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Ann Thorac Surg 2001;71:452-454
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Efficacy study of video-assisted thoracoscopic surgery pleurodesis for spontaneous pneumothorax

^a Thoracic Surgical Unit, Austin & Repatriation Medical Centre, Heidelberg, Victoria, Australia

Accepted for publication September 22, 2000.

Address reprint requests to Prof Clarke, 55 Victoria Parade, Fitzroy, Victoria 3065, Australia
e-mail: clarkecp{at}bigpond.net.au

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. This study aims to assess the efficacy of video-assisted thoracoscopic surgery pleurodesis in the treatment of spontaneous pneumothorax with particular reference to the rate of recurrence after abrasion pleurodesis and postoperative neuralgia.

Methods. One hundred one patients who underwent 109 video-assisted thoracoscopic surgery pleurodesis procedures in the Austin & Repatriation Medical Centre between January 1992 and June 1998 were identified from a computerized database. The follow-up period was from 8 months to 7 years and 1 month (mean, 44.4 months). Patients were telephoned and asked as to whether recurrence occurred, and if so, when it occurred and how it was treated. They were asked to grade their current pain level from 0 to 6.

Results. Eighty-two patients were contacted, corresponding to 88 video-assisted thoracoscopic surgery pleurodesis procedures that were followed up (80.7%). There were five recurrences (5.7%). The pain level was rated as 0 in 64 cases (72.7%), 1 in 27 cases (23.9%), 2 in 1 case (1.1%), and 3 in 2 cases (2.3%).

Conclusions. These data suggest that video-assisted thoracoscopic surgery pleurodesis is a valid alternative to thoracotomy with pleurectomy for treatment of spontaneous pneumothorax with an acceptable recurrence rate and minimal amount of postoperative neuralgia.

	Introduction

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Spontaneous pneumothorax most commonly occurs in tall, young, lean males and particularly in those who smoke [1–5]. It occurs after rupture of blebs, which generally occur at the apices of the upper lobes. Although the condition is rarely life-threatening, it does account for significant time off from work and hospitalization in an otherwise healthy patient group [6].

Pneumothorax has a tendency for recurrences (20% after first episode, 60% after second episode, and 80% after third episode) [7–14]. The first episode, if uncomplicated, is usually managed conservatively with intercostal catheter, analgesia, and observation. However, with each recurrence, it is more likely there will be further recurrent episodes, and, traditionally, definitive treatment consisting of thoracotomy, excision of the blebs, and a pleurodesis has been offered [11, 15–18]. Unfortunately, the high instance of postoperative neuralgia resulted in reluctance among physicians to refer patients for operative treatment until there had been several recurrences, compounding the overall morbidity.

The recent introduction of video-assisted thoracoscopic surgery (VATS) techniques for the performance of the procedure, and also the change from a pleurectomy to an ablation pleurodesis, has rekindled the interest in early definitive treatment with a significant reduction in overall morbidity and time lost from work. The study aims to establish the rate of postoperative neuralgia and the recurrence rate after VATS pleurodesis.

	Material and methods

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A cohort of 101 consecutive patients was identified from the computerized database of the thoracic surgical unit at the Austin & Repatriation Medical Centre. These patients had 109 VATS pleurodeses performed between January 1992 and June 1998. Patients more than 50 years of age were deliberately excluded so as to avoid patients with secondary pneumothorax from emphysema that is usually caused by rupture of a bulla.

Before the selected cohort there had been a great deal of variation in our technique as we switched from a pleurodesis through a transaxillary thoracotomy to one done purely by a VATS technique. The indications for operation included all patients having unilateral recurrence, and patients at initial presentation if there was a continuous air leak for more than 4 days, a total or tension pneumothorax, or a previous history of a pneumothorax on the contralateral side.

All the patients were then followed by telephone and consent obtained for their participation in the survey. They were asked questions from a standard questionnaire that include whether a recurrence occurred, when it happened, and how it was treated. They were then asked to grade their current pain level on a pain score from 0 to 6, whereby 0 is pain free; 1 is occasional discomfort; 2 is occasional use of analgesics; 3 is using nonopiate analgesics; 4 is regular pain using opiates; 5 is severe continuous pain; and 6 is incapacitated. The standard 1 to 10 visual analog scale for pain could not be used easily over the telephone, and a descriptive 0 to 6 scale proved more appropriate.

The operation was performed in a standard fashion under general anesthesia using intubation with a double-lumen endotracheal tube. The patients were then placed in a lateral decubitus position, and the ipsilateral lung was deflated.

A three-port approach was used incorporating the site of an intercostal tube if this had been placed in the axilla using modified Hassan cannulas or disposable Endopath cannulas (Ethicon Endo-Surgery Inc, Cincinnati, OH). When bullae were identified they were ligated with a Surgilie (United States Surgical Corporation, Norwalk, CT) or resected with an endo stapler. If the only abnormality was apical scarring, this area was excluded using an endo stapler without the knife.

The parietal pleura was abraded with a piece of Marlex mesh or strip of a diathermy scratch pad followed by instillation of 100 mL of alcohol iodine. Apical and basal intercostal catheters were left through the anterior and lowermost port sites, and gentle suction was used postoperatively.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Eighty-two of the 101 patients were successfully contacted. Four of them had bilateral VATS pleurodesis. One patient had 3 operations, having a VATS procedure on each side and a recurrence managed by a thoracotomy. This gave a total of 88 VATS cases being followed up, corresponding to an 80.7% follow-up rate.

There were 57 men and 31 women, and their ages ranged from 15 to 45 years. The mean age of the patients was 27 years. Fifty of the operations were performed on the right side and 38 on the left. Three of the VATS procedures were converted to open thoracotomy because of technical reasons. These were included in the analysis as a VATS procedure had been proposed.

The follow-up period as of February 1999 ranged from 8 months to 7 years and 1 month, with a mean follow-up of 44.4 months. There was a total of 5 recurrences, equivalent to 5.7% recurrence rate. Two of these were on the left side and 3 on the right side. The recurrences occurred at 2, 6, 9, 14, and 21 months after the initial operation (Fig 1).

View larger version (16K): [in this window] [in a new window]   Fig 1. Actuarial freedom from recurrent pneumothorax after video-assisted thoracoscopic surgery pleurodesis.

The rating of postoperative neuralgia on the standard pain score showed that 64 patients (72.7%) had no pain at all (pain score of 0). Twenty-seven patients (23.9%) had occasional discomfort but did not require any analgesia (pain level of 1). One patient (1.1%) used occasional nonopiate analgesia for discomfort. Only 2 patients (2.3%) required frequent nonopiates. Importantly, none of the patients contacted required anything stronger than nonopiate analgesia.

	Comment

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The management of spontaneous pneumothorax has always been a dilemma for the clinician as although it is rarely life-threatening, it affects an otherwise healthy population, leading to a waste of hospital beds and disruption of their working life. Conservative management for recurrent cases is inappropriate as further recurrences are likely, but referring physicians have been reluctant to refer patients for a thoracotomy because of the high instance of postoperative neuralgia.

Gaensler [17] originally popularized the complete parietal pleurectomy in 1956 to obtain a pleurodesis. This technique certainly has the best chance of obtaining a permanent pleurodesis but at an increased risk of neuralgia because of damage to intercostal nerves both secondary to the need to spread ribs and from direct damage at pleurectomy. It also makes further thoracic operations extremely difficult should any of these young patients require thoracic surgical intervention in future years.

For these reasons, ablation pleurodesis was recommended by Clagett in 1968 [19]. Initially this procedure was performed through a full posterolateral thoracotomy, but more recently the transaxillary approach has been the one of choice as advocated by Deslauries and colleagues [16]. Although this latter approach gives a better cosmetic result, there is little difference in postoperative neuralgia rate, which is largely related to the need to spread the rib with pressure, traction on the associated intercostal nerves, and disruption of the costotransverse joints [20–24]. Both approaches are followed by significant prolonged intercostal neuralgia [25].

Video-assisted thoracoscopic surgery was first used to treat pneumothorax in 1990 by Levi and associates [26]. The following years saw further refinement in the technique [27–30]. Several subsequent publications confirmed the feasibility of the method with low recurrence rate, pleasing cosmetic result, and a much lower incidence of postoperative neuralgia. However, the long-term efficacy of the method and its postoperative neuralgia rate remain questionable owing to the limited period of follow-up in these studies.

The long-term follow-up of patients with spontaneous pneumothorax is notoriously difficult as they are mostly young, fit, and highly mobile. The longer the term of follow-up, the more likely there will be missing patients. Yet, in our series with a mean follow-up period of 44 months, a recurrence was noted as late as 21 months after the operation. Therefore, a longer follow-up period is likely to have a lower follow-up rate but would be closer to a true recurrence rate. Our overall recurrence rate of 5.7% and follow-up rate of 80.7% with a follow-up period of 44 months compares favorably with most other published series, which have relatively short periods of follow-up [25, 31–33].

Certainly, the recurrence rate of our VATS pleurodesis is slightly higher than after pleurectomy (0% to 5%) [9, 16, 34] but this has been accepted as it is likely a number of these patients will require a thoracotomy in later life. This is a much more practical proposition with intact but fused pleura rather than having the lung directly adherent to the chest wall.

Similarly we have eschewed the use of talc in younger patients, although this gives an excellent pleurodesis, as the talc remains in the eschar and there is a long-term risk of developing a malignancy.

Significantly, the low instance of postoperative intercostal neuralgia of 3.4% is particularly gratifying, especially as none of them required anything stronger than nonopiate analgesia. Mouroux and associates [32] reported a similar rate of neuralgia at 3%. This is significantly lower than postoperative neuralgia rate after thoracotomy [32].

Our results of an acceptable recurrence rate and a gratifyingly low incidence of postoperative neuralgia reinforces our belief that a VATS ablation pleurodesis is the procedure of choice for patients with recurrent spontaneous pneumothorax, complicated pneumothorax, or persistent air leak. It should therefore be offered early in the course of the disease to reduce time off from work and periods of hospitalization.

Once a pleurodesis has been performed, there is a reduced likelihood of readmission for recurrence, and air leaks persisting for 4 days commonly go on for 10 to 14 days. Patients who initially present with a total or tension pneumothorax generally have a similar pattern if they recur, necessitating a further admission with an intercostal catheter rather than simple aspiration.

	References

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