Therapeutic Thoracoscopy Under Local Anesthesia

Abstract

To the EditorWe read with great interest the report by Nezu et al on thoracoscopic bullectomy performed under local anesthesia for the treatment of spontaneous pneumothorax (January 1997).1Nezu K. Kushibe K. Tojo T. et al.Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax.Chest. 1997; 111: 230-235Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar The authors selected patients with no pleural adhesions (by air insufflation and then x-ray), and they tried to identify their bullae preoperatively by using CT scans. They compared their results with those of a historical group in which the same procedure was performed under general anesthesia; they then concluded that the approach using local anesthesia is safe and is associated with a shorter hospital stay.We would like to raise four points. First, in our experience, it is relatively unusual for recurrent primary spontaneous pneumothorax not to have any adhesions, as the natural history of a ruptured bulla is eventual adhesion to the chest wall. Therefore, if this selection criteria is strictly followed, it seems that the described procedure will be applicable only to a relatively small group of patients. Second, although a CT scan can confirm the presence of apical bullae, it fails to identify ruptured bullae or blebs, which can coexist with unruptured bullae. The former requires careful thoracoscopic examination,2Yim A.P.C. Liu H.P. Complications and failures of video assisted thoracic surgery: experience from two centers in Asia.Ann Thorac Surg. 1996; 61: 538-541Abstract Full Text PDF PubMed Scopus (107) Google Scholar which is more difficult to carry out in a spontaneously ventilating lung. Third, the authors did not compare subjective or objective pain measurements (by visual analogue scale or analgesic requirements) between the two groups. The reported average postoperative hospital stay of 4.5 days in their local anesthesia group, although less than the 5.8 days reported in their general anesthesia group, is still longer than our result of 3.0 days in over 200 consecutive patients, whose procedures were all performed under general anesthesia.3Yim A.P.C. Video-assisted thoracoscopic management of primary spontaneous pneumothorax.Ann Acad Med Singapore. 1996; 25: 668-672PubMed Google Scholar Fourth, mechanical pleurodesis and pleureetomy, which are believed to be important components of surgical treatment,4Parry G.W. Juniper M.E. Dussek J.E. Surgical intervention in spontaneous pneumothorax [editorial].Respir Med. 1992; 86: 1-2Abstract Full Text PDF PubMed Scopus (43) Google Scholar are difficult to perform under local anesthesia. Besides, this leaves virtually no safety margin if major intraoperative complications do occur.Although bullectomy under local anesthesia is technically feasible, the claim that this approach is superior to its counterpart performed under general anesthesia with selected one-lung ventilation may be a little premature. To the EditorWe read with great interest the report by Nezu et al on thoracoscopic bullectomy performed under local anesthesia for the treatment of spontaneous pneumothorax (January 1997).1Nezu K. Kushibe K. Tojo T. et al.Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax.Chest. 1997; 111: 230-235Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar The authors selected patients with no pleural adhesions (by air insufflation and then x-ray), and they tried to identify their bullae preoperatively by using CT scans. They compared their results with those of a historical group in which the same procedure was performed under general anesthesia; they then concluded that the approach using local anesthesia is safe and is associated with a shorter hospital stay.We would like to raise four points. First, in our experience, it is relatively unusual for recurrent primary spontaneous pneumothorax not to have any adhesions, as the natural history of a ruptured bulla is eventual adhesion to the chest wall. Therefore, if this selection criteria is strictly followed, it seems that the described procedure will be applicable only to a relatively small group of patients. Second, although a CT scan can confirm the presence of apical bullae, it fails to identify ruptured bullae or blebs, which can coexist with unruptured bullae. The former requires careful thoracoscopic examination,2Yim A.P.C. Liu H.P. Complications and failures of video assisted thoracic surgery: experience from two centers in Asia.Ann Thorac Surg. 1996; 61: 538-541Abstract Full Text PDF PubMed Scopus (107) Google Scholar which is more difficult to carry out in a spontaneously ventilating lung. Third, the authors did not compare subjective or objective pain measurements (by visual analogue scale or analgesic requirements) between the two groups. The reported average postoperative hospital stay of 4.5 days in their local anesthesia group, although less than the 5.8 days reported in their general anesthesia group, is still longer than our result of 3.0 days in over 200 consecutive patients, whose procedures were all performed under general anesthesia.3Yim A.P.C. Video-assisted thoracoscopic management of primary spontaneous pneumothorax.Ann Acad Med Singapore. 1996; 25: 668-672PubMed Google Scholar Fourth, mechanical pleurodesis and pleureetomy, which are believed to be important components of surgical treatment,4Parry G.W. Juniper M.E. Dussek J.E. Surgical intervention in spontaneous pneumothorax [editorial].Respir Med. 1992; 86: 1-2Abstract Full Text PDF PubMed Scopus (43) Google Scholar are difficult to perform under local anesthesia. Besides, this leaves virtually no safety margin if major intraoperative complications do occur.Although bullectomy under local anesthesia is technically feasible, the claim that this approach is superior to its counterpart performed under general anesthesia with selected one-lung ventilation may be a little premature. We read with great interest the report by Nezu et al on thoracoscopic bullectomy performed under local anesthesia for the treatment of spontaneous pneumothorax (January 1997).1Nezu K. Kushibe K. Tojo T. et al.Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax.Chest. 1997; 111: 230-235Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar The authors selected patients with no pleural adhesions (by air insufflation and then x-ray), and they tried to identify their bullae preoperatively by using CT scans. They compared their results with those of a historical group in which the same procedure was performed under general anesthesia; they then concluded that the approach using local anesthesia is safe and is associated with a shorter hospital stay. We would like to raise four points. First, in our experience, it is relatively unusual for recurrent primary spontaneous pneumothorax not to have any adhesions, as the natural history of a ruptured bulla is eventual adhesion to the chest wall. Therefore, if this selection criteria is strictly followed, it seems that the described procedure will be applicable only to a relatively small group of patients. Second, although a CT scan can confirm the presence of apical bullae, it fails to identify ruptured bullae or blebs, which can coexist with unruptured bullae. The former requires careful thoracoscopic examination,2Yim A.P.C. Liu H.P. Complications and failures of video assisted thoracic surgery: experience from two centers in Asia.Ann Thorac Surg. 1996; 61: 538-541Abstract Full Text PDF PubMed Scopus (107) Google Scholar which is more difficult to carry out in a spontaneously ventilating lung. Third, the authors did not compare subjective or objective pain measurements (by visual analogue scale or analgesic requirements) between the two groups. The reported average postoperative hospital stay of 4.5 days in their local anesthesia group, although less than the 5.8 days reported in their general anesthesia group, is still longer than our result of 3.0 days in over 200 consecutive patients, whose procedures were all performed under general anesthesia.3Yim A.P.C. Video-assisted thoracoscopic management of primary spontaneous pneumothorax.Ann Acad Med Singapore. 1996; 25: 668-672PubMed Google Scholar Fourth, mechanical pleurodesis and pleureetomy, which are believed to be important components of surgical treatment,4Parry G.W. Juniper M.E. Dussek J.E. Surgical intervention in spontaneous pneumothorax [editorial].Respir Med. 1992; 86: 1-2Abstract Full Text PDF PubMed Scopus (43) Google Scholar are difficult to perform under local anesthesia. Besides, this leaves virtually no safety margin if major intraoperative complications do occur. Although bullectomy under local anesthesia is technically feasible, the claim that this approach is superior to its counterpart performed under general anesthesia with selected one-lung ventilation may be a little premature. Therapeutic Thoracoscopy Under Local AnesthesiaCHESTVol. 111Issue 6PreviewWe thank Drs. Yim and Izzat for their very pertinent comments on our article (January 1997).1 First, they claimed that recurrent primary spontaneous pneumothorax without any pleural adhesions is relatively unusual. However, we disagree; 56% of our patients with recurrent pneumothorax were preoperatively diagnosed by the air-infusion test to be practically free from adhesions. We have to admit that there might have been minimal adhesions present in such patients, and that our description may have been a little extreme. Full-Text PDF