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Ann Thorac Surg 2000;70:412-417
© 2000 The Society of Thoracic Surgeons

Original articles: general thoracic

Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy

Loïc Lang-Lazdunski, MDa, Xavier de Kerangal, MDa, François Pons, MDa, René Jancovici, MDa

a Department of Thoracic and General Surgery, Percy Military Hospital, Clamart, France

Address reprint requests to Dr Lang-Lazdunski, Service de Chirurgie Thoracique et Générale, Hopital d’Instruction des Armées Percy, 101 ave Henri Barbusse 92141 Clamart Cedex, France
e-mail: loic.lang{at}wanadoo.fr


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. The goal of the study was to report our 7-year experience with single-stage bilateral videothoracoscopy for bleb excision and pleural abrasion in patients suffering primary spontaneous pneumothorax.

Methods. From November 1992 through June 1999, 12 men were operated on in our department. Preoperative chest computed tomographic scans were obtained for all patients. Operative indications included simultaneous bilateral pneumothorax (n = 2), contralateral recurrence (n = 1), ipsilateral recurrence with contralateral blebs or bullae, and job restrictions (n = 9).

Results. Mean age at operation was 26 ± 6 years. All patients had multiple blebs or bullae located in upper lobes, and 4 patients (33%) had pleural adhesions. All blebs or bullae were resected at operation. The mean number of staple cartridges was 5 per patient (range, 3 to 8). All patients had bilateral pleurabrasion. There were no perioperative complications and no conversion to thoracotomy. The mean operative time was 168 ± 17 minutes (range, 140 to 190 minutes). The mean drainage time was 5 days (range, 4 to 26 days) and the mean hospital stay was 7.7 ± 1.4 days for 11 of 12 patients. Postoperative complications included prolonged air leak (16.5%), incomplete lung reexpansion (25%), and pleural effusion (8.5%). One patient required reoperation on the right side through transaxillary thoracotomy within 1 month of videothoracoscopy for pleurodesis failure. Follow-up was 100% complete. Mean follow-up is 50 ± 34 months (range, 9 to 88 months) and no patient has had recurrence of pneumothorax. All patients except one returned to full occupational activity within 5 weeks of surgery.

Conclusions. Single-stage bilateral videothoracoscopy for bilateral bleb excision and pleurabrasion is a safe procedure that does not result in major complications and provides excellent long-term results. This approach could be considered in young patients with bilateral primary spontaneous pneumothorax, or in those requiring radical therapy for the prevention of ipsilateral and contralateral recurrences.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Spontaneous pneumothorax remains a significant problem, with approximately 20,000 new cases per year in the United States [1]. Because conservative treatments and tube thoracostomy are associated with a 20% to 45% ipsilateral recurrence rate, and because contralateral recurrences may occur in approximately 15% of patients, spontaneous pneumothorax often poses a therapeutic problem, especially in young and active patients [1–4]. Four decades ago, Baronovsky and colleagues demonstrated an almost 100% occurrence of bilateral subpleural apical blebs in patients with spontaneous pneumothorax and introduced the concept of simultaneous bilateral treatment through bilateral thoracotomy [5]. They were strongly criticized because of the magnitude of surgery for what appeared to be prophylaxis in most patients [6]. Later, some investigators advocated median sternotomy as the ideal approach for the simultaneous treatment of both lungs, arguing that less pain is associated with median sternotomy and that immediate pulmonary function is more favorable [6, 7]. Recent studies have suggested that videothoracoscopy is a valid alternative to the transaxillary approach for the treatment of recurrent primary spontaneous pneumothorax [8–12]. Since 1992, we have decided to treat selected patients with primary spontaneous pneumothorax using single-stage bilateral videothoracoscopy for bilateral bleb excision and pleurabrasion. This study reports our 7-year experience of this technique.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
From November 1992 through June 1999, videothoracoscopy was performed in 227 patients for the treatment of spontaneous pneumothorax in our department. Twelve patients had a single-stage bilateral videothoracoscopy over this period. Data were collected retrospectively for all patients and included a detailed medical history, number of episodes of pneumothorax and their treatment modalities, nature of the lung disease (blebs or bullae with size, site, and number), existence of adhesions, operative time, number of staple cartridges used, duration of pleural drainage, hospital stay, mortality, complications, recurrences, and time to return to work. Patients were examined in the outpatient division at 1 and 3 months postoperatively and their chest roentgenogram analyzed. Information regarding late complications or recurrence of pneumothorax after discharge from outpatient follow-up was obtained from the respective referring physicians or directly from the patients.

Operative technique
While receiving general anesthesia the patients were intubated with a double-lumen endotracheal tube and placed in the appropriate lateral decubitus position. The patients were prepared and draped as for posterolateral thoracotomy. Single-lung ventilation was started. One 1.5-cm skin incision was made below the tip of the scapula in the sixth intercostal space, and a 0-degree 10-mm videothoracoscope was introduced through a 12-mm trocar. Two working ports were then placed under direct endoscopic visualization in the fourth anterior and eighth middle intercostal spaces. The apex of the lung was grasped with an endoscopic atraumatic lung-grasping forceps, and the lung was carefully inspected. All aspects of pulmonary lobes and scissures were inspected. Then, the apex of the upper lobe, which was invariably involved with multiple subpleural blebs or small bullae (< 2 cm) was resected using an endoscopic linear stapler (according to surgeon’s preference, either Endo-GIA 30 or 60, Auto Suture Company Division, USCC, Norwalk, CT or EZ 45, Ethicon Endo-Surgery, Inc, Cincinnati, OH). Several stapler cartridges were used per patient. Normal saline solution was instilled to check for air leaks. Pleurodesis was performed by vigorous pleural abrasion using a pledget of wide-mesh polyglycolic acid gauze (Davis & Geck Division, American Home Products, Danbury, CT) attached to the tip of a standard endoscopic grasper. The entire parietal and visceral pleura were abraded by inserting the grasper through the various port sites. Vigorous pleurabrasion was performed until a uniform aspect of bloody pleura was obtained in all patients. Two chest tubes (28F, Sherwood Medical, Tullamore, Ireland) were placed through the anterior and middle port sites and adequate lung reexpansion verified. The posterior port site was closed in two layers. The tubes were connected to an aspiration system and negative suction of -25 cm H2O was applied. The surgical specimens were systematically sent to the histopathology laboratory. After a short period of double-lung ventilation, the patient was rotated on the opposite lateral decubitus position, endotracheal tube placement verified and chest tube patency checked, and an identical procedure performed on the contralateral side. Videothoracoscopic procedures were performed by senior thoracic surgeons (R.J., F.P., L.L.L.) using the same technique.

Postoperative care
The patients were extubated in the operating room and observed for 4 to 6 hours in the intermediate care unit. Patients were transferred to the thoracic surgical unit the evening of surgery and were ambulated the next day. Pulse oxymeter and electrocardiogram were routinely monitored during the first 24 hours. Daily chest roentgenogram was obtained for each patient. Chest tubes were usually pulled out 5 cm after 3 days and removed after 4 to 5 days, when any pulmonary parenchymal air leak that may have been present had resolved and when pleural drainage was less than 100 mL per 24 hours. Active and passive physiotherapy was started on postoperative day 1 and maintained for 1 month. Subcutaneous low-molecular weight heparin was injected daily while patients had chest tubes.

Postoperative analgesia
An epidural catheter was placed just before surgery at the T6–T8 level, while patients received general anesthesia. This catheter was left in place for 4 days. Bupivacaine 0.125% was continuously infused and morphine (2 to 4 mg) was injected twice a day. Only the most recently operated patient in this series received morphine, through a patient-controlled epidural analgesia system. Intravenous ketoprofen (200 mg/day) was also given systematically for the first 48 hours. Oral therapy was started on postoperative day 5 with paracetamol, codeine, or dextropropoxyphene, and was adapted to individual requirements.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Follow-up was 100% complete for all patients. This series include 12 men. The mean age at operation was 26 ± 6 years (range, 18 to 37 years). Eight patients (67%) were active smokers. All 12 patients had at least one episode of pneumothorax requiring tube thoracostomy, and 5 patients had multiple episodes requiring tube thoracostomy. All patients had preoperative chest computed tomography (CT) for the detection of blebs or bullae. This examination was performed even in patients requiring maintenance of aspiration drainage during scanning. Bilateral apical blebs and small bullae (< 2 cm) were detected in 100% of patients, with 2 patients (17%) having multiple sites for blebs. The indications for operation are summarized in Table 1. Two patients were operated on after their first episode of bilateral simultaneous pneumothorax. One patient was operated on after his first episode of contralateral pneumothorax. Two patients were scuba divers and were operated on after their first episode of unilateral pneumothorax, in order to reassume their professional responsibilities. Seven patients with either a single occurrence of unilateral pneumothorax or ipsilateral recurrence(s) were on active duty in the French armed services, and required radical therapy to comply with the physical status required by the French Ministry of Defense. Table 2


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  		Table 1. Operative Indications

 

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  		Table 2. Clinical Data of 12 Patients Treated by Videothoracoscopic Pleurabrasion and Bilateral Bleb Excision

 
Four patients (33%) had pleural adhesions diagnosed at videothoracoscopy, all patients had multiple blebs or small bullae (< 2 cm) identified on the pulmonary apices, and two (17%) had blebs on other sites but always in the upper lobes. The mean number of staple cartridges used for resection of pulmonary apex was 5 per patient (range, 3 to 8). There was no peroperative complication and no patient required a conversion to thoracotomy. The mean operative time was 168 ± 17 minutes (range, 140 to 190 minutes). In-hospital mortality was 0% and no patient died after discharge. No patient required blood products. Postoperative complications included prolonged air leak in 2 patients (16.5%), incomplete lung reexpansion in 3 patients (25%), and pleural effusion in one patient (8.5%). There was only one treatment failure, in a 18-year old patient. This patient required secondary transaxillary minithoracotomy on postoperative day 26 for unsatisfactory pleurodesis and persistence of incomplete right lung reexpansion associated with pleural effusion. A new pleurabrasion was performed in the areas where the lung had collapsed. The postoperative course was uneventful, and the patient had removal of chest tubes after 6 days. All surgical specimens demonstrated typical subpleural blebs or small bullae in the pulmonary apices. Postoperative hospital stay was 10 ± 8.5 days (range, 6 to 37 days), and it was 7.7 ± 1.4 days for 92% of patients. The mean chest tube output was 1660 ± 550 mL (range, 830 to 2700 mL). Mean duration of pleural drainage was 4.7 ± 0.9 days on the left side and 5 ± 1.4 days on the right side for 92% of patients (5.5 ± 2.8 and 6.7 ± 6.2 days, respectively, if the patient who needed reoperation is included). Chest pain disappeared after 3 weeks in most patients and none was receiving analgesic medication 1 month after discharge from the thoracic surgical unit. All patients except one returned to work within 5 weeks, postoperatively. The young patient requiring transaxillary thoracotomy returned to occupational activity after 9 weeks. At 3 months, all patients were asymptomatic, with no residual dyspnea, and chest roentgenogram disclosed adequate lung reexpansion in 100% of cases. No patient suffered pneumothorax recurrence within 1 year of surgery. The mean follow-up is now 50 ± 34 months (range, 88 to 9 months); no patient has had recurrence of pneumothorax and all patients are satisfied with their surgical treatment. Table 3


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  		Table 3. Pattern of Recurrence in Spontaneous Pneumothorax Series From the Literature

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
The main goals of pneumothorax treatment are to obtain complete lung reexpansion, to eliminate intrapleural air, to restore normal pleural physiology, and to attempt recurrence prevention. Bed rest, simple aspiration, and tube thoracostomy without sclerosis do not target the risk of recurrence [1, 2, 4]. Recurrence rates have been studied in different patient populations. Several publications reported first ipsilateral recurrence rate in the absence of definitive prevention in 21.8% to 45% of patients with primary spontaneous pneumothorax [4, 13–18]. Contralateral recurrences have been reported in 5% to 15% of patients in most series [1, 2, 4]. However, the risk of contralateral recurrence may be higher in patients with radiographic evidence of contralateral bullae, and especially in teenage and young adult patients (in their 20s), in whom the risk has been reported to be as high as 60% [2]. Likewise, several investigators reported contralateral recurrence(s) after unilateral operation in 18% to 50% of their patients [2, 3, 19]. Although chest CT has been demonstrated to be of high value in the assessment of blebs and bullae in patients with primary spontaneous pneumothorax, no correlation was found between recurrences and the number, size, and distribution of blebs and bullae assessed by chest CT, in a prospective study of 35 patients [14]. Alternately, it has been suggested that the number of blebs or small bullae and the radiologic bleb score assessed by chest CT may be helpful in predicting the risk of ipsilateral recurrence [20]. Thus, there is presently no clear agreement regarding the value of chest CT in predicting ipsilateral or contralateral recurrence. In this setting, it appeared worthwhile to propose a prophylactic radical surgical approach for selected young patients with either a bilateral primary spontaneous pneumothorax or a unilateral primary spontaneous pneumothorax with contralateral blebs or bullae on chest CT and job restriction or occupational hazard (traveling or staying in geographic areas with suboptimal medical facilities). Our institution is the referral thoracic surgery department for all French armed services. We are referred many young patients on active duty in the army, air force, and naval forces, who require perfect physical condition and a treatment with an expected 0% recurrence rate. These patients need radical and definitive prevention of recurrences because of the possibility of staying in or traveling to geographic areas with no medical facilities, or because of job restrictions (divers, air force pilots, paratroopers, Navy officers, and sailors). In this setting and only in selected patients do we have extended operative indications differing from the usual indications accepted in civilian practice [21].

Many approaches have been advocated for the simultaneous treatment of both sides since Baronofsky and colleagues [5] proposed a bilateral thoracotomy for the treatment of unilateral spontaneous pneumothorax. Because simultaneous bilateral thoracotomy constitutes a major insult to the physical integrity of any patient, Baronovsky and coworkers have been severely criticized and the concept of simultaneous bilateral treatment of spontaneous pneumothorax has remained dormant for almost 20 years. Kalnins and associates in 1973 [7] and Neal and colleagues in 1979 [6] advocated median sternotomy as the ideal radical approach of spontaneous pneumothorax, arguing that less pain is associated with this approach than with lateral thoracotomy and that immediate postoperative pulmonary function is more favorable. According to those investigators, median sternotomy eliminates the necessity of staged bilateral thoracotomy, and total correction, including blebs or bullae excision and bilateral pleurodesis, is performed at one operation [6]. This attitude was advocated by Ikeda and coworkers [2] a decade later; they reported 29 patients with unilateral spontaneous pneumothorax operated on through median sternotomy. In their series, 8 of 10 patients had bullous lesions found on the contralateral lung although these were not diagnosed at preoperative chest roentgenogram [2]. Although median sternotomy is clearly less painful than thoracotomy, it may result in complications such as mediastinitis, sternal pseudarthrosis, or chronic pain on sternal wires. In addition, median sternotomy provides limited access to the posterior and basal portions of the lung, a fact that may be of concern in patients with blebs located in those areas. Table 4


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  		Table 4. Postoperative Complications, Duration of Pleural Drainage, and In-Hospital Stay in Recent Series of Patients Operated on by Video-Assisted Thoracic Surgery for Spontaneous Pneumothorax

 
Single-stage bilateral transaxillary thoracotomy has also been advocated by other investigators for selected patients with bilateral spontaneous pneumothorax [3]. Gamondes and colleagues [3] reported 30 patients operated on with this technique. Mean hospital stay was 11 ± 3 days and few patients suffered minor postoperative complications. Patients were followed-up for 50 ± 21 months. No recurrences have been observed, but 30% of their patients reported chronic postoperative pain or discomfort related to the thoracic incision. Although Deslauriers and associates [22] reported excellent results using unilateral transaxillary thoracotomy in 409 patients, with less than 1% recurrence, and although a recent study found no advantage of videothoracoscopy over transaxillary thoracotomy in regard to the operating time, amount of analgesics used, duration of thoracic drainage, and number of recurrences [23], we do not consider transaxillary thoracotomy as a first-line surgical approach for patients with recurrent unilateral or bilateral pneumothorax. Thus, although transaxillary thoracotomy skin incision is cosmetically excellent, this approach can result in severe pain from incisional trauma and from spreading the intercostal space. Furthermore, in our experience the most significant problem with this approach is the limitation in exposing blebs and bullae that are not located on the apex of the upper lobe.

We began performing videothoracoscopic bleb excision and pleurabrasion for primary spontaneous pneumothorax in 1991. Considering the good results obtained with this technique (cosmetic, postoperative pain, recurrences) in our first cohort of patients operated on for recurrent unilateral pneumothorax, we decided to propose a single-stage bilateral procedure to a few selected young patients with job restrictions or those with bilateral primary spontaneous pneumothorax and who required radical therapy and rapid return to full occupational activity. Since 1994, many investigators have reported favorable long-term results in patients with primary spontaneous pneumothorax operated on using video-assisted thoracic surgical (VATS) techniques [8–12]. Considering that immediate pain and shoulder dysfunction is less in patients operated on using VATS, compared to those operated on using thoracotomy, and that early postoperative pulmonary function is better with VATS [24], we estimate that videothoracoscopy may be the most appropriate approach for performing simultaneously bilateral bleb excision and pleurodesis. Although VATS may also be associated with intercostal neurovascular bundle injury and subsequent chronic postoperative pain, this complication has decreased with the accumulation of experience with this technique and with the reduction in diameter of most endosurgical instruments and videothoracoscopes. Videothoracoscopy allows a perfect visualization of all parts of the lung and pleura. Recent advances in stapling devices allows for the resection of all types of blebs or bullae. Pleurodesis can be achieved easily through either pleurectomy or pleurabrasion, with recurrence rates of less than 1% and 1.8% to 6.8%, respectively [8–12, 25]. Because apical pleurectomy has been associated with higher in-hospital complication rates [1], we estimate that pleurabrasion is more appropriate for a simultaneous bilateral procedure. Moreover, pleurabrasion is the standard method used in our department, and it has provided excellent long-term results in more than 220 patients, with a recurrence rate of less than 3%. Complication rates, duration of pleural drainage, and hospital stay in the present series compare with other series of patients operated bilaterally, and also unilaterally [2, 3, 6–12]. Although hospital stays tend to be longer in France than in North America, owing to the permissive health insurance system, 11 of 12 patients in this series were discharged home within 10 days of operation and the last 6 patients (50%) were discharged home within 7 days. According to the drainage policy used in our department after surgical pleurodesis, no patient in the present series had removal of all four chest tubes before the fifth postoperative day. We recognize that our drainage policy is not standard because many North American surgeons tend to use only one chest tube for drainage and to remove it before the fifth day. Prolonged air leak and pleural effusion were the most prevalent postoperative complications in this study, as in others [9–10]. Immediate postoperative pain may result in the accumulation of bronchial secretions, atelectasis, and inefficient physiotherapy, resulting in subsequent incomplete lung reexpansion and pneumopathy. These complications may be extremely deleterious in patients sustaining bilateral procedures. Therefore, we have adopted an aggressive policy regarding the control of postoperative pain and we systematically used epidural analgesia for adequate pain control, although this is an unusual requirement with VATS procedures. We believe that any contraindication to the placement of an epidural catheter should be cause for reconsideration of the single-stage procedure. Finally, a single-stage procedure may avoid the need for subsequent anesthetic and surgical procedures, and for another hospitalization with subsequent convalescence and physiotherapy, and it may therefore be cost effective in selected patients requiring radical bilateral therapy. Potential limitations of this study include a small number of patients and the fact that this is a retrospective study. In addition, this is a feasibility study rather than a prospective study comparing staged versus single-stage procedures for bilateral spontaneous pneumothorax. Moreover, this experience was achieved in a military hospital, in selected patients with job restrictions and special physical requirements, and may therefore not be easily transposed into civilian practice. Our goal was not to encourage the performance of unnecessary pleurodesis in patients with unilateral or bilateral primary spontaneous pneumothorax, but rather to consider the management of patients with bilateral pneumothorax and patients with special requirements or job restrictions. Only a prospective study including large numbers of subjects will be useful in establishing guidelines for when a single-stage bilateral videothoracoscopy should be offered.

We conclude that single-stage videothoracoscopy for bilateral bleb excision and pleurabrasion is a safe procedure. This technique did not result in major complications and provided excellent long-term results. This technique might be considered in selected patients with bilateral primary spontaneous pneumothorax or in those requiring radical therapy for the prevention of ipsilateral and contralateral recurrences. Unilateral operations and staged bilateral procedures should remain standard for the vast majority of patients with primary spontaneous pneumothorax.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

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Accepted for publication March 17, 2000.


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