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Ann Thorac Surg 1999;68:2383
© 1999 The Society of Thoracic Surgeons

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Correspondence

Treatment of pneumothorax with VATS and bullectomy under local anesthesia

^a Thoracic Surgery Department, Juan Canalejo Hospital, Las Jubías no. 84, 15006-La Coruña, Spain
^b Hospital Miguel Seruet, Isabel la Catolica 1, Zaragoza 50009, Spain

e-mail: jjrivas{at}jet.es

To the Editor

Video-assisted thoracic surgery (VATS) is, at present, the minimally invasive surgical technique of choice for the treatment of spontaneous recurrent or persistent pneumothorax. Usually, it requires general anesthesia and single-lung ventilation.

We found the article by Mukaida and colleagues [1], about a small series of 4 high-risk patients, operated with secondary pneumothorax under local and epidural anesthesia very interesting. In relation to this work, we propose to perform VATS under local anesthesia and sedation [2] in elderly patients with serious pathology who cannot tolerate general anesthesia, or who have high surgical risk. We present 2 such cases here.

Case 1 is a 87-year-old man who had a history of pulmonary tuberculosis (1950) with residual fibrotic lesions. He was admitted to another hospital for right tension pneumothorax, and was treated with thoracic drainage for 7 days, with persistent air leak and pulmonary reexpansion deficit. Right VATS was performed with three trocars, under local anesthesia and sedation. We observed pleural adhesions at the apex and mediastinum, and a single perforated 5 x 3 cm bulla located at the posterior segment of right upper lobe. Dissection of the bulla was carried out with two EndoGIA-35 mm (Ethicon Endo-Surgery Inc, Cincinnati, OH), completing the operation with pulverization of 5g purified talcum powder [3] and two thoracic drainages. He did not present air leak postoperatively, and the drainages were removed after 3 days, maintaining the pulmonary expansion and without complication. He was released from the hospital on the fourth day. After 18 months follow-up, recurrence of pneumothorax was not observed.

Case 2 is a 67-year old male ex-smoker with previous history of arterial hypertension, stroke 5 years ago and severe coronary artery disease, treated with aortocoronary bypass grafting, later obstructed. He presented spontaneous right pneumothorax with significant persistent air leak, initially treated with thoracic drainage for 6 days. Under local anesthesia and sedation, right VATS was performed with three trocars, showing apical adhesions, that were freed, and a large apical bulla that was excised with three EndoGIA-35-mm; we then added talcum powder pleurodesis [3] and one thoracic drain. After this procedure, no air leakage was presented, and the drainage was removed after 3 days. The patient was released from the hospital on the fourth day, and remains asymptomatic after 1 year follow-up.

In both cases, 200 mg of mepivacaine chlorohydrate was used for local anesthesia and 5 mg of intravenous midazolam for sedation. Patients were under continuous monitoring of blood pressure, electrocardiogram, and oxygen saturation.

In patients at high-risk for general anesthesia, due to advanced age, previous pathology, or both, diagnostic thoracoscopy or VATS [4] are possible under local anesthesia and sedation, allowing the employment of the same number of trocars and the same bullectomy techniques. In our experience, pleurodesis by pleural abrasion should be replaced by chemical pleurodesis with 5g of purified and sterile talcum powder.

The excellent results obtained, without complication and reduced postoperative stay, indicate that this technique should be considered to resolve well selected cases.

References

1. Mukaida T., Andou A., Date H., Aoe M., Shimizu N. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65:297-306.[Medline]
2. Nezu K., Kushibe K., Tojo T., Takahama T., 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]
3. Tschopp J.M., Brutsche M., Frey J.G. Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anesthesia. Thorax 1997;52:329-332.[Abstract]
4. Rivas de Andrés J.J., Torres J. Thoracoscopy and spontaneous pneumothorax. Ann Thorac Surg 1993;55:811.

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