Surgery For Spontaneous Pneumothorax Research Articles

Video-Assisted Thoracoscopic Pleurectomy in Spontaneous Pneumothorax Surgery.

Published experiences with thoracoscopic apical or total pleurectomy for patients with a pneumothorax are limited. We aimed to evaluate the long-term results and effectiveness of pleurectomy in our patients, that vast majority of whom underwent thoracoscopic apical or total pleurectomy. Between January 2001 and December 2010, in the Istanbul University Medical School Department of Thoracic Surgery, 67 patients, consisting of 52 patients with a primary spontaneous pneumothorax and 15 with a secondary spontaneous pneumothorax who underwent 72 processes of thoracoscopic resection of blebs or bullae and pleural symphysis, consisting of 43% total pleurectomy, 42% apical pleurectomy plus pleural abrasion, and 15% non-pleurectomy pleurodesis procedures due to prolonged air leak or recurrent spontaneous pneumothorax, were analyzed retrospectively. The applied pleural procedures were: 1. total pleurectomy 2. apical pleurectomy and pleural abrasion for the remaining parts and 3. non-pleurectomy pleurodesis procedures. The long-term outcomes of patients undergoing the three different pleural procedures were compared. Total pleurectomy process, apical pleurectomy and abrasion process for remaining parietal pleura, and non-pleurectomy pleurodesis procedures were performed 31, 30, and 11 times, respectively. No recurrence was observed in the total pleurectomy group, 1 recurrence was observed for the apical pleurectomy plus pleural abrasion group, and 2 recurrences were observed for the non-pleurectomy group. Video-assisted thoracoscopic pleurectomy is a safe and effective method in spontaneous pneumothorax surgery. Especially, total pleurectomy has efficient results in the prevention of recurrences.

Spontaneous hemopneumothorax: Our experience with surgical management

Spontaneous hemopneumothorax is rare, accounting for only 1%-12% of patients presenting with spontaneous pneumothorax. The optimal management of these patients remains controversial with no definitive guidelines on patient selection and timing of surgery. The aim of this study was to review our institution's surgical experience in the management of patients with spontaneous hemopneumothorax. We performed a retrospective review of all patients with spontaneous hemopneumothorax who underwent surgery from January 2000 to June 2013. Patient data were obtained from our institution's primary spontaneous pneumothorax database. Of 510 patients who underwent surgery for spontaneous pneumothorax, 33 (6.4%) developed spontaneous hemopneumothorax. The mean age was 24.0 years (range 16-40 years). In 30 (90.9%) patients, it was their first presentation of pneumothorax. There were 25 (75.8%) patients with Vanderschueren stage III spontaneous pneumothorax. Blood loss ranged from 250 to 3000 mL (mean 1280 mL). In 28 patients, a torn adhesion band was the source of bleeding. Thoracotomy was the surgical approach in 9 (27.3%) patients, and video-assisted thoracic surgery was used in 24 (72.7%). One patient required reoperation for retained clots. There was no mortality. Our results suggest that surgical management of spontaneous hemopneumothorax can be undertaken with minimal morbidity and mortality. With the increasing use of video-assisted thoracic surgery, definitive surgical management of spontaneous hemopneumothorax can be instituted earlier.

Invited Commentary

Prolonged air leak (PAL) is one of the most frustrating complications for both surgeons and patients after pulmonary surgery. This is especially true after surgery for spontaneous pneumothorax, in which a persistent air leak is most often the indication for surgery in the first place. Prolonged air leak has a variety of associated costs including increased length of stay, higher risk of empyema, and longer time required for patients to return to work. Although generally small, the mortality rate in patients with PAL, which was 3.6% in this study, is not insignificant. Being able to reliably predict which patients are at increased risk for PAL is very appealing to thoracic surgeons. In this cohort of over 2,000 spontaneous pneumothorax patients with well-accepted indications for surgery, the authors found that the risk of PAL was related to increasing age, higher American Society of Anesthesiologists (ASA) score, the performance of bilateral procedures, and bullae diameter. Analyses of risk factors for PAL after lobectomy have similarly demonstrated the effect of age. In these studies, poor lung function and the presence of adhesions have also been associated with an increased risk of PAL. The risk associated with higher ASA score in this study may reasonably be assumed to be a surrogate for these conditions. Interestingly, only half of the patients in this study received some form of pleurodesis. In addition, buttressing of staples lines was not employed. Application of these adjunctive maneuvers may have further decreased the 9.7% incidence of PAL that the authors report. Although not specifically designed to analyze outcomes in patients with secondary spontaneous pneumothorax (SSP), the inclusion of 492 such patients in this study offers important insights into the management of this challenging condition. Even when lung expansion is achieved and the initial air leak resolves after chest tube placement, recurrence rates for these patients approximate 50%. In this study [1Jiang L. Jiang G. Zhu Y. Hao W. Zhang L. Risk factors predisposing to prolonged air leak after video-assisted thoracoscopic surgery for spontaneous pneumothorax.Ann Thorac Surg. 2014; 97: 1008-1014Google Scholar], the incidence of PAL in patients with SSP was 31%. A closer look at these numbers reveals that older, more debilitated patients have even higher risks. The incidence of PAL in patients with chronic obstructive pulmonary disease was 44%. For patients older than 70 years (who presumably also had SSP), the rate was 50%. Perhaps most telling, PAL occurred in 94% of ASA 3 patients. As the authors discuss, numerous issues must be thoughtfully considered prior to operating on patients with SSP. These include the need to reinforce staple lines with pericardial strips, the extensiveness of pneumolysis, the type of pleurodesis to perform, and the influence of preoperative steroid use. It is tempting to resect all significant bullae, as the authors did in this study, even if they are not culprit lesions. This may, however, lead to additional space and air leak problems. Recent reports suggest improved outcomes for high-risk patients when the operation is performed without general anesthesia [2Noda M. Okada Y. Maeda S. et al.Is there a benefit of awake thoracoscopic surgery in patients with secondary spontaneous pneumothorax?.J Thorac Cardiovasc Surg. 2012; 143: 613-616Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar]. Postoperatively, the amount and duration of suction are important factors related to the duration of postoperative air leaks. Finally, identifying patients in whom surgical risk is prohibitive and who should instead be offered bedside pleurodesis when possible will be critical. Future studies are needed to more thoroughly address these issues as thoracic surgeons will be called upon more frequently to care for patients with SSP as our population continues to age. Risk Factors Predisposing to Prolonged Air Leak After Video-Assisted Thoracoscopic Surgery for Spontaneous PneumothoraxThe Annals of Thoracic SurgeryVol. 97Issue 3PreviewThe goal of this prospective study was to determine risk factors for prolonged air leak (PAL) for patients who underwent video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax. Full-Text PDF

先天性第VII因子欠乏症患者の自然気胸術後の止血に第VII因子製剤の投与が有効であった1例

症例は18歳，男性．17歳時に左自然気胸に対し手術が行われた．その際，軽度のPT延長を認め，精査の結果，先天性第VII因子欠乏症と診断された．今回，胸痛のため当科を受診し，左自然気胸術後再発の診断で胸腔鏡下に手術を施行した．肺尖部に認めたブラを処理し，止血を確認後，14Fr胸腔ドレーンを留置し手術を終了した．術翌日の胸部レントゲン写真で大量の胸水を認め，22Fr胸腔ドレーンに入れ換えたところ，大量の血性胸水を認めた．止血剤を投与し保存的加療を行ったが，約20 ml/時間の血性排液を認め，貧血の進行を認めたため，第VII因子製剤の投与を行ったところ，完全に止血が得られたため，術後3日目に胸腔ドレーンを抜去した．その後の経過は良好で術後7日目に退院となった．先天性第VII因子欠乏症患者の自然気胸術後の止血に第VII因子製剤の投与は有効であった．

A comparison study of axillary small incision and assisted thoracic surgery for spontaneous pneumothorax

Objective To study the clinical efficacy of axillary incision and thoracoscopic surgery for spontaneous pneumothorax.Methods 106 cases of spontaneous pneumothorax in our hospital were given axillary incision surgery(axillary incision group) and thoracoscopic surgery(thoracoscopy group).The intraoperative blood loss,operative time,chest tube drainage time,postoperative hospital stay and surgery costs were compared between the two groups,and the occurrence of complications were observed.Results The armpit small incision group,intraoperative blood loss was (44.5 ± 5.2) ml,the thoracoscopic amount of blood loss was (38.3 ± 6.5) ml (t =6.378,P ＜ 0.01) ;armpit operation time of the small incision group was (68.0 ± 5.3) min,thoracoscopic operative time was (60.8 ±6.0)min; armpit chest tube drainage time of small incision group was (2.8 ± 0.8)d,thoracoscopic group of chest tube drainage time was (2.0 ± 0.5) d; axillary small incision group,length of stay was (4.8 ± 0.7) d,the thoracoscopic group hospitalization time was (4.0 ± 0.6) d,(t =3.552,4.215,3.076,all P ＜ 0.05) ; axillary incision surgery costs was (1 550 ± 348) Yuan,the thoracoscopic group cost of surgery was (4 290 ± 573) Yuan (t =-24.823,P ＜ 0.05).Two groups of patients with no surgical complications,chest X-ray review of lung reexpansion good thoracoscopic group one cases of recurrence of pneumothorax,axillary incision group without recurrence (P ＞ 0.05).Conclusion Axillary small incision and thoracoscopic surgery for spontaneous pneumothorax have the similar efficacy,thoracoscopic surgery is less trauma,faster recovery,shorter hospital stay,but the high cost of surgery,if patients physical condition is acceptable,which can be used axillary incision surgery. Key words: Pneumothorax; Small incision in the armpit; Thoracoscopy

The Effect of Additional Pleural Procedures onto Recurrence Rates on the Spontaneous Pneumothorax Surgery

BackgroundSpontaneous pneumothoraxes constituted 1/1000 hospital admissions. They are particularly one of life threatening health issues in combination with bilateral pneumothorax, tension pneumothorax, repertory failure or COPD.ObjectivesThe cases of spontaneous pneumothorax represent a significant portion of the patients profile within the chest surgery clinics. The risk of recurrent pneumothorax in post thoracoscopy is between 2% and 14%, thus the subject of cure treatment and approach is still controversial. The cases were retrospectively treated due to spontaneous pneumothorax and their reasons, treatment approaches and results were comparatively examined with the literature.Patients and MethodsThe years between 2007 and 2010, according to our hospital clinic, outpatients and accident & emergency admission records, 79 patients were admitted with a diagnosis of spontaneous pneumothorax; and the patients’ age, gender, symptoms, types of pneumothorax, surgical intervention and recurrence, average length of stay, mortality and complications were retrospectively evaluated.ResultsSeventy of all the patients (88.6%) were male and 9 of those (13.7%) were female. The mean age was calculated as 45.50 ± 21.07 (0-85). The patients were comprised of 41 (51.9%) with primary spontaneous pneumothorax and 38 (48.1%) with secondary spontaneous pneumothorax. 55 of the patients (69.6%) with the first attack, and 24 patients (30.4%) with post tube thoracotomy’s 2nd or 3rd pneumothorax attack were admitted. Those who were accepted with post tube thoracostomy’s 2nd or 3rd attack made up 2/3 of the secondary spontaneous pneumothorax patients. 57 of the patients (68.4%) were treated with the tube thoracostomy. The tube thoracostomy related complication was 6.3%, hemorrhage due to parenchymal damage and massive air leak were observed. An open surgical method to 22 of those patients and apical resection and apical pleurectomy + tetracycline pleurodesis to 16 of whom and bullae ligation and mechanical abrasion to 6 patients were applied. The recurrence of pneumothorax in post-surgery was not observed for 1-3 year period Complication was not detected .Mortality, one patient (1.3%) died in post tube thoracotomy, which was a stage 4 lung cancer patient.ConclusionsMost cases for pneumothorax were consisted of the patients with the primary spontaneous pneumothorax; the patients with recurrent pneumothorax were comprised of secondary spontaneous pneumothorax patients and those of majority secondary spontaneous pneumothorax patients were observed with bullous emphysema profile. By looking at the pertinent literature, there are publications showing VATS with the recurrence rate ranging from 2% to 14% and post thoracotomy recurrence rate from 0% to 7%. We think that applying pleurectomy, mechanical abrasion and chemical pleurodesis additional to bullae ligation or apical resection in pneumothorax surgery will significantly reduce the recurrence rate.

Pleural abrasion versus pleurectomy in primary spontaneous pneumothorax surgery

Background: In this study, we aimed to compare the success of pleural adhesion procedures (pleural abrasion versus a pleurectomy) in preventing recurrence after the surgical treatment of primary spontaneous pneumothorax (PSP). Methods: Between January 2006 and December 2008, the results of 208 operations performed on 190 patients with PSP were examined. As pleural adhesion procedures, 87 pleural abrasions (group A) [20 via video-assisted thoracic surgery (VATS); 67 via axillary thoracotomy (AT)] and 121 apical parietal pleurectomies (group P) (34 via VATS; 87 via AT) were performed. The patients in groups A and P were followed up for a median of 46 (range 28-63) and 41 (range 28-63) months, respectively. They were monitored for recurrence, and, if present, the factors affecting the recurrence were then analyzed. Results: No differences between the groups were found with respect to age, pneumothorax side, surgical indications, surgical approach, duration of surgery, or complication development. The chest tube duration and hospitalization time were significantly shorter in group P (p=0.0001 and p=0.002, respectively). Recurrence developed in six patients (6.8%) in group A and one patient (0.8%) in group P (p=0.02). In the univariate analysis, no relationship was found between the rate of recurrence and the surgical approach, age, gender, pneumothorax side, or surgical indication. In the logistic regression analysis, the surgical approach and pleural adhesion procedure were independent predictors of recurrence (p=0.048 and p=0.034, respectively). Conclusion: A pleurectomy is more effective than abrasion at preventing postoperative recurrence in PSP surgery. Additionally, it has advantages in terms of chest tube duration and hospitalization time.

Surgical management of pneumothorax: significance of effective admission or communication strategies between the district general hospitals and specialized unit

A preoperative delay in emergency surgery for spontaneous pneumothorax is associated with a poor outcome after surgery and a prolonged hospital stay. To reduce preoperative delays, all tertiary referrals from district general hospitals to our thoracic surgery unit were processed through a 'clinical decisions unit' (CDU). Prior to the establishment of the CDU, these patients were added to a waiting list for a surgical bed. This study has reviewed the effect of this change in admission policy on the efficiency of treatment for non-elective spontaneous pneumothorax. An intergroup comparison (pre-CDU group vs. post-CDU group) was made of the following parameters: referral to transfer time, transfer to surgery time and length of inpatient stay in the referring and tertiary hospitals. There were no significant differences in gender, diagnosis, treatment in the referring hospitals, postoperative clinical outcome, or indications for or type of surgery. The total length of inpatient stay in the referring and tertiary hospitals was significantly reduced for the post-CDU group (12 vs. 15 days; P<0.001), which was attributed to the earlier transfer of patients (18 vs. 78 hours; P<0.001) hours. Allowing surgical access to a traditional medical admission unit is therefore, cost-effective and significantly improves the efficiency of non-elective pneumothorax surgery.

Laparoscopic Anti-Reflux Surgery Improves Daytime Somnolence

Laparoscopic Anti-Reflux Surgery Improves Daytime Somnolence

Risk Factors, Incidence, Temporal Course and Outcomes of Air Leaks Following Surgery for Spontaneous Pneumothorax

Risk Factors, Incidence, Temporal Course and Outcomes of Air Leaks Following Surgery for Spontaneous Pneumothorax

Can Intrapleural C-Reactive Protein Predict VATS Pleurodesis Failure?

Intrapleural inflammatory reaction after surgery for spontaneous pneumothorax is a key indicator whether an effective pleurodesis has been achieved. In this study, we tested the hypothesis that intrapleural C-reactive protein (CRP) might precisely quantify the postoperative pleural inflammation, offering potentially useful information for patient management. The study population consisted of 75 consecutive patients who underwent video-assisted thoracoscopic pleurectomy or pleural abrasion for spontaneous pneumothorax between April 2003 and August 2004. We assessed CRP levels in pleural and blood samples taken daily in the first 4 postoperative days. Intrapleural CRP profile was significantly lower in patients who underwent pleural abrasion, in younger patients (< 25 years) and in patients who were not drained before surgery. Patients with pleurodesis failure had a lower CRP peak with a delayed peak. Receiving operating characteristics (ROC) analysis showed that the cutoff value of intrapleural CRP for pleurodesis failure was 25 mg/l on the second postoperative day (sensitivity 87.5 %, specificity 66.6 %, positive predictive value 24.1, negative predictive value 97.7 %). Pleural CRP levels of less than 25 mg/l on the second postoperative day indicate only a moderate pleural inflammation.

Position of a Chest Tube at Video-Assisted Thoracoscopic Surgery for Spontaneous Pneumothorax

Background:Video-assisted thoracoscopic surgery (VATS) is a good therapeutic option for young patients with primary spontaneous pneumothorax (PSP), but there sometimes exists unexpected prolonged hospital stay due to air leak after the operation. Objectives: The goal of this retrospective study was to clarify if the position of the chest tube placed at VATS for PSP affected the periods of postoperative hospital stay. Methods: Seventy-one cases with PSP under age 40 who undertook VATS from January 1994 to February 2001 were examined for several factors. They were classified into two groups by the location of the tip of the chest tube placed at VATS as follows: upper medial pleural space (group I) and outside of there (group II). Results:Fifty-three of the 71 cases (75%) were classified in group I and 18 (25%) were in group II. Between the two groups, there were no differences as to preoperative characteristics of the patients and intraoperative findings of blebs or bullae. On the other hand, postoperative air leak-related complications were more frequent in group II than in group I (p = 0.004). Mean postoperative hospital stay was 5.1 ± 1.9 days in group I and 8.4 ± 4.3 days in group II (p < 0.0001). Conclusions:Patients with the tip of the chest tube in the upper medial pleural space at VATS could be discharged earlier than the other patients. The chest tube placement is one of the important factors for the outcome of VATS for PSP.

Primary vs delayed surgery for spontaneous pneumothorax in children: which is better?

Background Controversy exists regarding the timing of surgery for spontaneous pneumothorax (SP), which can be performed either after the first development of pneumothorax or after a recurrent spontaneous pneumothorax has occurred. Treatment after recurrence is often adopted because of the purported low recurrence of SP treated nonoperatively and the historical morbidity of open surgery. However, the effectiveness of VATS (to video-assisted bullectomy and pleurodesis) has raised the possibility of performing primary VATS (PV) in all patients. The authors therefore hypothesized that PV is safe and effective for SP and sought to perform a cost-benefit analysis of PV vs secondary VATS (SV). Methods After institutional review board approval, consecutive patients with SP (1991-2003) and no comorbidities were retrospectively divided into PV vs SV. Demographics, recurrent pneumothorax after VATS, length of stay, and costs were compared by Student's t test/ χ 2. The predicted incremental cost of PV was (cost of PV) − {[cost of nonoperative treatment × (1 − recurrence rate)] + cost of SV × recurrence rate}. Data are means ± SEM. Results There were 54 spontaneous pneumothoraces in 43 patients (11 bilateral), of whom 3 were excluded because of open thoracotomy. Of 51 pneumothoraces, nonoperative treatment was attempted in 37, of whom 20 recurred and thus required SV. Primary VATS was performed in 14. Both groups had similar age, sex, weight, height, admission heart rate, and room air oxygen saturation. Total treatment length of stay was significantly shorter for PV vs SV (7.1 ± 0.96 vs 10.5 ± 1.2, P = .04). However, morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs 0/20 P < .05). Based on the observed recurrence rate of 54%, performing PV on all patients with SP would increase cost by $4010 per patient and require a recurrence rate of 72% or more to financially justify this approach. Conclusions Contrary to the hypothesis, the increased morbidity and cost do not justify a strategy of PV blebectomy/pleurodesis in children with SP. Instead, secondary treatment is recommended.

Long-Term Results after Video-Assisted Thoracic Surgery for Spontaneous Pneumothorax

Objective: Analysis of the long-term results of video-assisted thoracic surgery (VATS) for spontaneous pneumothorax in patients treated in two surgical centres from May 1994 until December 2000.Methods: A cohort of 86 patients was studied retrospectively. For final analysis, 74 patients undergoing 76 VATS procedures were included.Results: Sixty-three procedures for primary spontaneous pneumothorax (PSP) and 13 procedures for secondary spontaneous pneumothorax (SSP) were performed. In 78.9% (n = 60) blebs or bullae were resected with an endostapler device. In 2.6% (n = 2) an apical fibrotic zone was resected. In 71.1% (n = 54) a subtotal pleurectomy was performed combined with an abrasion in 41 cases. In 21.1% (n = 16) a total pleurectomy and in 7.8% (n = 6) an abrasion was performed. Operative mortality was 1.3% (n = 1) and total operative morbidity 25.4% in the PSP group and 76.9% in the SSP group. Mean follow-up was 36 months. The global recurrence rate was 5.3% (n = 4), being 4.8% (n = 3) in the PSP group and 7.7% (n = 1) in the SSP group. Recurrences occurred at 1 (n = 2), 2 (n = 1) and 16 (n = 1) months after the initial operation. The incidence of postoperative neuralgia was 17.1% (n = 13). One patient needed analgesics for the neuralgia.Conclusion: VATS treatment of spontaneous pneumothorax proves to be effective. In cases of SSP, VATS treatment is feasible but a higher morbidity rate should be anticipated.

自然気胸に対する胸腔鏡下肺切除後再発の検討

胸腔鏡手術を行った自然気胸症例47例57回を対象とした.術後再発は, 4例6回(10.5%)であった.再発の原因として,ブラの切除が不十分と思われた症例が1例,他の5例はブラの見落としまたは新生と考えられた.自然気胸に対する胸腔鏡手術では,入念な観察と充分な切除が重要と思われ,手術症例の今後のブラ新生に関する観察,研究も必要と思われた.

Multifocal Micronodular Pneumocyte Hyperplasia and Lymphangioleiomyomatosis in Tuberous Sclerosis with a TSC2 Gene

A 45-year-old woman with a long-standing diagnosis of tuberous sclerosis (TSC) is presented. She has multifocal micronodular pneumocyte hyperplasia (MMPH) and lymphangioleiomyomatosis (LAM) of the lung, together with the detection of TSC2 gene mutation. During surgery for spontaneous pneumothorax, an open-lung biopsy was performed. Micronodules were well defined, measuring approximately 4 mm in diameter. These MMPHs were histologically composed of papillary proliferation of Type II pneumocytes, with positive immunoreactivity of keratin and surfactant apoprotein. The cystlike spaces, with dilatation and destruction of air spaces, were diffusely formed, and the walls were composed of the spindle cells. Such LAM showed positive immunoreactivity for HMB-45 (a monoclonal antibody specific for human melanoma) and tuberin (the gene product of TSC2). On germline mutation analysis using leukocytes of the present patient, a TSC2 gene mutation was confirmed as a deletion of G (or g) on Exon 9 by polymerase chain reaction–single-strand conformational polymorphism. However, no mutation was detected in her son. With microdissection analysis using paraffin-embedding lung tissues, LOH of the TSC2 gene preliminarily was detected in a LAM lesion but not in MMPH. It is suggested that MMPH, in addition to LAM, could be another pulmonary lesion in TSC patients and that the detection of TSC2 and/or TSC1 gene could essentially be useful for the pathogenesis of MMPH and LAM in TSC patients.

Incidence of chronic pain after minimal-invasive surgery for spontaneous pneumothorax.

Recently, it has been shown that minimal-invasive surgical procedures like operations for spontaneous pneumothorax result in a reduction of pain in the immediate postoperative course. However, little is known on the influence of minimal-invasive thoracic surgery on long term disability. Therefore, we analyzed the incidence of chronic pain in patients after minimal-invasive operation for primary (PSP) or secondary (SSP) spontaneous pneumothorax. In the study included were 78 patients (PSP: n=59; SSP: n=19; male: 58, female 20) who had been treated at our institution between 1992 and 1995. The median age was 37 years (range: 17-84). The patients were interviewed by a standardized questionnaire or alternatively by phone or in the outpatient clinic. Complete follow up data were obtained from 60 patients which were further analyzed. After a median follow up of 59 months (range 35-79) 41 (68.3%) patients were completely free from any complaints. However 19 (31.7%) patients suffered from chronic pain. Two of them (3.3%) required daily oral pain medication. The incidence of chronic complaints was more frequent in patients with pleurectomy (47.1%) as compared to patients with mechanical pleurodesis only (25.6%; P=0.107). On a visual analog pain scale (ranging from 0 to 100) five (8.3%) patients described a pain intensity <10, 12 (20%) patients between 10 and 20 and two (3.3%) patients >50. In the majority of the patients the pain was located in the area of the trocar incisions. Six (10%) patients had a chronic complaints in the ipsilateral shoulder. The incidence of chronic postoperative complaints after minimal-invasive procedures for spontaneous pneumothorax is relatively high. This has to be considered if minimal-invasive procedures are discussed to be an alternative to simple drainage therapy for the first episode of spontaneous pneumothorax.

Thoracoscopic surgery for spontaneous pneumothorax.

Spontaneous pneumothorax in apparently healthy individuals is a relatively common occurrence. The management of patients with spontaneous pneumothorax remains controversial. With the advances in thoracoscopic techniques and instrumentation, video-assisted thoracic surgery (VATS) is now accepted by many as the procedure of choice for surgical treatment of spontaneous pneumothorax. We report our combined experience with 757 patients who suffered from recurrent or persistent spontaneous pneumothorax treated by VATS over a 5-year period. Surgical indications included persistent air leak (n = 165), recurrence (n = 325), radiologically demonstrated huge bulla (n = 12), spontaneous hemopneumothorax (n = 13), incomplete expansion of the lung (n = 212), and bilateral involvement (n = 30). Several surgical procedures were undertaken, based on the thoracoscopic findings: endoscopic stapled bullectomy (n = 312), argon beam coagulation (n = 6), endoscopic suturing (n = 52), and endoloop ligation (n = 352). In 49 cases, mechanical or chemical pleurodesis was the only procedure performed. There were no mortalities or intraoperative hazards. Complications consisted of wound infections (n = 16), localized empyema (n = 2), chest wall bleeding (n = 1), and persistent air leaks (bulla type III) (n = 31). The median duration of the operation was 55 minutes (15-160 minutes), and the average postoperative hospital stay was 4.5 days (range 0-27 days). There were 16 recurrences (2.1%), after a mean follow-up of 30 months (range 1-60 months). Seven patients had recurrence from 9 to 17 months after stapled bullectomy. All the remaining patients had recurrence after failed pleurodesis. On the basis of our results, we conclude that video-assisted thoracoscopic management allows effective, safe performance of standard surgical procedures, avoiding a formal thoracotomy incision. We consider thoracoscopy the treatment of choice for patients with pneumothorax requiring surgical therapy.

Delayed referral reduces the success of video-assisted thoracoscopic surgery for spontaneous pneumothorax

Background. Video-assisted thoracoscopic surgery (VATS) is now the generally preferred surgical treatment for spontaneous pneumothorax but is more difficult once pleural adhesions have developed. To test the hypothesis that VATS is under-used because of prolonged pleural intubation, we have audited the effect of preoperative management on subsequent surgical outcome. Method. Data are expressed as median (range). A prospective audit of clinical outcome in 42 consecutive patients (30 male, 12 female, aged 39 [19–81] years) referred to a Regional Unit for non-elective pneumothorax surgery. VATS was attempted whenever possible. Results. VATS was successful in 32 patients (group V) but 10 (24%) patients (group T) required thoracotomy and decortication of an empyema thoracis. Only seven (17%) patients were operated upon within 7 days of presentation, and 10 patients (24%) waited for more than 21 days. The delay from presentation to operation was significantly longer in group T (22 days vs. 10 days, P<0·05, Wilcoxon). There were significantly more preoperative pleural interventions in patients in group T than in group V ( P<0·05, Wilcoxon). Postoperative stay was longer in group T (7 days vs. 3 days, P<0·05) and there was a significant overall correlation between preoperative delay and postoperative stay ( r=0·64). Conclusion. Delayed referral for pneumothorax surgery and multiple pleural interventions predispose to pleural sepsis and preclude VATS detrimentally affecting clinical outcome. Changes in referral practice are advocated.

Video assisted thoracic surgery for spontaneous pneumothorax.

Video assisted thoracic surgery for spontaneous pneumothorax.