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Ann Thorac Surg 1998;65:324-327
© 1998 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Efficiency of Video-Assisted Thoracic Surgery for Primary and Secondary Spontaneous Pneumothorax

Division of Thoracic Surgery and Pulmonary Medicine, Central Hospital Gauting, Gauting, Germany

Accepted for publication August 6, 1997.

Dr Passlick, Division of Thoracic Surgery, Department of Surgery, Klinikum Innenstadt, University of Munich, Nussbaumstrasse 20, 80336 Munich, Germany.

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
Background. The objective of the study was to analyze the efficiency of video-assisted thoracic surgery (VATS) for the treatment of primary (PSP) or secondary (SSP) spontaneous pneumothorax in an initial series of 99 patients.

Methods. From April 1992 to December 1995, 74 men and 25 women with a median age of 31 years (range, 17 to 85 years) were treated by VATS for persistent (n = 40) or recurrent (n = 59) PSP (n = 65) or SSP (n = 34). Postoperative parameters such as use of analgesics, length of hospital stay, and duration of drainage were compared with those of a control group of 100 patients treated by lateral thoracotomy between January 1988 and December 1991.

Results. Conversion to lateral thoracotomy was necessary in 6 (9.2%) patients with PSP and in 10 (29.4%) patients with SSP, in most cases because of adhesions. Postoperative complications occurred in 1 (1.7%) patient with PSP and in 6 (25%) patients with SSP. There were no operative deaths. After a median follow-up period of 29 months, 4 (4.8%) recurrences were noted. All recurrences occurred in patients with PSP and during the first year of our experience. Compared with lateral thoracotomy, treatment by VATS resulted in a significantly shorter hospital stay and drainage duration in patients with PSP but not in patients with SSP. The use of analgesics was reduced in all patients treated by VATS independent of the type of pneumothorax.

Conclusions. Surgical treatment by VATS is a viable alternative to lateral thoracotomy in patients with PSP. The usefulness of VATS in patients with SSP remains to be defined.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Spontaneous pneumothorax can be subdivided into primary spontaneous pneumothorax (PSP), which results from the rupture of a subpleural bleb when the underlying lung is otherwise normal, and secondary spontaneous pneumothorax (SSP), in which the air leak is related to the presence of an underlying disease (eg, bullous emphysema, histiocytosis, lymphangioleiomyomatosis) [1] [2]. Patients who have recurrent pneumothorax or persistent air leaks after drainage therapy are candidates for surgical therapy.

The aims of surgical treatment are closure of the air leak and pleurodesis, and these are achieved in most institutions by parietal pleurectomy or pleural abrasion [2] [3] [4]. The surgical approach to the thoracic cavity consists of an anterolateral or axillary thoracotomy. To reduce thoracotomy-related morbidity and mortality, the use of video-assisted thoracic surgery (VATS) has been advocated by several authors [2] [4] [5]. Although the reported results for patients with PSP who are treated thoracoscopically compare favorably to those of patients who are treated by thoracotomy, the role of the thoracoscopic approach for patients with SSP is still unclear [1] [2] [6]. Therefore, we performed a retrospective study comparing the efficiency of VATS in patients with PSP or SSP in an initial series of 99 patients from a single institution. For comparison of postoperative and long-term results, we also analyzed the results of patients treated by lateral thoracotomy during a period before VATS was introduced in our department.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Patients and Criteria of Evaluation
This retrospective study was performed on an initial series of 99 consecutive patients with PSP or SSP who were treated primarily by VATS (VATS group) between April 1992 and December 1995. All hospital charts were reviewed and analyzed according to the following parameters: preoperative data (sex, age, underlying disease, smoking history, length of preoperative hospital stay, preoperative treatment modalities, number of previous recurrences); intraoperative findings (number and site of pathologic findings, blood loss, operation time, conversion rate), and postoperative parameters (complications, length of hospital stay, drainage duration, analgesic use).

This series included 74 male and 25 female patients with a median age of 31 years (range, 17 to 85 years). In 48 (48.5%) patients, the pneumothorax was located on the left side, in 50 (50.1%) patients, it was located on the right side, and in 1 (1%) patient, it was located on both sides. Among the 65 patients who had PSP (median age, 28 years; range, 17 to 53 years), 20 (30.8%) presented with a persistent pneumothorax (air leakage for more than 5 days) and 45 (69.2%) with a recurrent ipsilateral pneumothorax (first ipsilateral recurrence: n = 14; second: n = 16, third: n = 9, fourth: n = 6). The causes of SSP in the remaining 34 patients (median age, 60 years; range, 27 to 85 years) included emphysema (n = 24), tuberculosis (n = 1), malignancy (n = 5), lymphangioleiomyomatosis (n = 1), and fibrosis (n = 3). Twenty (58.8%) of these patients had a persistent pneumothorax and 14 (41.2%) were operated on for a recurrent episode (first ipsilateral recurrence: n = 8; second: n = 2, third: n = 2, fourth: n = 2). Conversion to thoracotomy was defined as any additional incision or any extension of the usual trocar incisions.

For evaluation of long-term results and recurrence rates, questionnaires were sent to all patients. Patients who did not respond were contacted by telephone. Complete information was obtained from 93 (93.9%) of 99 patients. Six (6.1%) patients were lost to follow-up. Eight patients (all with SSP) died within the observation period (median, 29 months; range, 3 to 47 months) of cardiopulmonary disease (n = 5) or cancer (n = 3).

For comparison of postoperative parameters, we retrospectively analyzed in the same manner a historical control group of 100 consecutive patients with PSP (n = 57) or SSP (n = 43) who were treated between January 1988 and December 1991 by lateral thoracotomy (thoracotomy group). There were no statistically significant differences between the thoracotomy group and the VATS group with respect to basic demographic data (ie, age, sex) or specific disease-related parameters (ie, number of previous recurrences, underlying diseases in case of SSP, length of preoperative hospital stay). Follow-up information was obtained from 91 of 100 patients.

Operative Technique
All procedures were performed under general anesthesia using a double-lumen tube to allow single lung ventilation. The patients were placed in a lateral position.

In the VATS group, a 10-mm trocar was introduced through the sixth intercostal space in the midaxillary line just anterior to the latissimus dorsi for the insertion of a 0-degree endoscope. Two additional ports then were inserted under direct vision: a 12-mm trocar through the fifth intercostal space on the mammary line and a 5-mm trocar posteriorly through the fifth or sixth intercostal space. The lung then was displaced gently with round-tipped instruments to look for bullae or other pathologic findings from its apex to its base. Warm saline solution was instilled during slight pulmonary ventilation to identify the site of the air leak. Bullae were identified in 72 (72.7%) patients. They were located in the upper lobes (including the lingula on the left side and the middle lobe on the right side) in 63 (87.5%) patients and in the lower lobes in 2 patients and they were generalized in 7 (9.7%) patients. In 83 patients, the procedure was completed successfully by VATS. Lesions were resected with an endoscopic linear stapler (Endo-GIA 30; Auto Suture, Tönisvorst, Germany) in 75 of these patients and with an endoscopic loop alone in 3 patients, and pleurodesis only was performed in 5 patients. When no blebs were visible, a small portion of the apical upper lobe was resected to obtain lung tissue for histopathologic examination. The median number of stapler cartridges used per patient was two (range, two to eight cartridges).

Pleurodesis was performed by pleural abrasion using a swab mounted to the tip of a standard curved dissector. In addition, in 34 patients (PSP: 28 patients, SSP: 6 patients), a partial parietal pleurectomy from the apex to the fifth or sixth intercostal space was done. At the end of the procedure, one 28F drain was inserted through the middle port site; the other port sites were closed in two layers. Suction with a negative pressure of 15 cm of H₂O was applied for at least 24 hours or until the air leak stopped.

In the thoracotomy group, the surgical incision was extended from the latissimus dorsi to the mammary line. The thoracic cavity was entered through the fifth intercostal space. Blebs were identified in 73 patients and were resected using a TA 55 or a reloadable GIA 50 stapler (Auto Suture), or the bullous area was clamped and resected and the defect was hand-sutured with Vicryl 3.0 sutures (Ethicon, Norderstedt, Germany). Pleurodesis was performed by mechanical pleural abrasion using gauze. In 18 patients, a partial parietal pleurectomy was done. Two drains (32F and 28F) were placed through the seventh or eighth intercostal space at the end of the procedure. The same criteria as used for the patients in the VATS group were applied for the removal of the drains.

Statistical Analysis
Differences in the relative frequency of events were compared by a ² test or, when appropriate, Fisher’s exact test. Continuous variables were tested by a Wilcoxon rank-sum test. The level of confidence was defined at a p value of less than 0.05. All procedures were performed using the statistical software package SPSS (SPSS Software, Munich, Germany).

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Conversion to Thoracotomy
Extension of the trocar incisions or conversion to a limited lateral thoracotomy was necessary in 6 (9.2%) patients with PSP and in 10 (29.4%) patients with SSP (p = 0.001), in most instances because of massive adhesions (Table 1). In 1 patient with SSP, a large apical bulla was not resectable by VATS alone and required lateral thoracotomy to allow adequate overview. Bleeding at one of the trocar sites was controlled in 2 patients with PSP by minithoracotomy to allow direct visualization and electrocoagulation of the injured vessels. In 1 patient with SSP, massive bleeding from the subclavian artery resulted from electrocoagulation of a small pleural vessel in the vicinity of the artery and required an emergency thoracotomy.

Postoperative Results and Comparison With Lateral Thoracotomy
For analysis of postoperative parameters (use of analgesics, length of hospital stay, drainage duration, inability to work), the VATS group was compared with a historical control group of patients treated by lateral thoracotomy. In patients with PSP, the use of analgesics, the postoperative hospital stay, the drainage duration, and the inability to work were reduced significantly in the VATS group compared with the thoracotomy group (Table 3). In contrast, in patients with SSP, only the use of analgesics was reduced in patients after VATS (Table 4). All other parameters were not significantly different between the groups.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

Many surgical techniques have been described for closing air leaks and performing pleurodesis. In some centers, the fistula almost always is closed by wedge resection using an endoscopic stapler, whereas in others, the endoscopic loop technique, electrocoagulation or laser coagulation of blebs, or a combination of different methods is favored [1] [7] [8] [10] [11]. The techniques used to achieve pleurodesis vary greatly. A recent survey in Germany involving 19 institutions and 1,365 VATS operations for spontaneous pneumothorax revealed that the most frequent procedure was a (apical) parietal pleurectomy, followed by pleural abrasion, no pleurodesis, electrocoagulation of the pleura, fibrin glue, and insufflation of talcum [3]. The extreme variability of patient- and procedure-related parameters makes direct comparison of the various reports difficult. Previously, we tried to solve this problem by strictly dividing our patients into those with PSP and those with SSP. However, the current study has a retrospective design, which did not allow us to assess some specific parameters, such as the level of postoperative pain or the amount of analgesics used.

In our series of patients with PSP, we obtained acceptable short- and long-term results. There was only one postoperative complication in a patient with PSP, which was a prolonged air leak that stopped without further intervention on the 12th postoperative day. Compared with a historical control group of patients treated by lateral thoracotomy, the use of analgesics, the postoperative hospital stay, and the postoperative drainage duration were reduced in the VATS group, confirming the results of previous reports [2] [5] [7]. However, there were four recurrences in patients with PSP, all occurring in the first 18 postoperative months and during the first year of our experience. The second intervention in these patients revealed that the pleurodesis initially performed by pleural abrasion was incomplete. Therefore, we changed our policy and performed an apical parietal pleurectomy from then on. Thereafter, we observed no further recurrences. In the historical control group of patients with PSP, no recurrences were observed.

In this initial series of patients with PSP, we noticed a conversion rate to thoracotomy of 9.2%, which is relatively high compared with other reports [6]. However, this number includes patients who required small extensions of their incisions to control bleeding from the trocar sites, and it also might reflect the initial learning curve with this new technique.

Similarly, as in a recent report from a French group, the delay in return to occupational activity was comparatively long in our patients [2]. However, the difference in recovery time (3 weeks) between the VATS group and the thoracotomy group can be explained best by the improved comfort after VATS.

In contrast to patients with PSP, we currently cannot recommend VATS as the approach of choice in all patients with SSP. The presumed benefits of VATS (reduction of pain, shorter hospital stay, and shorter drainage duration) were less clear in patients with SSP (Table 4). Although we did not observe any recurrences after a successful video-assisted operation, we noticed postoperative complications in 25% of the patients with SSP (Table 2), which were due mainly to persistent air leaks. Similar results were obtained by Mouroux and colleagues [6], who reported a complication rate of 27.7%, and by Waller and associates [1], who reported a rate of primary treatment failure in patients with SSP of 26.6%. These numbers are relatively high compared with our thoracotomy group of patients with SSP, in whom we observed postoperative complications in only 3 (7%) patients (one persistent air leak, one case of postoperative bleeding, and one wound infection). Therefore, one can assume that the VATS approach is not applicable to all patients with SSP. In the future, the results might be improved by more careful selection of patients and by improvement of the surgical technique to prevent postoperative air leaks.

In conclusion, VATS is a valid alternative to open thoracotomy in patients with PSP that has a low complication rate and acceptable long-term results. In view of the high number of primary treatment failures, the VATS approach does not seem to be applicable to all patients with SSP.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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2. Bertrand PC, Regnard JF, Spaggiari L, et al. Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS. Ann Thorac Surg 1996;61:1641-1645.[Abstract/Free Full Text]
3. Hürtgen M, Linder F, Friedel G, Toomes H Video-assisted thoracoscopic pleurodesis. A survey conducted by the German Society for Thoracic Surgery. Thorac Cardiovasc Surg 1996;44:199-203.[Medline]
4. Liu HP, Lin PJ, Hsieh MJ, Chang JP, Chang CH Thoracoscopic surgery as a routine procedure for spontaneous pneumothorax. Results from 82 patients. Chest 1995;107:559-562.[Abstract/Free Full Text]
5. Nezu K, Kushibe K, Tojo T, Takahama M, Kitamura S Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax. Chest 1997;111:230-235.[Abstract/Free Full Text]
6. Mouroux J, Elkaim D, Padovani B, et al. Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases. J Thorac Cardiovasc Surg 1996;112:385-391.[Abstract/Free Full Text]
7. Naunheim KS, Mack MJ, Hazelrigg SR, et al. Safety and efficacy of video-assisted thoracic surgical techniques for the treatment of spontaneous pneumothorax. J Thorac Cardiovasc Surg 1995;109:1198-1203.[Abstract/Free Full Text]
8. Hazelrigg SR, Landreneau RJ, Mack M, et al. Thoracoscopic stapled resection for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1993;105:389-393.[Abstract]
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