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Ann Thorac Surg 1998;66:592-599
© 1998 The Society of Thoracic Surgeons
a Departments of Thoracic Surgery, Hôpitaux Universitaires de Strasbourg and Hôpital Sainte Marguerite, Marseille, France
Address reprint requests to Dr Massard, Department of Thoracic Surgery, Hôpitaux Universitaires de Strasbourg, F-67091 Strasbourg, France
e-mail: (Gilbert.Massard{at}chru-strasbourg.fr)
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Abstract |
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 Top Abstract IntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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Introduction |
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TopAbstractIntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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When going through publications dealing with treatment of spontaneous pneumothorax, the reader may be misled. Most articles review a patient population including both primary and secondary spontaneous pneumothorax. There is also a varying algorithm of indications for surgical management: the "newborn tool" stimulates surgical activism, and some over-enthusiastic authors advocate aggressive management as soon as the first episode [5].
Over the past 4 years, many articles have been published with the conclusion that VATS has definitely proved itself as the gold standard of treatment for spontaneous pneumothorax. Surprisingly, in the era of evaluation and accreditation, this statement has not been founded on large-scale controlled studies.
The present review has been made of the most relevant articles selected by a screening of the Medline database; some historical references have been chosen according to the frequency of citation. Results achieved with open operation have been considered as the standard that should be equalled by less invasive techniques. Early and long-term results of minimally invasive techniques such as chemical pleurodesis, minithoracotomy, and video-assisted surgery are discussed. The potential advantages of video-assisted surgery, in terms of postoperative hospital stay, pain, and eventually cost of treatment, have been critically reviewed.
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Historical reference: surgical treatment with thoracotomy |
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TopAbstractIntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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Surgical management of pneumothorax has a double objective. Virtually all authors agree that the cause should be treated by resection of blebs, suture of apical perforations, and even blind apical stapling when no obvious lesion has been identified. The second aim of treatment is to create diffuse adhesions to prevent any further recurrence. Long-standing and still unresolved discussion has opposed the proponents of partial or total pleurectomy to the partisans of pleural abrasion [8, 9]. The former believe that pleurectomy is the more efficient treatment, whereas the latter speculate that abrasion preserves the extrapleural plane for a hypothetic and future thoracotomy. Several authors added treatment of the visceral pleura by iodine or silver nitrate [10, 11]. In fine, most published large-scale series show outstanding long-term results with a recurrence rate of less than 1%, regardless of whether the pneumothorax is primary or secondary and whether an abrasion or a pleurectomy has been performed (Table 1) [11–13]. A previous review of the literature, however, demonstrated a slight advantage of pleurectomy over abrasion: the recurrence rate was 0.4% after pleurectomy (n = 752) and 2.3% after abrasion (n = 301) [13]. Although the primum movens of spontaneous pneumothorax is a lung disorder, pleurodesis appears to be mandatory: Körner and colleagues [14] have performed apical wedge resections without pleurodesis through thoracotomy, resulting in a recurrence rate of 5%.
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Despite the relatively recent time period reviewed in the work referenced in Table 1, hospital stay was prolonged to a mean of 14 days. This prolonged stay was partially explained by cultural reasons: chest tubes were left in place for 4 to 6 days as a rule, and thoracotomy was thought to require a hospitalization of at least 12 days. Nonetheless, hospital stay was prolonged by 4 days in patients with secondary pneumothorax [11].
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"Historic" alternatives to thoracotomy |
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TopAbstractIntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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Chemical pleurodesis
Chemical pleurodesis has been promoted by chest physicians comfortable with thoracoscopy, thus prolonging the traditions of phtysiology. Instillation of irritating substances into the pleural space should cause local aseptic inflammation leading to dense adhesions. The most popular agents have been talc, tetracycline, and silver nitrate, which share the substantial advantage of a low cost. However, silver nitrate application is particularly painful, and induces a major exudative reaction; therefore, its use has not been reported in recent publications [2]. Injectable tetracycline is no longer commercially available; besides, results were not really satisfactory, because the recurrence rate was estimated at 16% in a series of 390 consecutive patients [15]. Talc poudrage has the lowest recurrence rate of all chemical agents [16]. In a comparative trial including 96 patients, the recurrence rate was 36% after simple drainage, 13% after tetracycline pleurodesis, and 8% after talc poudrage [17]. The overall failure rate of talc poudrage is probably higher and may be estimated at 10% to 15% [3, 18, 19] (Table 2). According to Guérin and colleagues [3], half of the failures were immediate failures, prompting subsequent thoracotomy.
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With modern technology, fibrin glue has been tested as a primary treatment for pneumothorax but has shown an unacceptably high recurrence rate of 25% [22]. Therefore, and because of the cost and biologic risks of this material, we do not agree with the statement that fibrin glue might be a valuable alternative to the classic algorithm.
The high failure rate of any kind of chemical pleurodesis makes this type of treatment unsuitable for primary spontaneous pneumothorax. Exceptional use of talc poudrage should be restricted to otherwise inoperable patients with secondary pneumothorax.
Transaxillary minithoracotomy
This approach, popularized by Becker and Munro [4] as early as 1976, should by all means be considered a minimally invasive operation in terms of shortness of both incision and hospital stay. The incision is carried at the hairline of the axilla and measures 5 to 6 cm at most; the chest is entered through the third intercostal space. Apical pleurectomy or abrasion is performed, and the apexes of the upper and lower lobe are carefully inspected. Blebs or bullae can be drawn to the level of the skin and stapled outside the chest. A single tube is left for 24 hours.
A large experience published by Deslauriers and colleagues in 1980 [23] included 362 consecutive patients. Pleurodesis was induced by apical pleurectomy. Four patients required reoperation for bleeding (n = 3) or air leak (n = 1), and a further 30 experienced minor complications (9.4%). Mean hospital stay was 6 days. Only 2 patients (0.4%) presented with recurrent pneumothorax.
Without any doubt, this straightforward procedure is efficient as far as operating room cost is concerned. Cosmetic results are excellent. Long-term results are optimal.
A recent reappraisal by Simansky and Yellin [24] confirmed a reduced hospital stay averaging 4.6 days. However, the recurrence rate among 39 consecutive patients was 4.6% at a mean follow-up of 33 months. The relatively high failure rate could be explained by the fact that bullae were treated with laser coagulation rather than by stapled resection; abrasion was performed instead of pleurectomy to induce pleurodesis.
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Overall results with video-assisted thoracic surgery |
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TopAbstractIntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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Complications
It is surprising to perceive that complications rates are quite similar to thoracotomy [29]: the magic of surgery without incision does not prevent complications! In the series presented by Mouroux and colleagues [26], the cumulative complication rate was 10%. When considering the cause of pneumothorax, the complication rate was 6.75% for primary pneumothorax versus 27.7% for secondary pneumothorax; these figures again equal those achieved with thoracotomy [26]. The most frequent complication is prolonged air leak (>5 days), which is observed in approximately 8% of patients [6, 27, 30]. Failing pleurodesis and hemothorax require reoperation; the incidence of reoperation has been close to 5% [25].
Recurrence after operation
Most series suggest that the medium-term (less than 3 years of follow-up) rate of recurrence after VATS procedures is between 5% and 10% (Table 3) [25–30]. To be perfectly honest, "failure during hospitalisation treated by thoracotomy" [29] should be considered an early recurrence. Recurrences are certainly increased when compared with thoracotomy: in a historical comparison by Dumont and colleagues [29], the recurrence rate was 0.4% after thoracotomy and 6% after VATS (
2 = 10.635; p < 0.01) [29]. A multicenter study by Naunheim and colleagues [27] reports a somewhat heterogeneous series of 113 patients, because the method of pleurodesis differed: abrasion, 45%; sclerotic agents, 24%; laser, 13%; pleurectomy, 10%; none, 10%. The overall recurrence rate was 4.1%, and actuarial freedom of recurrence was estimated 95% at 6 months. Similarly, Bertrand and colleagues [25] reported a freedom of recurrence of 95% at 42 months in a review of 163 patients. In the latter series, 3 patients had a complete recurrence requiring a second operation, and 3 had partial recurrence managed conservatively, which accounts for a recurrence rate of 3.6%. However, 4 patients were reoperated on via thoracotomy for immediate failure during the initial postoperative hospital stay; when these patients are included, the total rate of recurrence is 6% [25]. A National Survey in the United States stated a 7% failure rate in 1993 [31]. No definitive conclusion on recurrence rates can be drawn without a controlled trial. Besides, published series probably underestimate recurrence: follow-up is short and 8.5% to 10% of patients are lost to follow-up [25, 27]. This proportion of patients lost to follow-up seems far too high for a benign disease and short-term surveillance; it is likely that patients with postoperative recurrence choose a different surgeon, as they would do for failed hernia repair or recurring varicose veins.
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The importance of pleurodesis is nicely demonstrated by Inderbitzi and colleagues [6], who observed a total of 6 recurrences in 72 patients followed up (8.3%). However, a more precise analysis shows varying results according to technical details: it appears that combined resection of blebs and pleurodesis is the safest treatment [6] (Table 4). Inderbitzi and colleagues themselves consider that isolated ligation has a failure rate of 19.2%, when including prolonged air leaks; therefore, the results do not differ from those of simple chest tube drainage! Chemical pleurodesis instead of abrasion or pleurectomy is also less successful; the combination of thoracoscopic bullectomy and tetracycline pleurodesis resulted in an early failure rate of 9% [32].
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Why should there be less success when the technique allows for improved vision in comparison with a minithoracotomy? A first reason might be that fewer blebs are recognized and treated during VATS [25]. Open operation was usually performed with single-lumen intubation, whereas VATS requires double-lumen intubation and one-lung ventilation. It is probable that during VATS operations some blebs are deflated together with the lung and therefore missed. This hypothesis is confirmed by the observation that in patients who undergo reoperation, the causes of failure are most often unrecognized blebs or bullae.
A second reason might be a certain degree of fear to abrade! With the magnification, the perception of hemorrhage is exaggerated, and a less than optimal abrasion may be performed. Finally, the area between the trocars remains out of view and may not be abraded adequately.
The lower degree of tissue trauma and the less intense biologic reaction observed with VATS might be a determinant factor of less efficient pleurodesis: release of inflammatory and vasoactive mediators (C reactive protein, prostacyclin and thromboxane A2) was significantly lower in VATS patients as compared with a similar sample of thoracotomy patients [33].
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Potential advantages of video-assisted thoracic surgery |
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TopAbstractIntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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Duration of drainage
Duration of drainage is obviously one of the main determinants of hospital stay after any kind of thoracic operation. We agree with Mouroux and colleagues [26] that variations in duration of drainage appear attributable more to the number of drains and to the habits of surgical teams than to the surgical method itself. Video-assisted thoracic surgery has certainly caused several teams to shorten their routines of drainage (Table 6).
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Back in the domain of pneumothorax, we lack prospective comparative trials. Subjectively, referring to patients operated on bilaterally with thoracotomy and subsequent VATS, the latter procedure appears as less painful. Dumont and colleagues [29] demonstrated a significantly lower level of pain after VATS when compared with a historical control group operated on through a lateral thoracotomy: 42% of VATS patients required level 3 analgesics versus 95% in patients who had formal thoracotomy. With a similar methodology, Hazelrigg and colleagues [36] compared 20 and 26 patients gathered in a multicenter trial; 7.7% of VATS patients and 70% of thoracotomy patients required parenteral narcotics after 48 hours.
Long-term pain is a distressing problem after thoracotomy. However, its evaluation is subjected to a variable rating. Bertrand and colleagues [25] estimated that 63% of patients experienced residual chest pain after VATS for pneumothorax, which was considered minimal in 58% of them, moderate in 38%, and severe in 4%. Comparatively, 61% had persistent pain after a lateral thoracotomy for pneumothorax, and the pain was considered minimal in 65%, moderate in 33%, and severe in 2%. Mouroux and colleagues [26] reported a similar incidence of 3% of severe chest pain. Surprisingly, chronic pain has not been reduced by VATS; one should not neglect crushing injury to the intercostal nerves when relatively large instruments are used in narrow intercostal spaces. Motility of the shoulder recovered completely within 1 month after VATS and in only 62% of patients at 3 months after posterolateral thoracotomy (p < 0.0001) [34]; the latter should be tempered by the fact that many surgeons have preferred muscle-sparing incisions for benign disorders.
Return to activity
Return to occupational activity has been evaluated in two series with reference to historical control groups. A first series demonstrated a return to activity within a mean of 42 days after VATS and 74 days after thoracotomy [25]. In this second series comparing two groups of 16 patients, return to work was possible 1 month after VATS and 2.6 months after thoracotomy (p < 0.002); leisure activities were resumed at 2 months after VATS and 4 months after thoracotomy (p < 0.0005) [34]. However, a controlled, prospective study is lacking; one should not neglect a changing philosophy toward postoperative recovery between these two historical comparisons.
Cost
Unfortunately, pneumothorax is a common problem and as such accounts for a considerable expenditure of money and resources. Quite naturally, most authors interested in cost analysis conclude that VATS is less expensive owing to a shorter hospital stay [37]. Dumont and colleagues [29] demonstrated a difference of 4.5 days between a cohort of VATS patients and a historical control group. The estimated reduction in cost was $2,300, whereas the increase in cost due to stapling material was estimated at $245. The shorter hospital stay should counterbalance the enhanced cost of disposable material used intraoperatively. These conclusions are biased by the consideration that the reduced hospital stay is not solely due to a changing operative approach. Accurate cost analysis should not only focus on hospital stay, which might be the same for VATS as for an open operation with a limited thoracotomy such as the transaxillary variant [4, 23], owing to an improved discharge policy. It is therefore surprising that none of these studies made any attempt to consider the cost of video equipment, which has simply been considered to be in place to be used. Therefore, we have to refer to a recent evaluation of patients undergoing lung biopsy, which is a very similar operation. This study has demonstrated that VATS increases the cost over minithoracotomy by $1,000 when the cost of video equipment is taken into account [38]. Similarly, Allen and colleagues [39] estimated the median operating room charge at $1,970 for VATS versus $778 for thoracotomy. Miller [40] estimated that the total cost was $10,400 for VATS procedures versus $6,150 to $6,750 for thoracotomy; he concluded that at the present time, there is no procedure that can be done more cheaply by video-assisted thoracoscopy than by conventional open technique.
Hidden costs include prolonged operating room time, VATS equipment, and disposable material, but also the increased cost of double-lumen catheter intubation, which is mandatory for VATS. The disposables are more expensive; most anesthesiologists perform bronchoscopy to check adequate position of the tube, and induction of anesthesia takes more time. Fear of missing blebs during thoracoscopy leads to a "high-tech" management including routine computed tomographic scan to obviate blebs [41]. To control the total cost, it seems reasonable to withhold computed tomographic scan in patients with primary spontaneous pneumothorax because it should not affect patients’ treatment [42].
The cost of expanded indications has never been alluded to [43]: some authors now advocate definite treatment at the first episode [5]. Cost of recurrence should also be considered; in addition, the psychologic impact of recurrence in patients who have undergone operation is inevaluable [44].
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Randomized trials |
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TopAbstractIntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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Waller and colleagues [45] compared VATS and thoracotomy in a consecutive series of 60 patients, who were followed up for a median period of 15 to 16 months. All patients were treated by bleb resection and apical pleurectomy; thoracotomy was a limited posterolateral incision carried through the auscultatory triangle. Operative time was longer by 8 minutes in the VATS group (p < 0.01). There was no difference in morphine consumption, in duration of drainage, or in hospital stay. However, postoperative forced expiratory volume in 1 second was lower in the thoracotomy group.
Kim and colleagues [46] have compared VATS and transaxillary minithoracotomy. Operative time, amount of analgesics, and chest tube drainage time were very similar. However, 4 of 30 patients managed with VATS did have recurrence. Kim and colleagues concluded that transaxillary minithoracotomy is the preferred approach owing to the lower cost and improved cosmetic result.
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Conclusions and perspectives for video-assisted thoracic surgery |
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TopAbstractIntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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When going through recent publications, there is an obvious shift of indications, because most teams perform an operation at the second episode. This seems reasonable, because the spontaneous recurrence rate is certainly in excess of 50%. Recent work also demonstrated that an air leak is unlikely to seal beyond 48 hours; operative management of persisting pneumothorax therefore may reasonably be performed at an earlier stage.
In contrast, we consider excessive the suggestion that "VATS should be considered in patients with a first episode of idiopathic spontaneous pneumothorax, because these predominantly young patients may profit most from definitive therapy" [6]. Although thoracoscopy might immediately identify patients at risk for recurrence by disclosing blebs, there is no argument in favor of a correlation between thoracoscopic findings and patterns of recurrence [17]. Outside of large teaching hospitals, emergency thoracoscopy under local anesthesia is further limited by the availability of experienced and skilled physicians [19]. Schramel and colleagues [5] concluded that VATS should be performed for first episodes, by comparing total cost of conservative management and thoracoscopic management over two time periods. However, this study is biased because surgical patients of the historical control group underwent formal thoracotomy; when total hospitalization is taken into account, including "waiting time before VATS," cost efficiency does not appear. We note that in a country like France, daily hospital charges double when comparing a medical ward with a surgical unit; even with similar duration of hospital stay, chest tube drainage in a medical ward reduces the cost by 50%. Besides, the 80% of patients who will not have recurrence are subjected to an unnecessary surgical procedure.
Cole and colleagues [47] concluded that VATS should not be considered as the standard treatment of spontaneous pneumothorax: postoperative complications are similar to open procedures, but long-term results are less valuable. This conclusion is perhaps unfair when assigned to a definitive statement. Video-assisted thoracic surgery is an interesting tool for teaching hospitals, because the teacher can adequately follow the trainee. Video-assisted thoracic surgery is obviously less painful than a posterolateral or lateral thoracotomy. Video-assisted thoracic surgery has indirectly contributed to promote a cost-effective discharge policy. Increased experience should lead to improved results. In fine, surgical judgement, not a drive for novelty, must be used to compare thoracoscopic surgery with an open operation through a short axillary incision [48]. When cost is a problem, the transaxillary technique appears as a valuable alternative with anticipated equal immediate results, and probably improved long-term results. Therefore, a large, controlled study comparing VATS and transaxillary approach is more than desirable.
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References |
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TopAbstractIntroductionHistorical reference: surgical..."Historic" alternatives to...Overall results with video...Potential advantages of video...Randomized trialsConclusions and perspectives for...References |
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