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Ann Thorac Surg 2003;75:1593-1596
© 2003 The Society of Thoracic Surgeons

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Original article: general thoracic

Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomized study

^a Department of Surgery, Faculty of Medicine, Kuwait University and Chest Diseases Hospital, Safat, Kuwait

Accepted for publication November 21, 2002.

^* Address reprint requests to Dr Ayed, Department of Surgery, Faculty of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait
e-mail: adel{at}hsc.kuniv.edu.kw

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
BACKGROUND: The objectives of the study were to review our experience of video-assisted thoracoscopic apical pleurectomy and to evaluate whether suction or water seal is superior in the postoperative treatment of primary spontaneous pneumothorax.

METHODS: One hundred consecutive patients undergoing thoracoscopy for primary spontaneous pneumothorax from January 1995 to December 1999 were prospectively randomly assigned after surgery to receive suction or water seal to their chest tubes after a brief period of suction.

RESULTS: There were 50 patients in each group. The two groups were evenly matched for age and operation performed. The method of management was stapling of an identified bleb or apex of the upper lobe and apical pleurectomy. Postoperative prolonged air leak longer than 5 days occurred in 8 patients (8%), 7 in the suction group and 1 in the water seal group (p = 0.03). The mean duration of chest tube days was lower in the water seal group (2.7 days) than in the suction group (3.8 days; p = 0.004). The mean hospital stay in the water seal group was 3.7 days and in the suction group it was 4.8 days (p = 0.004). Mean follow-up was 48 months (range, 30 to 60) for all patients. Pneumothorax recurred in 2 patients (2%). The recurrences occurred in the first year.

CONCLUSIONS: Video-assisted thoracoscopic apical pleurectomy is effective and safe for treating primary spontaneous pneumothorax. Placing chest tubes on water seal after a brief period of suction shortens the duration of chest tube placement and hence the hospital stay.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Primary spontaneous pneumothorax (PSP) occurs after the rupture of small bullae or a subpleural bleb in otherwise normal lungs. The indications for surgical treatment include persistent air leak after intercostal tube drainage, recurrent PSP, and contralateral PSP [1]. The video-assisted thoracoscopic surgery (VATS) approach probably represents the treatment of choice for PSP [1–4]. Prolonged air leak is a frequent complications after blebectomy [1, 5]. The most important postoperative care issue that may have an impact on air leaks is chest tube management [6]. The preference of the vast majority of thoracic surgeons is to place chest tubes with 10 to 20 cm H₂O suction after pulmonary resection [7]. The impact of negative suction on air leak has been studied recently [6, 8]. The aims of this study were to describe our experience of VATS apical pleurectomy in Kuwait and to evaluate whether suction or water seal is superior in the management of chest tubes after VATS blebectomy of 100 consecutive patients with PSP.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
The study was conducted at Chest Diseases Hospital in Kuwait, which is the only center for the surgical treatment of chest disorders in Kuwait. Patients with a recurrent or persistent PSP were considered eligible for inclusion. Exclusion criteria were presence of underlying lung disease and recurrent PSP after surgery. After informed verbal consent and after confirmation of absence of exclusion criteria, 100 consecutive patients from January 1995 to December 1999 were included. None of the patients refused to participate in the trial. Preoperative investigation included complete blood cell count, serum electrolytes, renal function tests, and chest radiograph.

Operative technique of VATS
With the patient under general anesthesia using a double-lumen endotracheal tube and one-lung ventilation. The patient was placed in a posterolateral thoracotomy position. A 10-mm trocar was introduced through 1.5-cm skin incision in the eighth intercostal space at the mid axillary line for insertion of a 0° videothoracoscope (Karl Storz, Tuttlingen, Germany). Two additional ports were then inserted under direct vision: a 12-mm posterior trocar through the fifth intercostal space on the anterior axillary line and a 12-mm posterior trocar through the fifth intercostal space near the tip of the scapula. Bullae or blebs were identified and grasped with an empty sponge stick. When no blebs were visible a small portion of the apical upper lobe was resected. The excision was done by using an Endo-GIA stapling device (Auto suture Company; United States Surgical Corp, Norwalk, CT). Then apical pleurectomy was performed from the apex to the third intercostal space. Pleurectomy was performed with a hook electrocautry; the longitudinal limit of the resection ran in an apical direction along the sympathetic trunck to the height of the left subclavian artery or the brachiocephalic trunck on the right side. The pleura was incised at least 1 cm away from the sympathetic trunck. Then it was grasped with the endograsper, raised, and divided with the dissector. Once the plane was developed pleural stripping was achieved by lifting the pleural flap with the aid of a gauze pledget. The area of pleurectomy requires precise hemostasis. None of the patients had bleeding complications. A 28F chest tube was inserted through the inferior incision in the eighth intercostal space and was connected to an underwater seal suction with a negative pressure of 20 cm H₂O in all patients. This was done in an attempt to establish initial reexpansion of the lung. Suction was continued in the recovery room for 2 hours. Then patients were disconnected from suction for transfer to the ward.

Postoperative care
All patients were extubated in the operating room and transferred to the thoracic surgery ward. All patients underwent chest radiography. In the ward they were randomized to either remain on water seal or to be placed on negative 20 cm suction. The intercostal drain was removed when the underlying lung was fully expanded with no air leakage and less than 100 mL pleural fluid drained through the tube for 24 hours. All patients were discharged the day after removal of the chest tube.

Postoperative assessment
Data recorded for all patients included the number of episodes of pneumothorax, the operative time, the presence of blebs or bullae, and the number of disposable stapler cartridges. The output and duration of pleural drainage after operation, length of hospital stay, postoperative air leak, and recurrences were also recorded. All patients were followed up in the outpatient department at intervals of 1 week, 1 month, 3 months, and 6 months for as long as 1 year. The follow-up included clinical history, physical examination, and chest radiographs for all patients. Then patients were followed up with a telephone communication up to 48 months postoperatively. Inquires were made regarding recurrence of pneumothorax and new pulmonary symptoms. The recurrence was proved by chest radiography during the follow-up period.

Statistical analysis
Data were expressed as mean ± SD, data analyses were made using SPSS software windows version 8 packages (SPSS, Chicago, IL). The cut-off level for statistical significance was p less than 0.05. The unpaired Student’s t test was used to assess the significance between the means of variables in the two groups. The Pearson ² test was used to ascertain the significance of association between two categorical variables. The ² test was replaced by Fisher’s exact test if the cell frequencies of any of the 2 x 2 contigency table went below 5.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The series included 94 male and 6 female patients (age 22.9 ± 3.9 years, range 13 to 30 years). Sixty-five patients (65%) were operated on after a recurrent episode of PSP. In 35 patients (35%) VATS was done because of persistent air leak for more than 7 days. VATS was unilateral in all cases and all procedures were performed by the same surgeon, on the right side in 59 cases (59%) and on the left side in 41 cases (41%). All patients were successfully treated using the VATS technique.

The mean operative time was 53.4 ± 9.3 minutes (range 30 to 80). Subpleural blebs or bullae were present in 75 cases (75%) and they were resected by an endoscopic stapler. In the absence of an identifable lesion, the apex of the upper lobe was excised; this was done in 25 cases (25%). Apical pleurectomy was done in all cases.

Postoperatively 50 patients were randomly assigned to each group. The groups were evenly matched for age. The clinical data on these groups are shown in Table 1. The mean duration of chest tube drainage was 3.3 ± 1.7 days (range, 2 to 12). The mean 24 hours pleural drainage for all patients was 158 ± 71.3 mL (range, 50 to 350 mL).

Air leak
Air leak occurred in 5 of 25 patients in whom no blebs were identified and in 3 of 75 occurred in patients with visible blebs. The different is statistically significant (p = 0.02). In 8 patients in the water seal group (16%) a small apical pneumothorax developed, none of which caused any clinical compromise; these were allowed to resolve on their own. Five cases were resolved within 24 hours and 3 were resolved by the patient’s first postoperative outpatient visit 1 week after discharge. None of them were admitted to the emergency department with symptomatic pneumothorax. No patient had a pneumothorax in the suction group.

The range of cartridges in the air leak patients was 3 to 4 staples (mean, 3.4 ± 0.5) whereas the range of cartridges in patients with no air leak was 1 to 5 staples (mean, 2.4 ± 0.78; p = 0.001).

These were no deaths in this series and no patients required monitoring in the intensive care unit. All patients in this study were followed up regularly. The mean follow-up time was 48 months (range, 30 to 60). Recurrent ipsilateral pneumothorax occurred after 2 of the 100 procedures (2%). These occurred at 4 weeks and 3 months after the original VATS procedure. These 2 patients were admitted to hospital and chest radiographs confirmed the presence of a small ipsilateral pneumothorax. Both recurrences healed by rest without pleural drainage. These recurrences occurred in patients in whom no blebs were identified (2 of 25 patients; 8%) and none occurred in patients with visible blebs. The difference is statistically significant (p = 0.01). Both recurrences were from the suction group.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Thoracoscopic surgery can be carried out safely and effectively in the treatment of recurrent or persistent PSP [9]. VATS allows inspection of the entire lung, identification of blebs or bullae, and resection of the bullous disease. There is excellent consensus among surgeons that VATS, which commonly includes bullectomy and either mechanical pleurodesis or partial pleurectomy, is the approach of choice when an interventional procedure is considered necessary [10]. The common goals are to reexpand the lung, stop the air leak, and prevent recurrence [10]. Many surgical techniques such as stapler, loop technique, or electrocoagulation have been described for resecting the blebs or bullae [10–13]. We have used a stapled excision of the apex of the lung if no blebs or bullae were found.

The point of controversy is the method of pleurodesis. Methods of promoting pleural adhesion have included mechanical abrasion with guaze [2, 4, 12], instillation of talc [2, 9], and pleural irritation with laser or cautery [2]. Data are reported from previous studies that these may provide inadequate pleurodesis accounting for a recurrence rate that varies from 3% to 10% [4, 11, 14]. The importance of pleurodesis is nicely demonstrated by Inderbitzi and colleagues [11], who observed a total of 6 recurrences in 72 patients (8.3%) followed up. It appears that combined resection of blebs and pleurodesis is the safest treatment [10, 11]. Apical pleurectomy is also effective for pleurodesis and would perhaps provide a more definitive pleural symphysis with a decreased likelihood of subsequent recurrence as shown from a previous study [5]. A report by Deslauriers and colleagues [15] presented the results of more than 400 transaxillary procedures in which apical pleurectomy was performed after excision of blebs. The rate of ipsilateral recurrence was less than 1%. This approach should be considered when no blebs or bullae are visualized. Apical pleurectomy was used in all patients in this study with a recurrence rate of 2% and no complication was attributable to the procedure.

This prospective randomized trial has looked at the management of postoperative chest tubes, whether to place them on water seal or suction. Placement of chest tubes on water seal after a brief period of suction results in significantly shorter time to removal of chest tubes (2.7 days) than does suction (mean, 3.8 days, p = 0.004). This study also showed that the use of a water seal shortens the hospital stay more than suction (mean, 3.7 days for the water seal group versus 4.8 days for the suction group; p = 0.004). When a water seal was used, 1 patient had postoperative prolonged air leak for more than 5 days whereas in the suction group 7 patients had prolonged air leak. This difference is statistically significant (p = 0.03). These observations are consistent with the findings of Marshall and associates [7], who showed, first, that the duration of air leak was shorter in the water seal group (mean, 1.5 days) than in the suction group (mean, 3.27 days; p = 0.05); and second, that the mean times to removal of chest tubes were 3.33 days in the water seal group and 5.47 days in the suction group (p = 0.06). In a study by Cerfolio and colleagues [6] 67% of air leaks resolved on postoperative day 3 when tubes were placed on water seal on postoperative day 2, whereas only 7% of air leaks in patients on suction resolved by postoperative day 3.

In the water seal group 8 patients (16%) had a small pneumothorax develop but none resulted in any clinical compromise and was managed conservatively; and they were allowed to resolve on their own. Marshall and associates [7] found that 12% of patients placed on water seal had a small pneumothorax develop without any clinical problems; these were put on -10 cm of H₂O suction for 24 hours.

The most frequent postoperative complication was prolonged air leak lasting more than 5 days [3, 11]. Eight patients (8%) in this series had prolonged air leak. Naunheim and associates [3] reported an 8% incidence and 2 patients required a second operation to treat this complication. Bertrand and colleagues [16] found that 3.6% had prolonged air leak and 2 patients required a reoperation. The cause of an air leak problem is either an air leak on the row of staples or missed blebs or bullous areas. In this study the mean number of cartridges was 3.4 in the air leak patients versus 2.4 in patients with no air leak (p = 0.001). Thus the resection of the bullous area has to be done with care and a minimum number of cartridges. Another observation from this study was air leak occurred in 5 of 25 patients in whom no blebs were identified versus 3 of 75 in patients with visible blebs (p = 0.02). Therefore the entire lung should be inspected for other blebs or bullae. In a collapsed lung a small bleb, especially when ruptured, can be difficult to identify and must be searched for. If left behind it may lead to recurrence [10].

Most series report medium-term follow-up with a mean range from 6 to 38 months [2, 4, 9, 16]. Recently a report by Cardillo and associates [9] showed an overall recurrence rate 4.4% at a mean follow-up of 38 months; most recurrences occurred within 1 year from surgery. In a study of 97 patients treated with VATS, Mouroux and colleagues [2] showed 3 recurrences at 1, 5, and 6 months after the intervention. In another study of 99 patients treated with thoracoscopy for primary and secondary spontaneous pneumothorax, Passlick and associates [4] reported 4.8% recurrences after a median follow-up period of 29 months. All recurrences occurred in patients with PSP during the first year from surgery [4]. In the present report the analysis of our results at a mean follow-up of 48 months reveals 2% recurrence rate. The recurrences occurred at 1 and 3 months from surgery. Therefore long-term follow-up did not add to the rate of recurrence.

In conclusion VATS apical pleurectomy can be done safely and effectively in the treatment of PSP. Placing chest tubes on water seal postoperatively results in less air leak, shorter time to chest tube removal, and shorter hospital stay. Long-term follow-up did not show an increase in the number of recurrences.

	References

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