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Ann Thorac Surg 2004;77:1802-1805
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Lung wedge resection improves outcome in stage I primary spontaneous pneumothorax

^a Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria
^b Department of General Surgery, University of Vienna Medical School, Vienna, Austria

Accepted for publication October 8, 2003.

^* Address reprint requests to Dr Mueller, Department of Cardiothoracic Surgery, Waehringer Guertel 18-20, A-1090 Vienna, Austria
e-mail: michael-rolf.mueller{at}akh-wien.ac.at

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
BACKGROUND: To evaluate the role of apical lung wedge resection in patients with recurrent primary spontaneous pneumothorax with no endoscopic abnormalities at surgery as compared with simple apical pleurectomy.

METHODS: We performed a retrospective analysis on 126 consecutive video-assisted thoracoscopic surgery (VATS) procedures in 113 patients treated for stage I recurrent PSP between January 1994 and December 2001. Two surgical strategies were applied: simple apical pleurectomy (57 procedures, 45.2%: group A) and apical pleurectomy together with an apical lung wedge resection (69 procedures, 54.8%: group B).

RESULTS: Mean duration of chest tubes was 1.4 days (range, 1 to 7), mean hospital stay was 2.4 days. Three patients (2.4%) required redo VATS, 2 in group A (3.5%) for persistent air leak and 1 (1.4%) in group B for apical hematothorax. Mean follow-up was 38.7 months. Overall recurrence rate was 3.2%. Four patients in group A (7%) experienced recurrent ipsilateral pneumothoraces 4 to 73 weeks (mean, 30.2) after surgery. No recurrences were observed in group B (p = 0.009).

CONCLUSIONS: In this selected group of patients without endoscopical abnormalities, VATS offers low recurrence rates. However, these data suggest that apical pleurectomy should be accompanied by apical lung wedge resection even for this favorable category of patients.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Primary spontaneous pneumothorax (PSP) is a common disease mainly caused by the rupture of apical subpleural blebs. The majority of cases may be treated sufficiently by needle aspiration or a chest tube. Without further treatment, recurrence rates are considerably high. In a compilation of 11 studies of PSP in which patients were treated with observation, needle aspiration, or drainage through a chest tube, the average rate of recurrence was 30%, with a range of 16% to 52% [1]. A recurrent or persistent PSP requires a more sophisticated approach.

Treatment options include tube thoracostomy with instillation of tetracyclin, talc, or other pleural irritants, total pleurodesis through thoracotomy, apical parietal pleurectomy through video-assisted thoracoscopic surgery (VATS), and apical lung wedge resection as an adjunct or solitary treatment. Recurrence rates with VATS or open surgery vary between 1% and 14% [2–10], nonsurgical approaches are associated with recurrence rates of 8% to 25% [2, 11, 12]. Especially in elective patients with recurrent PSP without endoscopic abnormalities (Vanderschueren stage I) [13] and without air leak at surgery, conflicting evidence exists as to whether VATS should be accompanied by apical lung wedge resection. At our department, two surgical strategies have historically evolved. One strategy emphasizes a simple pleurectomy; the other adds a routinely performed apical lung wedge resection.

The aim of this retrospective analysis was to evaluate the role of apical lung wedge resection in patients with no detectable blebs or adhesions during VATS as compared with the conventional approach of simple apical pleurectomy.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between January 1994 and December 2001, 206 consecutive procedures were performed in 182 patients (75% male; mean age, 35.3 years; range, 14 to 80) for recurrent spontaneous pneumothorax. Analysis was by case history, chest computed tomography (CT) scan, operation report, pathologic report, chest tube duration, length of stay and outpatient follow-up. Vanderschueren's classification was used to determine the extent of morphologic alterations: stage I no endoscopic abnormalities, stage II pleuropulmonary adhesions, stage III blebs/bullae less than 2 cm, and stage IV bullae more than 2 cm [13]. In this analysis, in order to exclude nonelective cases, all patients with chest tubes at surgery were excluded in a first step, as the presence of a fistula routinely requires wedge resection. Patients with evidence of blebs reported in chest CT, operation report or pathologic report were excluded from statistical analysis in a second step. Thereby only stage I patients entered the study.

These patients showed no evidence of lung disease in the preoperative chest CT as well as no endoscopic abnormalities at VATS. Hence, all patients finally included had a history of PSP but none of them had a pneumothorax at the time of surgery.

Elective VATS aimed at recurrence prophylaxis. These 126 procedures in 113 patients (74.6% male; mean age, 31.5 years; range, 14 to 49) were assigned to two therapy arms according to the preference of two individual surgeons. Group A (57 procedures, 45.2%) routinely received a standardized simple pleurectomy by the same responsible surgeon, and group B (69 procedures, 54.8%) routinely received a standardized apical pleurectomy together with a standardized apical lung wedge resection by the other responsible surgeon. Both surgeons are experienced in general thoracic surgery for more than 20 years. Therefore, learning curves may be definitely excluded. Thirteen patients had a second VATS procedure for PSP of the other lung after a mean period of 25 weeks (range, 0 to 114).

Surgical technique
Under general anesthesia (double-lumen intubation) patients were laterally positioned. One 12-mm trocar was used for the camera, an Endo-Stapler and Endo-Grasper (Ethicon, Norderstedt, Germany), or hook diathermia was introduced directly through a second incision. In all cases, apical parietal pleurectomy was performed and generally extended until the third rib.

In a first step, the presence of air leaks was evaluated by water submersion test during an inspiratory hold of 30 mm H₂O. In case of a parenchymal fistula, routine wedge resection was performed, and patients were excluded from further analysis for this study. The lung was thoroughly evaluated for adhesions or blebs and patients with any endoscopic abnormalities were also excluded. Of 126 remaining procedures for stage I disease, group B patients routinely received a standardized apical lung wedge resection together with the standard apical parietal pleurectomy. Group A patients received no additional treatment. At the end of the procedure a single chest tube (Charriere 20, Axion Medical Inc, Maastricht, The Netherlands) was placed through the anterior incision and properly guided to the apex and the lung inflated at an inspiratory hold of 30 mm H₂O. No suction was applied to the chest tube.

Statistical analysis
Demographic, medical, intraoperative, and postoperative data were collected on all patients. Continous variables are expressed as mean ± SD. Categorial variables are expressed as percentages. After testing for normality of distribution, continous variables were compared using Student's t test. Categorial variables were compared using the ² test or Fisher's exact test as appropriate. Statistical analysis was performed with SPSS 11.0 statistical software (SPSS, Chicago, IL).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Clinical outcome
A total of 126 apical pleurectomies were performed in 113 patients. Of these, 13 patients had a second VATS procedure for PSP in the other lung after a mean period of 25 weeks (range, 0 to 114). Three patients (2.4%) required redo VATS, 2 in group A (3.5%) for persistent air leak and 1 (1.4%) in group B for apical hematothorax (p = 0.431). Chest tubes were removed after a mean duration of 1.4 days (range, 1 to 5) in group A and after 1.6 days (range, 1 to 7) in group B (p = 0.259). The mean hospital stay was 2.5 days (range, 2 to 7) in group A and 2.7 days (range, 2 to 10) in group B (p = 0.238; Table 1).

Follow-Up
Follow-up was complete in all patients. During a mean follow-up period of 37.9 months (range, 5 to 93) in group A and 39.5 months (range, 6 to 94) in group B, 4 recurrent pneumothoraces in 4 patients were observed after surgical procedures for PSP on the same side. The overall recurrence rate was 3.2%. All recurrences developed in group A patients after a simple apical pleurectomy (7.0%). No recurrences were seen after pleurectomy together with an additional apical lung wedge resection (group B). Recurrences occurred exclusively in male patients (aged 21 to 44 years; mean age, 33.7) 28.1 to 71.8 weeks (mean, 49) after the operation. Pneumothoraces always developed in the lower part of the chest and never in the apex. All 4 patients underwent surgical revision and total pleurectomy by VATS. During surgery all patients presented with massive apical adhesions in the area of the initial pleurectomy. No air leaks could be detected; however, 1 patient had massive mediastinal emphysema. Statistical analysis revealed significantly lower recurrence rates in patients who had an additional apical lung wedge resection together with an apical pleurectomy (p = 0.009).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
In this selected group of patients without endoscopical abnormalities, VATS offers low recurrence rates through a minimally invasive approach. However, these data suggest that apical pleurectomy should be accompanied by apical lung wedge resection even in this favorable category of patients.

The presence of subpleural blebs is a common finding during chest surgery [1, 14–19]. However, the evidence of bullae during the evaluation of a primary spontaneous pneumothorax (PSP) is not predictive of recurrence. Therefore, the presence of bullae by themselves should not form the basis of decisions regarding the prevention of recurrence [2]. The etiology of the typical apical subpleural blebs is obscure. Some authors have postulated a difference in alveolar pressure in the upright human between the base and the apex of the lung [20]. In the upright position, the weight of the lung makes the intrapleural pressure at the lung base less negative than it is in the apex. The volume of each alveolus at the base of the lung is less than in higher regions, which may serve as an explanation for a higher mechanical stress to the apical regions and the preference for the development of blebs. On the other hand, the effect of gravity in the upright position causes a greater volume change per unit of lung tissue as one approaches the base of the lung. This fact should be considered in deciding the extent of pleurodesis in the treatment of PSP.

In the literature, the classification of PSP by Vanderschueren forms the basis of decision making concerning staged surgical approach [13]. Stage I and II patients without bullae at surgery are treated by pleurodesis (pleurectomy or talc poudrage), whereas patients in stage III and IV receive additional treatment of the bullae either by ligation or stapling [21]. Interestingly, the overall recurrence rate in patients with no evidence of blebs (stages I and II) was 5.37% after subtotal pleurectomy or talc poudrage. Stage III patients receiving ligation of the bullae had the highest rate of recurrences (12.19%), whereas the best results were achieved in stage III patients treated by stapling of the bullae and pleurodesis [21]. These results support our observations of superior long-term freedom from recurrence in stage I patients treated by apical pleurectomy in combination with apical lung wedge resection.

In our series, pleurodesis was always achieved by apical parietal pleurectomy. Talc poudrage is strictly avoided owing to severe adverse effects reported in the literature. Respiratory failure due to insufflated talc led to experimental confirmation of systemic distribution of talc after intrapleural administration. Therefore, talc poudrage should be avoided to promote pleurodesis in young patients with benign diseases and even in malignant diseases with a very good prognosis [3, 22].

The general understanding of the underlying mechanism of the development of PSP is the rupture of a subpleural bleb into the free pleural space. It is further a well-known situation to every chest surgeon that, even if we can identify blebs in the typical areas, we are not always able to verify an air leak. On the other hand, we see patients with spontaneous mediastinal emphysema without pneumothorax. An alternative explanation of the underlying pathway seems to be very attractive in this concern: After bullae have formed, inflammation-induced obstruction of the small airways increases alveolar pressure, resulting in an air leak into the lung interstitium. The air then moves to the hilus, thereby causing pneumomediastinum; as mediastinal pressure rises, rupture of the mediastinal parietal pleura occurs, causing pneumothorax [2]. Histopathological analysis and electron microscopy of tissue obtained at surgery have not shown that there is a defect in the visceral pleura through which air escapes from bullae into the pleural space [23].

This theory may well serve as an explanation for the significantly superior results after combined segmental resection and pleurectomy. Simple pleurectomy does not seem to prevent rupture of blebs into the parenchyma and the indirect development of pneumothorax.

In this retrospective analysis, thoracoscopic apical parietal pleurectomy with or without additional apical lung wedge resection was associated with acceptably low long-term recurrence rates. An overall recurrence rate of about 3% is in accordance with the recent literature and even compares with more invasive therapy concepts [8]. Among this favorable category of patients without air leak or blebs found at surgery, however, a simple apical parietal pleurectomy was associated with a recurrence rate of 7%. Patients who had an additional apical lung wedge resection for the same clinical situation did not suffer from recurrent PSP.

Limitations of the study
The main limitation of this study is its retrospective, nonrandomized design. In fact, the subjective decision about which approach to use may represent a certain bias. Nevertheless, the quality of a standardized apical parietal pleurectomy down to the third rib, as routinely performed in our institution, is independent of the individual surgeon. Therefore, the surgical technique used to achieve radical apical pleurectomy does not impact on quality and the final result. Additionally, owing to the low incidence of recurrences, a much higher number of cases in a multicenter setting would be more adequate to evaluate the actual value of a lung wedge resection in patients with stage I PSP.

Taking these limitations into account we conclude that, for this selected group of patients without endoscopical abnormalities, VATS offers low recurrence rates through a minimally invasive approach. However, these data suggest that apical pleurectomy should be accompanied by apical lung wedge resection even for this favorable category of patients.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Martin Czerny Tatjana Fleck Franz Eckersberger Walter Klepetko Ernst Wolner Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Czerny, M. Articles by Mueller, M.-R. Search for Related Content PubMed PubMed Citation Articles by Czerny, M. Articles by Mueller, M.-R. Related Collections Lung - other