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Ann Thorac Surg 2000;69:357-361
© 2000 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Carlo Forlanini Hospital, Rome, Italy
Address reprint requests to Dr Cardillo, Department of Thoracic Surgery, C. Forlanini Hospital, Via Portuense 332, I-00149 Rome, Italy
e-mail: giucardil{at}tin.it
Presented at the Poster Session of the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.
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Abstract |
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Methods. From July 1992 to May 1998, 432 patients underwent VATS treatment of PSP. Indications were: recurrent ipsilateral pneumothorax: 322 cases; persistent air leak following a first episode: 93 patients; recurrence following VATS: 16 cases; recurrence following thoracotomy: 1 patient. Vanderschueren’s classification was used for staging. Surgical indications were: stages I and II, subtotal pleurectomy or talc poudrage; stages III and IV, stapling or ligation of the bullae and subtotal pleurectomy or talc poudrage. Differences in recurrence rates were calculated to compare the specific procedures.
Results. No postoperative deaths occurred. Complication rate was 4.16%. Conversion rate was 2.3%. Mean follow-up was 38 months (2 to 72 months). Overall recurrence rate was 4.4%. Specific recurrence rates following stapling and talc poudrage were, respectively, 1.27% and 1.79%. Talc poudrage and stapling of the bullae are respectively superior to subtotal pleurectomy (p < 0.0001) and ligation (p < 0.0001).
Conclusions. Stapling of the bullae and talc poudrage by VATS represent the treatment of choice of PSP.
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Introduction |
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From the beginning of the 1990s, with the introduction of video-assisted thoracic surgery (VATS), the treatment strategy for SP has progressively changed and, nowadays, VATS probably represents the gold standard in the treatment of SP even if there is a lack of large-scale controlled studies [3–8].
In the present article, we report indications, techniques, and long-term results of our 6-year experience in the videothoracoscopic treatment of 432 patients with PSP. Different videothoracoscopic treatment options are compared and discussed.
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Material and methods |
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All procedures were performed with the patient under general anesthesia and one lung ventilation. The patient was placed in the lateral position with the arm held abducted to allow maximum superior displacement of the scapula. The first incision was always placed in the fifth or sixth intercostal space in the midaxillary line, and a 0-degree telescope connected to a video camera was introduced through a 10.5 mm trocar sleeve. Two further trocars were introduced, under thoracoscopic control, respectively through the fourth intercostal space in the anterior axillary line, and through the fifth intercostal space in the auscultatory triangle. Carbon dioxide was never necessary to enlarge the spontaneous pneumothorax. The lung was inspected during gentle ventilation with saline in the pleural cavity to detect air leak or small blebs and bullae. The pathologic lung lesions that were diagnosed endoscopically were classified according to Vanderschueren’s classification [9]: stage I: no endoscopic abnormalities; stage II: pleuropulmonary adhesions; stage III: blebs/bullae less than 2 cm; stage IV: bullae more than 2 cm.
The surgical protocol was: stage I: isolated pleurodesis (subtotal pleurectomy or talc poudrage); stage II: lysis of all adhesions and isolated pleurodesis (subtotal pleurectomy or talc poudrage); stages III and IV: treatment of the bullae (stapling of the bullae or ligation of the bullae) and pleurodesis (subtotal pleurectomy or talc poudrage).
As regards pleurodesis, it was achieved by endoscopic subtotal parietal pleurectomy in the first period of our experience (153 patients treated from July 1992 to August 1995) and by endoscopic talc poudrage in the second period of our experience (279 patients treated from September 1995 to May 1998).
Endoscopic parietal pleurectomy was performed according to Inderbitzi and colleagues [10]: the fifth rib represents the caudal limit of the pleurectomy, so that the basal lung section is not restricted. The longitudinal paravertebral limit provides the anatomic guideline for the sympathetic nerve. The pleural incision is made 1 cm to the side of the nerve to avoid damage by the (monopolar) coagulation hook and runs apically to the level of the left subclavian artery, or, on the right side, the brachiocephalic trunk. The pleurectomized area requires a precise hemostasis.
Talc poudrage was accomplished by nebulization in the pleural cavity of 2 grams of asbestos-free sterilized talc. As regards the treatment of the bullae, it included always grasping at the base together with healthy tissue; in stage III, bullae were ligated with a 0 or 00 coated vicryl Roeder loop (Endoloop EJ 10G, Ethicon Inc, Somerville, NJ) or treated by minimal wedge resection with the endoscopic stapler (TSB 35, Ethicon Endosurgery, Cincinnati, OH). In stage IV, bullae were always resected by means of the endoscopic stapler. At the end of the surgical procedure, usually one drain (28 French gauge) was placed through the existing incisions under endoscopic control with a blunt guide.
If the water-seal revealed a major air leak, the lung is routinely reinspected by telescope (water-seal test).
Statistical analysis
As outcome variable, we used the recurrence rates computed as the number of patients having recurrence after the initial treatment on the overall patients treated with the specific procedure. To compare subtotal pleurectomy versus talc poudrage and stapling of the bullae and ligation of the bullae, we calculated the differences between the recurrence rates in each group and the relative standard errors considering the variable studies having a binomian distribution. To test the statistical significance of the effect of the treatment, we calculated the 95% confidence intervals.
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Results |
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The conversion rate to open procedures was 2.3% (10 patients). Reasons for conversion were: extensive pleural adhesions with obliteration of the pleural cavity: 8 cases; positive water-seal test (large air leak at the end of the videothoracoscopic procedure): 2 cases. The videothoracoscopic evaluation of the lung was accomplished according to Vanderschueren’s classification and showed: stage I: 30 (6.94%) cases; stage II: 63 (14.58%) cases; stage III: 201 (46.53%) cases; and stage IV: 138 (31.94%) cases.
Postoperative complication rate was 4.16% (18 of 432); it included 4 cases of subcutaneous emphysema, 5 cases of localized pleural effusions, 6 prolonged air leaks (>5 days), 1 minimal pleural detachment, 1 apical hematoma, 1 transient Bernard-Horner syndrome. Four of the 5 localized pleural effusions and the apical hematoma occurred after pleurectomy; the remaining localized pleural effusion occurred after isolate talc poudrage. Pleural effusions were treated by thoracentesis. The transient Bernard-Horner syndrome occurred after monopolar coagulation of apical pleuropulmonary adhesions. Prolonged air leaks occurred after ligation of the bullae (4 cases) and after stapling of the bullae (2 cases, stage IV). They resolved spontaneously. Subcutaneous emphysema occurred at the beginning of our experience: 3 cases following ligation of the bullae and 1 case following stapling of the bullae. Minimal apical pleural detachment occurred 3 days after isolate talc poudrage and resolved spontaneously.
Mean time to removal of chest tubes was 5.4 days (range 4 to 11 days). Mean hospital stay was 6.1 days. All patients were included in the follow-up. The mean follow-up was 38 months (range 2 to 72 months) and included clinical history, physical examination, and chest radiographs during maximal inspiration and expiration every 6 months.
Recurrent pneumothorax is defined as a pneumothorax greater than 10% of the hemithorax in size. Recurrences were seen in 19 (4.4%) patients (see Table 1): Stage I (30 cases): one recurrence of 10 (10%) subtotal pleurectomy; it occurred 10 months after surgery. One recurrence of 20 (5%) talc poudrage; it occurred 13 months after VATS. Stage II (63 cases): one recurrence of 21 (4.76%) subtotal pleurectomy; it occurred 11 months after operation. Two recurrences of 42 (4.76%) talc poudrage; they occurred, respectively, 11 months and 17 months after surgery. Stage III (201 cases): ten recurrences of 82 (12.19%) ligation of the bulla + subtotal pleurectomy, with a mean time to recurrence of 13 months. One recurrence of 21 (4.76%) stapling of the bullae + subtotal pleurectomy; it occurred 9 months after surgery. One recurrence of 22 (4.54%) ligation + talc poudrage; it occurred 25 months after VATS. No recurrence of 76 (0%) stapling + talc poudrage. Stage IV (138 cases): one recurrence of 19 (5.26%) stapling + subtotal pleurectomy; it occurred 7 months after surgery. One recurrence of 119 (0.84%) stapling + talc poudrage; it occurred 12 months after surgery.
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The mean recurrence rate following talc poudrage or subtotal pleurectomy, apart from the stage of the disease and from the type of treatment of the bulla, is, respectively, 1.79% versus 9.15% (p = 0.00018); differences in recurrence rates were -8.7% (14.2%, -3.1%). The mean recurrence rate following stapling or ligation of the bullae, apart from the stage of the disease and the from the type of pleurodesis, is, respectively, 1.27% versus 10.57% (p = 0.000037); differences in recurrence rates were -9.30% (-13.9%, -4.7%). The highest recurrence rate has been found in patients treated by ligation of the bullae and subtotal pleurectomy (12.19%).
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Comment |
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In case of recurrent pneumothorax, the recurrence rate is very high: approximately 50% after a second episode and 80% after a third episode so that surgery is mandatory [13]. Another indication for surgery is failure of chest drainage of a first episode of PSP (persistent air leak longer than 5 days; failure of lung expansion). In the field of surgical treatment of PSP, VATS has become more popular than thoracotomy and currently it probably represents the gold standard of the therapy even if there is a lack of large-scale controlled studies [3–8]. Comparing the results of VATS and conventional surgical therapy in the treatment of recurrent spontaneous pneumothorax, the mean recurrence rate after VATS was higher than the mean recurrence rate after conventional standard thoracotomy and very close to the results of transaxillary minithoracotomy: respectively, 4%, 1.5%, and 4.6% [1, 8, 14]. It must be stressed that such data pay a tribute to the learning curve of VATS. In our series, the initial recurrence rate of 12.19% (with ligation of the bullae + subtotal pleurectomy) reported in the first period of our experience has been reduced to an impressive 0% (with stapling of the bulla + talc poudrage) in the second period of our experience. However, in experienced hands, VATS has showed reduced operation time, drainage time, complication rates, and hospital stay resulting in a more raid return to the normal daily activities of the patients [5, 8, 15].
In the evaluation of thoracoscopic findings, Vanderschueren’s 4-stage classification, in our opinion, seems to be a useful tool giving a better understanding of the disease: it is possible to classify the disease (evidence or absence of adhesions, blebs, and bullae), to stratify the different treatment options, and to differentiate recurrences [16].
VATS gives a more precise view of the entire lung compared to CT scan, traditional thoracoscopy, or thoracotomy. In a large study of 622 patients treated with traditional thoracoscopy, Van der Brekel and associates reported no pathomorphological changes in 45% of cases [17]. In a study of 100 cases treated with traditional thoracoscopy, Boutin and associates reported no pathomorphologic changes in 45% of cases [18]. In a study of 79 patients treated with VATS, Inderbitzi and colleagues, showed no pathomorphologic changes in only 5.1% of cases [10]. In the present report, a normal lung (stage I) was found in 30 of 432 patients (6.94%). The analysis of our results, at a mean follow-up of 38 months, reveals the highest rate of recurrences (12.19%) in 82 patients in stage III who underwent ligation of the bullae and subtotal pleurectomy. The best results, with a recurrence rate of 0% are achieved in 76 patients in stage III treated by stapling of the bullae and talc poudrage. The overall recurrence rate in patients with no evidence of blebs (stages I and II) was 5.37% (5 of 93).
The statistical analysis of our series showed no significant differences in 93 patients staged I and II between the different techniques of isolated pleurodesis with a recurrence rate of 6.45% (2 of 31) in patients treated by subtotal pleurectomy versus 4.8% (3 of 62) in patients treated by talc poudrage (p = 0.37). Such data are in agreement with Naunheim and colleagues: in their article, the recurrence rate when no blebs had been identified was 27.3% versus 0% and 2.7%, respectively, when one or multiple blebs were identified [19].
The analysis of the pattern of recurrences showed residual blebs in 2 cases and no evident reasons in 3 cases. The high rate of recurrence should be determined by the incorrect staging of the lesion and, subsequently, by the incorrect treatment of the disease: Isolated pleurodesis is not the right therapy in the presence of blebs or bullae. If we correctly stage the disease, the overall recurrence rate in patients with no evidence of bullae decreases to 3.29% (3 of 91). From the analysis of our data, we are not in agreement with Naunheim who suggests blind apical stapling in patients with no evidence of bullae. In our opinion, isolated pleurodesis is the right choice with stage I disease.
Comparing the different techniques of pleurodesis employed in this study, apart from the treatment of the bullae in all 432 patients, the difference between talc poudrage and subtotal pleurectomy is highly significant with a recurrence rate of 1.79% versus 9.15%, respectively, in talc poudrage and subtotal pleurectomy (p = 0.00018).
A similar low rate of recurrences with talc poudrage has been reported in the literature [20]. Moreover, there are some recent reports that stress the efficacy of talc poudrage in the management of spontaneous pneumothorax [7, 21].
The biology of talc-induced pleurodesis has been recently focused upon by Van den Hewel and associates who showed that talc-induced inflammation is characterized by an influx of polymorphonuclear neutrophils related to interleukin-8, followed by an accumulation of monocytes [22].
As regards the potential drawbacks of talc poudrage, we stress that fear of mesothelioma development can be excluded reasonably by the use of asbestos-free talc [23]; the threat of long-term respiratory insufficiency is unfounded: a long-term survey of 75 patients who underwent talc poudrage has shown only a mild restrictive respiratory impairment [24]; the presence of a barrier to any subsequent thoracotomy with the need of an extrapleural access is the same as for pleurectomy or extensive pleural abrasion. Recently, fibrin glue has been tested for pleurodesis but has shown an unacceptably 25% recurrence rate and a very high cost [25].
Concerning the treatment of the bullae apart from the technique of pleurodesis in 339 patients staged III and IV, the difference between stapling and bullae ligation is highly significant with a recurrence rate of 1.27% versus 10.57%, respectively, in stapling and in ligation (p = 0.000037). A similar high rate of failure with ligation of the bullae (11.9%) has been observed by Inderbitzi and colleagues [10]. Recently, a report by Liu and associates showed a self-made endoscopic loop to be safe and effective in managing blebs and bullae with no recurrences in 217 patients at a mean follow-up of 28 months [19]. Nevertheless, we believe that in patients with PSP, bulla ligation should be replaced by stapling wedge resection.
As regards treatment of recurrences, there is a general lack of experience in the world literature. Our series of 12 cases of redo-VATS represent a good preliminary experience so that we always recommend redo-VATS in recurrence following VATS, even if a controlled clinical trial should be done.
In conclusion, in a first episode of PSP, pleural drainage represents the standard treatment; in case of bilateral simultaneous pneumothorax, we suggest pleural drainage and contralateral VATS treatment (because of the high morbidity of bilateral simultaneous recurrence). VATS becomes our treatment of choice in patients with spontaneous hemopneumothorax, in patients with first episode of PSP and previous contralateral pneumothorax, in patients whose professions put them at risk (pilots, scuba divers, sportsmen), in patients with treatment failure of a first episode of PSP, and in patients with recurrent SP.
Videothoracoscopic examination enables detection of blebs and bullae and very thin leaking areas, provided that the examination is done during gentle ventilation with saline in the pleural cavity. In our opinion, Vanderschueren’s 4-stage system provides a chance to classify pneumothorax and to stratify the different treatment options.
In early stages (stages I and II), isolated talc poudrage is our favored treatment; we do not add blind apical stapling. In the presence of blebs and bullae (stages III and IV), stapling wedge resection is strongly advised. Talc poudrage must be always added.
In recurrences following VATS, we believe that redo-VATS will probably represent the treatment of choice, even if, up to the present time, there has been very little experience with this treatment. A minimum 2-year follow-up is necessary for the evaluation of the results.
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Acknowledgments |
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References |
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