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Ann Thorac Surg 1998;65:924-926
© 1998 The Society of Thoracic Surgeons

Thoracoscopic Operation for Secondary Pneumothorax Under Local and Epidural Anesthesia in High-Risk Patients

^a Department of Surgery II, Okayama University School of Medicine, Okayama, Japan

Accepted for publication November 12, 1997.

Address reprint requests to Dr Shimizu, Department of Surgery II, Okayama University School of Medicine, 2-5-1 Shikata-cho, Okayama-city, Okayama, 700-0914, Japan

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Video-assisted thoracic operations usually require single-lung ventilation under general anesthesia. However, for high-risk patients with other underlying pulmonary diseases, one has to consider risks of general anesthesia itself.

Methods. Four high-risk patients (4 men; mean age, 73 years) with intractable secondary pneumothorax and other underlying pulmonary diseases were treated by video-assisted thoracic operations under local and epidural anesthesia. Absorbable polyglycolic acid sheets and fibrin glue were used to control the air leakage.

Results. The mean duration of the procedure was 108 minutes. Pain and cough reflex were well controlled, and spontaneous breathing and hemodynamics were well maintained during the operation. The mean duration of the postoperative chest drainage was 5 days. No significant postoperative complication was encountered. No pneumothorax had recurred at a mean follow-up of 16 months.

Conclusions. Video-assisted thoracic operations can be performed safely under local and epidural anesthesia for the treatment of intractable secondary pneumothorax in high-risk patients. The air leakage can be controlled with the use of polyglycolic acid sheets and fibrin glue without bullectomy.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Video-assisted thoracic surgery has become a standard therapy for spontaneous pneumothorax. This operation is usually performed under general anesthesia and requires single-lung ventilation with a double-lumen endobronchial tube. This report covers a series of 4 high-risk patients who underwent videothoracoscopic surgical procedures under local and epidural anesthesia for the treatment of intractable secondary pneumothorax.

	Material and methods

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Patients
The preoperative characteristics of the patients are listed in Table 1.

Patient 2, a 72-year-old man, had development of left pneumothorax during steroid therapy for the treatment of bronchiolitis obliterans organizing pneumonia in November 1994. At the time of admission, 15 mg of prednisolone was given daily and chemical pleurodesis failed to stop the air leak. Computed tomographic scan demonstrated severe emphysema with multiple bilateral bullae.

In patient 3, a 76-year-old man who had been on home oxygen therapy due to severe emphysema, left pneumothorax developed in June 1995. He had had a past history of left pneumothorax and chemical pleurodesis. Computed tomographic scan demonstrated severe diffuse bullous emphysema with left apical dead space in spite of the chest tube placement. His arterial oxygen tension was 52.0 mm Hg on room air.

Patient 4, a 77-year-old man with a known history of pulmonary fibrosis, was sent to us for the treatment of left pneumothorax in March 1996. There was a significant left basal dead space with a massive air leakage from the chest tube. His arterial oxygen tension was 47.5 mm Hg under 2 L/min of oxygen administration. His forced vital capacity and forced expiratory volume in 1 second before developing pneumothorax were 1,460 mL and 1,250 mL, respectively.

All patients were sent to us with a chest tube in place. Pleurography was performed through the chest tube, and air leak sites were identified in all patients. The mean duration of preoperative chest drainage was 39 days (range, 22 to 49 days).

Anesthetic and surgical technique
A thoracic epidural catheter was placed immediately before the operation. Bupivacaine 0.26% (5 to 7 mL) was injected into the epidural space at induction and added as needed during the operation for analgesia. Intravenous sedation with fentanyl citrate (100 µg) or hydroxyzine hydrochloride (15 mg) was used when required. Patients maintained spontaneous breathing during the subsequent procedure, and oxygen was administered via a facial mask as needed. The patient was then positioned in a lateral decubitus position with the affected side up. After additional local anesthesia with 1% lidocaine, a thoracoscope was inserted via a port through the sixth intercostal space at the midaxillar line. The source of the air leak was identified, which often required the instillation of saline solution into the thorax, at the same location as seen on the pleurography in all 4 patients. Two further ports were placed anterior and posterior to the borders of the latissimus dorsi. Significant pleural adhesion was seen in all patients, and we avoided unnecessary dissection that might create additional air leakage. Aerosolized fibrin glue was injected into the hole of the leaking bulla. Then, the bulla was covered with a piece of polyglycolic acid sheet. Finally, we sprayed the sheet with aerosolized fibrin glue (Fig 1). In only 1 patient (patient 2), the leaking bulla was excised with an Endo-GIA (Auto Suture, Japan) fitted with strips of polyglycolic acid sheets. One intercostal drain was left in situ on low suction to a pressure of 10 cm H₂O.

View larger version (86K): [in this window] [in a new window]   Fig 1. Significant pleural adhesions were observed. The bulla was covered with a piece of polyglycolic acid sheet at the leakage point, and aerosolized fibrin glue was sprayed over it.

	Results

Top Abstract Introduction Material and methods Results Comment References

	Comment

Top Abstract Introduction Material and methods Results Comment References

Pain and cough were controllable by the local and epidural anesthesia in all 4 patients. Patients maintained spontaneous breathing, and the half-deflated lung provided a satisfactory view for the thoracoscopic operation. Preoperative pleurography was helpful in identifying the location of air leakage and pleural adhesion. Thus we could determine the best site for the first port and the level of the epidural catheter. There were no significant changes in blood pressure or arterial blood gas throughout the operation. Operative time exceeded 2 hours in 2 patients because of significant pleural adhesions; however, the operation was carried out safely by the administration of additional epidural anesthetic. Postoperatively, pain was well controlled with the use of epidural anesthesia, and diclofenac sodium suppository was also used as needed.

We used polyglycolic acid sheet and aerosolized fibrin glue to seal the air leakage in our series. Polyglycolic acid sheet has been used to buttress staple lines and eliminate air leakage through the staple holes. Polyglycolic acid sheet is absorbable, resistant to infection, and flexible for easy molding to the required surface. Ogawa and associates [11] have reported a method of spraying the staple line with aerosolized fibrin glue. In 3 of our patients, bullectomy could not be performed because of several pleural adhesions. We thought that pleural dissection would cause unnecessary lung injury and additional air leakage. Therefore, we simply covered the hole of the leaking bulla with a piece of polyglycolic acid sheet and sprayed the sheet with aerosolized fibrin glue. Although the bulla was not removed, no pneumothorax had recurred at a mean follow-up of 16 months.

We conclude that video-assisted thoracic surgical procedures can be performed safely under local and epidural anesthesia for the treatment of intractable secondary pneumothorax in high-risk patients, and that the air leakage can be controlled with the use of polyglycolic acid sheet and fibrin glue without bullectomy.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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