patients with primary spontaneous pneumothorax were treated by video-assisted thoracic surgery. Seventy patients were treated for a recurrent episode, 64 patients for a persistent primary spontaneous pneumothorax, 24 patients for a contralateral episode, and 5 patients for a bilateral primary spontaneous pneumothorax. Stapling of bullae with an Endo-GIA stapler (Auto-Suture, Elencourt, France) was performed in 90% of the cases and parietal pleural abrasion was performed in each case.
Results. One revisional lateral limited thoracotomy was required for bleeding. Six patients had a prolonged air leak; 2 of them were reoperated on by lateral limited thoracotomy. Two patients have had an incomplete reexpansion of the lung and required a reoperation. The duration of hospitalization was 6.9 ± 3 days. With a mean follow-up of 24.5 months, three recurrences requiring a reoperation occurred; 3 other patients had a partial recurrence and healed by rest without drainage. The mean time to return to the occupational activity of the patients was 42 ± 34 days. These results were compared with those of a previous series of 87 patients operated on by lateral limited thoracotomy.
Conclusions. With the development of surgical technique and video equipment, video-assisted thoracic surgery will probably become the treatment of choice of primary spontaneous pneumothorax.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Spontaneous pneumothorax (SP) is a fairly common disorder with an age-adjusted incidence of 7.4 cases per 100,000 person-years for men and 1.2 cases per 100,000 person-years for women [1]. It may be subdivided into primary SP (PSP) resulting from the rupture of small bullae or blebs and secondary SP in which the lesion is related to the presence of an underlying lung disease (eg, major emphysema, hystiocytosis, lymphangiomatosis). The aims of treatment are to allow full reexpansion of the lung and to prevent recurrence. Rest and intercostal tube drainage of the pleural space are usually the methods of treatment of acute episodes. However, incomplete reexpansion of the lung and early recurrence may be as high as 25% [2, 3]. Surgical treatment of SP in the past was fairly straightforward: thoracotomy, suture of the leaking lung or bullae resection [4–6], and pleurectomy [4, 5] or pleural abrasion [6]. This was successful with a recurrence rate between 0.5% and 1% but had the obvious morbidity of a thoracotomy [4–6].
Recently, advances in thoracoscopic instrumentation (optics, instruments, endoscopic staplers) have led some authors [7–9] to modify the surgical approach. In fact, video-assisted thoracic surgery (VATS) allows the same procedures to be realized as through a thoracotomy: resection of bullous disease areas [7], pleural abrasion [8], and pleurectomy [9]. The aims of VATS in the treatment of SP are a decrease in the intensity of postoperative pain, a decrease in the duration of postoperative hospitalization, and an earlier return to occupational activity. Thus, if VATS is a logical and valid alternative in the treatment of this benign disease, the approach should have a morbidity rate (prolonged air leak, long-term residual pain) and a recurrence rate equal to or less than those seen in SP treatment through a thoracotomy.
Long-term results of the VATS approach are not well known. The aim of this report was to study these results on a large series and to compare them with a previous series of patients operated on by lateral limited thoracotomy (LLT).
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Technique
All procedures were performed under general anesthesia. The patients were placed in the lateral position and intubated using a double-lumen endotracheal tube (Carlens).
Three trocar introduction incisions (10, 10, and 12 mm) were performed. Correct positioning of these trocars is very important. After ventilation of the affected lung was blocked a first trocar was always inserted posteriorly between the latissimus dorsi and trapezius muscles in the sixth intercostal space, allowing the introduction of the camera. A 0-degree optical telescope was inserted and connected to a video camera, which made all endoscopic maneuvers visible on a video monitor. Under visual control two other incisions were performed after this introduction: one anteriorly on the thorax in the fourth intercostal space on the anterior axillary line and the other in the eighth or ninth intercostal space, according to the patient's morphology, to the point of the scapula. The lung surface was inspected, looking for bullae from its apex, which constitute the most common source of recurrent air leak to the basis. The lung could be gently displaced with round-tipped instruments to reveal all of its surface. The camera could be moved to any of the trocars to get better views of the remaining chest cavity. Instillation of serum into the pleural cavity followed by inflation of the lung greatly facilitated demonstration of the air leak. The resection of bullous disease was realized by 30-mm Endo-GIA staplers (Auto-Suture, Elencourt, France) and the parietal pleural abrasion by a plug of Marlex mesh on a clamp. No patient required a conversion to thoracotomy.
One hundred forty-six patients (90%) had at least one bullous area or bleb resected. The size of these bullae was between 0 and 2 cm in 105 cases (72%), between 2 and 5 cm in 29 cases (20%), and between 5 and 10 cm in 12 cases (8%). The number of staple cartridges per patient was 3.7 ± 1.7. If no bullous area was seen no pulmonary resection was performed.
At the end of this procedure, two 30F drains were inserted into the lateral and anterior incisions and connected to an underwater seal suction with a negative pressure of 20 cm H2O. The suction was continued for at least 3 days or until the air leak stopped. If a control chest roentgenogram showed no residual pneumothorax, the drains were removed and the following day the patient was discharged. All the patients were discharged with a 21-day rest.
Historical Comparison
For valid studying of postoperative results a comparison was made with 87 patients previously operated on by LLT (LLT group) for PSP between January 1, 1990, and October 31, 1991 (22 months). There were 20 women (23%) and 67 men (77%) aged 30.7 ± 11 years (range, 18 to 49 years). Thirty-eight patients (44%) were treated for a persistent PSP, 27 patients (31%) for a recurrent episode (mean, 2.3; range, 1 to 5), 19 patients (22%) for a contralateral PSP, and 3 patients (3%) for a bilateral PSP. We excluded patients with a secondary SP.
In this group the LLT was performed with the patient in the lateral position. The arm was elevated and fixed to the anesthetic screen crossbar. The surgical incision was extended from the latissimus dorsi to the external border of the pectoralis major. The chest cavity was entered through the fourth intercostal space. After exploration, the resection of bullous disease was performed with a TA 55 (Auto-Suture) and the parietal pleura was abraded with a sponge. Eighty-four patients (97%) had a bullous area resected. The size of the bullae was between 0 and 2 cm in 74 cases (85%) and between 2 and 5 cm in 13 cases (15%). The number of staple cartridges per patient was 1.9 ± 0.9. The same criteria as used for VATS group patients were applied for the removal of the drains and for the discharge of patients.
The two series were strictly comparable in terms of sex ratio, mean age, and surgical indications (Table 1
). All these patients were operated on by the same surgeons.
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Statistical Analysis
Comparability of the groups was checked by the 
test for quantitative variables expressed by mean and standard deviation and by the 
2 test for qualitative variables. Results were analyzed by these same tests. The level of confidence was defined at p less than 0.05. The freedom from recurrence was analyzed by the Kaplan-Meier method.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Postoperative Course
One patient (0.6%) required a revisional thoracotomy by LLT for bleeding at day 1. The cause of the bleeding was an excessive pleural abrasion. This patient required no blood products.
Six patients (3.6%) had a prolonged air leak (>7 days). Two patients were reoperated on by LLT at day 14 and day 22. The cause of the failure was a missed bullous area for the first patient and an air leak on the row of staples for the second patient. The course after the reoperation was uneventful for both patients, with a duration of postoperative drainage of 4 days. For the 4 other patients the second drain was removed on day 8 in 3 patients and on day 9 in 1 patient. No patient required a subsequent drainage after the removal of the second drain.
Two patients (1.2%) had incomplete reexpansion of the lung and had to be reoperated on by LLT (day 10 and day 12). During the reoperation an air leak was found on the row of the staples. After this reoperation no complication was noted, and the duration of the postoperative drainage was 5 days. No patient required monitoring in the intensive care unit. No intraoperative or postoperative death occurred. The duration of systematic postoperative drainage was 4.4 ± 1.5 days (range, 3 to 22 days). The duration of postoperative hospitalization was 6.9 ± 3.0 days (range, 5 to 28 days).
Late Follow-up
Three patients (1.8%) had recurrence requiring a reoperation. The postoperative course after the first surgical procedure was uneventful in 2 patients and complicated by a prolonged air leak for 9 days in the other patient. The time to reoperation was 1 month, 1 month, and 3 months. All reoperations were performed by LLT. During the reoperation the observed lesions were a missed bullous area on the lingula in 1 patient, an air leak on the row of the staples in 1, and only an inadequate pleural symphysis in 1. In every case these patients had an inadequate pleural symphysis despite the pleural abrasion. A partial recurrence occurred in 3 patients at 3, 8, and 28 months after the VATS procedure. These three recurrences healed with rest. The freedom from recurrence rate was 95% at 42 months (Fig 1). Table 2 compares the complications that occurred during the 19-month period of this series (revisional thoracotomy, prolonged air leak, incomplete reexpansion of the lung, and recurrence rates). Return to occupational activity occurred at 42 ± 34 days.
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Comparison With the Lateral Limited Thoracotomy Group
One patient required revisional thoracotomy, at day 4, for bleeding. There was 1 patient (1.1%) with a prolonged air leak; the second drain was removed at day 12. There was no incomplete reexpansion. The duration of systematic postoperative drainage (5.6 ± 1.7 days; range, 3 to 16 days) and the duration of postoperative hospitalization (10.3 ± 1.7 days; range, 5 to 30 days) were significatively longer (p < 0.001) than in the VATS group. The return to occupational activity (74 ± 60 days) was also significantly longer (p < 0.001) than in the VATS group.
The mean follow-up was 33 ± 10 months (range, 24 to 45 months). Eleven patients (12.6%) could not be reached.
One patient (1.1%) required a reoperation at 1 month for recurrence. The cause of failure was an inadequate pleural symphysis without obvious air leak. Fifty-three patients (61%) presented pain of the operated side. This pain was minimal in 65% of the patients, moderate in 33%, and severe in 2%. As in the VATS group 68% of the patients had diffuse pain and 32% had localized pain along the intercostal space. One patient also presented a discrete and transient ptosis. These results were not significantly different from those of the VATS group.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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In this retrospective series we could not study the impact of VATS on immediate postoperative pain and pulmonary dysfunction, but Waller and associates [10], in a prospective and randomized series, studied validly the immediate postoperative course. They showed a trend toward a lower postoperative analgesic requirement in patients treated by VATS. Thus, these patients were mobilized faster and had a shorter hospital stay. Furthermore, there was an important benefit of VATS over thoracotomy with a significant reduction in postoperative respiratory dysfunction (forced expiratory volume in 1 second and forced vital capacity). We confirmed a significant reduction in the duration of postoperative hospitalization; in addition, we demonstrated that the mean duration to return to occupational activity was significantly shorter in the VATS group than in the LLT group. However, in the VATS group we observed a slight increase in immediate reoperation rate in comparison with our previous experience of patients operated on by LLT. These findings confirmed several reports [9, 11, 12] in the recent literature.
In our series, 2 patients with a prolonged air leak and 2 patients with an incomplete reexpansion required a reoperation. The cause of the reoperation was either an air leak on the row of the staples (3 patients) or a bullous area unseen during the exploration by VATS (1 patient). This suggests inadequate treatment of the cause of the PSP. In the first 3 patients the suture line at the base of the bullae was probably not placed with a sufficient margin of healthy parenchyma. Thus, the resection of the bullous area has to be careful. To avoid air leak at the staple line Cooper and colleagues [13] proposed the use of bovine pericardial strips to buttress it for patients with diffuse emphysema. We routinely use these strips for operation of the emphysema but we did not use them in PSP. In some cases (numerous bullae) the strips may decrease the air leak, and selective use, considering the cost, may be justified in surgical management of PSP.
In the last patient the exploration by VATS was incomplete and a bullous area was missed. As a result, the three trocar introduction incisions have to be large enough (10 mm) to allow insertion of the camera to perform complete exploration of the pleural cavity under different angles. Furthermore, use of a 30-degree or a 60-degree optical telescope may improve the visualization of particular sites of the lung during VATS. In this way, preoperative computed tomography in fine cuts may help in the detection of the bullous disease [14] and in choosing the surgical procedure. This examination allows one to exclude patients with an underlying lung disease such as major emphysema. In fact, for these patients the results of VATS are less favorable than for PSP [10, 15].
The three recurrences that required a reoperation occurred within 3 months. The cause of the recurrences was first of all inadequate pleurodesis. These failures suggest that the pleural abrasion performed by VATS is less effective than by LLT. In our experience pleural abrasion has been the procedure of choice for pleurodesis for 20 years. We have chosen this procedure to decrease the postoperative bleeding related to pleurectomy [4, 5, 16] and to make easier a subsequent thoracotomy in these young patients. Pleural abrasion was very effective through an LLT; it seemed less effective through VATS. This is probably due to the lack of specific video equipment. In the future the development of technology may allow us to perform safer pleural abrasion. Analysis of our results showed that most of our failures (prolonged air leak, incomplete reexpansions of the lung, recurrences) were observed in the first 19-month period (see Table 2
). Although the difference between both periods did not reach a statistical signification, it is obvious that there is a learning curve for the surgeons using VATS. Once the surgeons are familiar with this method, bullectomy and pleural abrasion may be as effective as by LLT.
In case of reoperation it was performed by LLT because we were afraid to propose to the patients a reoperation by a procedure that has been a failure, and there is at least a partial symphysis that makes this second procedure by VATS more difficult.
Some series [9, 11, 12] showed that the long-term results after the VATS procedure are slightly less favorable than after LLT. In particular, Naunheim and associates [12] found a recurrence rate of 4.1% in a prospective, multicenter series of 113 patients operated on by bullous resection and pleural abrasion or pleurectomy or laser pleurodesis with a 13-month follow-up. In contrast, only Liu and colleagues [8] found no recurrence in 37 patients operated on by bullous resection and pleural abrasion with a 22-month follow-up. Datas in the literature [4–6] concerning surgical treatment of SP by thoracotomy with bullous disease resection and pleural abrasion or pleurectomy showed a recurrence rate requiring reoperation ranging between 0.5% and 1%. Thus, it seems that VATS is slightly less effective than LLT for the management of SP. To improve the results of the VATS procedure, efforts should be make to develop surgical techniques and video equipment (Endo-GIA stapling devices).
Late postoperative thoracic pain was observed with equal frequency in the two groups. Nevertheless, this pain was moderate and intermittent in more than 95% of patients, and fewer than a quarter of the patients required minor analgesic treatment (aspirin or paracetamol) for relief. These results of the VATS procedure are disappointing. In most cases, the cause of pain was probably injury of the intercostal nerve by the large trocars (10 mm or 12 mm). These trocars are essential for the use of the stapling devices. A great improvement would be to decrease the size of these stapling devices.
We were surprised by the long delay in return to occupational activity of the patients in both groups. In France, the delay in return to occupational activity unfortunately is long. However, the difference in recovery time (30 days) must be emphasized. Such a result can only be explained by the improved comfort due to management by VATS. Thus, we always recommended a 21-day rest from the day of patient exit. If the delay in return to occupational activity of patients in the LLT group was longer, it was probably related to slower recovery.
Further studies are necessary to definitively consider VATS as the treatment of choice of PSP. Video-assisted thoracic surgery is a recent procedure, and a period of learning is necessary to better determine selection criteria and to improve surgical procedure. Efforts should be made to develop video equipment to make the endoscopic procedures less invasive. With these improvements VATS will probably be the treatment of choice of PSP considering the decrease in the duration of hospitalization and earlier return to occupational activity, as well as the reduction in postoperative respiratory dysfunction.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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References |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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