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Ann Thorac Surg 1997;63:1830-1831
© 1997 The Society of Thoracic Surgeons
Department of Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Matteo, University of Pavia, 27100 Pavia, Italy
To the Editor:
In the era before video surgery, bullectomy and apical parietal pleurectomy via minithoracotomy (transaxillar) access as popularized by Deslauriers and colleagues [1] was the most widespread method of treating recurrent pneumothorax. Many authors concordantly reported near 0% recurrence rates with this treatment. The recurrence of the pneumothorax with this procedure is precluded by the apical parietal pleurectomy [1], which invariably results in firm pleurodesis; thus even if bullous disease is incompletely resected at time of the operation, complete pneumothorax cannot develop thereafter.
Video-assisted mini-invasive bullectomy with or without pleurectomy or other pleurodesis maneuvers has become increasingly popular and is now the most frequent indication for video-assisted thoracic surgery (VATS). However the recurrence rate with this approach has been constantly reported to be significant (1.7% to 11% [2, 3]) and certainly higher than that reported after open treatment. Although the recurrence rate of all techniques is within the limits (0% to 12%) of reasonably acceptable surgical procedures, recurrence of pneumothorax after surgical treatment has some special implications, at least in a particular but consistent subset of pneumothorax patients, that of teenagers with apical or marginal blebs.
In these patients psychological factors rather than objective health impairment are frequently the true motivation for seeking surgical treatment. The psychological limitations of normal physical activity and sport caused by the possibility of the recurrence together with the necessity of medical advice or roentgenograms at any minor chest pain are frequent complaints. The conditions imposed in planning travel in geographic areas with suboptimal medical facilities may also be felt as a strong restriction by some subjects.
The benign nature of the pneumothorax and its recurrence in this setting is easily recognized by physicians and pneumologists who in fact became enthusiastic supporters of VATS, allowing them to avoid directing the patient to formal thoracotomy, a procedure often thought to be disproportionate to the benign nature and course of the underlying disease. This benignity, however, may not be so easily appreciated by the patients, at least on the psychological plane. The theoretical possibility of simultaneous complete bilateral occurrence further challenges the psychological equilibrium of the patient and his or her relatives. In our experience most patients asked for surgical treatment after the first or second episode had already been successfully treated and tube drainage removed. It seems clear that the psychological disturbance due to the possibility of unpredictable recurrence of pneumothorax dominates the discomfort due to the pneumothorax itself.
It is obvious that any treatment that does not offer a 0% recurrence rate in these patients is unsatisfactory and does not fit with their demands. In fact, the advantage offered by a treatment with an expected recurrence rate of 5% (VATS) versus 10% to 20% with no treatment at all may not be appreciated by these patients at a psychological level. The only way to regain full psychological freedom of activity and movement is a treatment that has an expected 0% recurrence rate.
It is to be hoped that increasing experience in VATS procedures that include effective pleurodesis maneuvers [4] will in the future achieve the same results attained by open transaxillar bullectomy and pleurodesis, at least in the selected group of young patients with localized blebs or bullae in otherwise normal lung. The indication for bilateral treatment should also be considered, in selected cases, within this final goal of a 0% recurrency rate.
References
This article has been cited by other articles:
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  C. Rossella, P. Buniva, A. Aluffi, and S. Nazari Simultaneous Bilateral Apical Bullectomy Through Access From Only One Side Ann. Thorac. Surg., March 1, 2005; 79(3): 1098 - 1098. [Full Text] [PDF]
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 S. Nazari, P. Buniva, A. Aluffi, and S. Salvi Bilateral open treatment of spontaneous pneumothorax: a new access Eur. J. Cardiothorac. Surg., November 1, 2000; 18(5): 608 - 610. [Abstract] [Full Text] [PDF]
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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]
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