Therapeutic Thoracoscopy Under Local Anesthesia

Abstract

We thank Drs. Yim and Izzat for their very pertinent comments on our article (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 (84) Google Scholar 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. However, there were many patients with recurrent pneumothorax who were practically adhesion-free. Furthermore, we operated on the patients within a relatively short period after the onset of recurrent spontaneous pneumothorax, which may have influenced the higher ratio of the adhesion-free patients in our series. As for their second claim, we agree that CT scans fail to identify ruptured bullae or blebs coexisting with unruptured bullae. Although they mentioned the difficulty in locating ruptured bullae in the lung of a patient receiving mechanical ventilation, we can control the expansion and collapse of the lung using a valved port with an insufflation stopcock, with the patient under local anesthesia and sedated, as described in our paper. In response to their third question, we did not perform subjective or objective pain measurement between the two groups during or after the operation. However, there are no apparent clinical differences between the two groups in terms of complaints of pain. As for the average duration of postoperative hospital stay, our results (4.5 and 5.8 days for the local and general anesthetia groups, respectively) were longer than those obtained by Yim.2Yim A.P.C. Video-assisted thoracoscopic management of primary spontaneous pneumothorax.Ann Acad Med Singapore. 1996; 25: 668-672PubMed Google Scholar However, there may be many differences in his circumstances and ours, such as social medical insurance systems. Under such conditions, we do not think it is appropriate to simply compare the durations of hospital stay. We agree with their fourth comment about the importance of mechanical pleurodesis or pleurectomy in the management of spontaneous pneumothorax. We do only fibrin glue pleurodesis in our procedure, and other pleurodesis procedures are hardly required because of the low recurrence rate of 3.1%. Fibrin glue pleurodesis can be easily performed with the patient under local anesthesia and sedated; this was the method we used for simple cases. Certainly, our procedure is not applicable to all of the patients with spontaneous pneumothorax at this time. However, considering several advantages, such as its minimal invasiveness, this procedure can be used as an alternative for selected patients with uncomplicated spontaneous pneumothorax.