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Ann Thorac Surg 1995;60:931-933
© 1995 The Society of Thoracic Surgeons
Section of Thoracic Surgery, University of Tennessee Center for the Health Sciences, Memphis, Tennessee, and Department of Thoracic Surgery, Naval Medical Center San Diego, San Diego, California
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. We compared a retrospective series of 89 patients treated conventionally with a consecutive group of 30 patients undergoing VATS pleural abrasion. The 89 earlier patients were predominantly male (81%). Treatment groups included observation/aspiration (7 or 17%), tube thoracostomy (32 or 36%), multiple tubes (7 or 9%), and thoracotomy (43 or 48%). Of the 30 patients treated with VATS, 18 (66%) were male. Primary indications for operation were recurrent pneumothorax (17) and persistent air leak (9).
Results. Hospital lengths of stay (LOS) for the earlier group were 5 days for simple tube and 7 days for primary thoracotomy; LOS for initial intervention followed by thoracotomy exceeded 15 days in all subgroups. The average LOS in the VATS group was 13 days; 6 patients treated with primary VATS (no chest tube) had a mean LOS of 6.5 days. Complications included 3 (10%) prolonged air leaks (more than 7 days) and 2 (7%) early recurrences.
Conclusions. We do not recommend VATS as primary therapy for spontaneous pneumothorax; tube thoracostomy remains the treatment of choice. However, we strongly support surgical intervention early (3 days) in patients with a persistent air leak, and as primary therapy in a nonurgent situation if standard indications exist. This study shows no advantage of VATS over conventional thoracotomy in hospital stay or complication rate.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The advent of video-assisted thoracic surgery (VATS) has renewed interest in the therapy of spontaneous pneumothorax. We retrospectively reviewed a series of 89 patients treated by a single thoracic surgical group (F.H.C., F.H.C. Jr, and A.K.) at Methodist Hospitals of Memphis. Results in these patients were compared with a prospective, nonrandomized series of 32 pneumothoraces in 30 patients treated with VATS (all authors). We were particularly interested in hospital length of stay (LOS) and recurrence rates in these patients, and in whether we could justify VATS as therapy for the initial occurrence of spontaneous pneumothorax.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Management policies in groups I and II were consistent throughout the study period. Patients (n = 6) with small pneumothoraces were treated by observation only. Most patients (n = 73) had initial tube thoracostomies under local anesthesia; operative intervention was reserved for prolonged air leaks (>5 to 7 days), recurrent pneumothorax, or the second ipsilateral or first contralateral pneumothorax. Axillary thoracotomy was done for primary pneumothorax with roentgenographic evidence of significant collapse and absence of adhesions; posterolateral thoracotomy was done for secondary pneumothorax with adhesions. Surgical therapy included closure of air leaks, bleb or bullae resection, and dry gauze pleural abrasion. Pleurectomy and chemical pleurodesis were not employed. Follow-up visits were at 1 week and 3 months after operation and included chest roentgenogram and clinical evaluation. We did not carry out questionnaire follow-up or formal long-term checkups on all patients in the retrospective group; complications were noted as they presented but were not formally sought and may be underreported.
Since 1991, VATS techniques have been used in 30 patients. Indications for VATS were essentially as described for the earlier patients, although the definition of ``prolonged air leak'' was closer to 3 days. A prospective registry was maintained recording demographic data, preoperative and postoperative course, duration of operation, and total and postoperative LOS. Follow-up was more thorough than in groups I and II in that inquiries about complications were concurrently recorded.
Video-assisted thoracic surgical procedures were accomplished with general endobronchial anesthesia. A 12-mm trochar, through which the rigid thoracoscope was placed, was introduced through the sixth or seventh intercostal space. Secondary incisions, usually two, were placed under direct intrathoracic visualization. Instruments were frequently inserted directly through the incisions without further ports. Blebs were resected with the Endo-GIA stapling device (US Surgical, Norwalk, CT); pleural abrasion was mechanical and carried out with dry gauze passed into the chest. Most patients returned directly to the ward without an intensive care stay; analgesia was intravenous morphine sulfate and scheduled ketorolac.
Data in each group were tabulated and are presented as mean. Means were compared between each group by the paired t test using the Bonferonni approach. Values were considered statistically significant when the p value was less than 0.05.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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. There is a significant difference (p < 0.01) in mean age distribution between the earlier patients (groups I and II) and VATS patients (group III), reflecting differences in the three institutions involved in the latter series. The increased age of the earlier patients might indicate a greater incidence of secondary pneumothoraces.
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delineates the LOS for each group and subset, along with the details of treatment modalities. In patients in whom tube thoracostomy preceded surgical therapy, the LOS was 15 days; patients successfully treated with simple tube thoracostomy had a 5-day LOS. The 5 patients in group III who required open thoracotomy and the 6 patients who had only primary VATS had identical postoperative LOSs of 6.5 days.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Published literature indicated that recurrence rates after tube thoracostomy alone are as high as 60% [2]. In a prospective, randomized trial of tetracycline pleurodesis versus tube alone, recurrence rates were 40% for tube alone and 25% for the tetracycline group [3]. Almind and associates [4] compared simple drainage, talc pleurodesis, and tetracycline instillation and found recurrence rates of 36% for drainage, 13% for tetracycline, and 8% for talc. Before the availability of VATS, simple thoracoscopy with direct visualization of the pleural space and lung and chemical pleurodesis was frequently used in Europe. Vanderschueren [5] recommended thoracoscopy as the initial intervention, using local anesthesia and talc poudrage as the chemical agent in all patients with limited disease. He reported recurrence rates as low as 6%, although there are theoretical problems with placing pleural talc in young patients. Other sclerosing agents have been placed through the scope, including tetracycline, doxycycline, and fibrin glue [6].
The timing of definitive surgical repair in the management of spontaneous pneumothorax with prolonged air leak has been steadily moving toward a shorter observation period. Granke and associates [7] presented, at the meeting of the Southern Thoracic Surgical Association, a series of 119 patients with spontaneous pneumothorax, of whom 78 underwent thoracotomy. Postoperative LOS was 8 days for the operative group; Granke and associates recommended operation in patients with an air leak persisting more than 72 hours. Schoenenberger and colleagues [8] noted that closure of air leakage was maximal at 48 hours, and recommended proceeding to thoracotomy thereafter. Murray and associates [9] used an axillary thoracotomy as the primary therapy for the initial episode of pneumothorax because of low morbidity, short hospital stay, and low recurrence rate. Their mean postoperative LOS was 4.2 days. There were no recurrences in this group of 14 patients. Donahue and colleagues [10] reported 83 operative pleurodeses with 5 (5.6%) early and 3 (3.6%) late recurrences. Maggi and associates [11] reported a series of 94 open pleurodeses with no recurrence during the follow-up period.
The key questions regarding VATS with pleural abrasion are (1) whether these procedures are equivalent to open procedures with regard to a low recurrence rate, and (2) whether morbidity will be lower and hospital LOS be shorter to warrant use of VATS in lieu of tube thoracostomy as primary therapy for the initial episode of spontaneous pneumothorax.
Hazelrigg's group [1] compared 26 patients having VATS with 20 separately selected patients managed with traditional thoracotomy. Mean hospital stay was less, parenteral narcotic use after 48 hours was less, and there were no recurrences in 26 patients followed up for 8 months. Other series, however, have shown higher recurrence rates with VATS [12]. Interbitzi and colleagues [13] reported 12 cases using VATS with apical pleurectomy, and reported no recurrence in patients followed up for a mean of 1 year. The same authors reported a larger series [14] using initial diagnostic thoracoscopy under local anesthesia, followed by formal VATS if the pathology warranted it. They eliminated the initial step because the vast majority of patients went on to VATS, and currently recommend VATS as the initial therapy for spontaneous pneumothorax. They reported a recurrence rate of 6.2% in this larger series with a longer follow-up period. In another recent report, Waller and colleagues [15] reported a randomized series of surgical therapy versus VATS. The only significant postoperative difference was in forced vital capacity and forced expiratory volume in 1 second measured 3 days after operation; morphine requirement seemed lower in the VATS group but did not reach statistical significance. Mean LOS was only 4 days, but 3 patients (10%) in the VATS group required thoracotomy. Long-term recurrence of pneumothorax was significant: 2 of 29 patients (6.9%) with VATS had recurrence and 1 patient died. The complications in both groups occurred only in patients with secondary pneumothoraces.
To summarize the literature and our own data: (1) Tube thoracostomy can be accomplished with local anesthesia and has a slightly decreased hospital stay, but carries a recurrence rate up to 60%. (2) Conventional thoracotomy remains the ``gold standard,'' with a recurrence rate of less than 1% and hospital stays of approximately 6.2 days. (3) Video-assisted thoracic surgery (in our hands) had an unacceptably high early recurrence rate, although results do appear to be improving with more aggressive pleural abrasion. Most of the theoretical advantages of VATS, such as decreased morbidity and earlier return to work, were not addressed in this report; the 7% incidence of chronic incisional pain in our VATS group is disturbing.
We believe that preliminary tube thoracostomy for the initial spontaneous pneumothorax is appropriate, that ``prolonged air leak'' should be defined as 48 hours, that operative intervention with another pneumothorax should be undertaken without a preliminary tube, and that recommendation of VATS over conventional thoracotomy (on the basis of our recurrence and complication rates) is not yet justified.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr F. Hammond Cole, 1325 Eastmoreland, Suite 310, Memphis, TN 38104.
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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