Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax?

The question addressed by a best evidence topic approach using a structured protocol was whether pleurectomy using video-assisted thoracoscopic surgery (VATS) resulted in better outcomes than open pleurectomy for primary spontaneous pneumothorax. Altogether 45 relevant papers were identified of which nine papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VATS pleurectomy has been shown to be comparable to open pleurectomy in the treatment of spontaneous pneumothorax, with a meta-analysis and several RCTs showing reductions in length of hospital stay and analgesic requirements. Postoperative pulmonary dysfunction has also been shown to be reduced after VATS pleurectomy in two RCTs, although a third study found no significant difference. A concern may be a four-fold increase in the recurrence of pneumothorax following VATS pleurectomy as compared to open pleurectomy reported in a recent meta-analysis of four randomised and 25 non-randomised studies performed in 2007 and published in the Lancet, although a second meta-analysis of only the randomised trials did not show this difference.     

Should all patients with duodenal adenocarcinoma be considered for aggressive surgical resection?

BACKGROUND: Long-term survival for duodenal adenocarcinoma is inconsistent in the literature, and the biology of duodenal adenocarcinoma is poorly understood. METHODS: One institution's experience with duodenal adenocarcinoma from 1984 to 2005 is reviewed. Clinicopathologic data were analyzed, and overall survival was estimated using Kaplan-Meier curves with log-rank test. RESULTS: Of the 52 patients, 35 (67%) underwent potentially curative surgery; 31 survived the postoperative period and were included in the analysis. Of these, the median survival was 34 months (range 6 to 186 months) compared with 13 months (range 1 to 24 months) for those not undergoing curative surgery (P < or = .001). Clinicopathologic factors favoring long-term survival were tumor size >3.5 cm (P < or = .001) and T-stage < or =4 (P = .014). CONCLUSIONS: Clinicopathologic factors important to survival in duodenal cancer are T4 tumor status and tumor size. Interestingly, larger tumors were less likely to be invasive, and patients with these tumors had improved survival. The biology of this cancer is poorly understood; therefore, aggressive resection for all duodenal adenocarcinomas is recommended for all patients medically fit to undergo resection.     

Pleurectomy in primary pneumothorax: is extensive pleurectomy necessary?

BACKGROUND: The aim of the study was to evaluate the results of parietal pleurectomy in patients with primary spontaneous pneumothorax comparing extensive pleurectomy performed by thoracotomy versus more limited pleurectomy performed by VATS. METHODS: Records of the patients operated on for primary pneumothorax at Royal Brompton Hospital from January 1994 to April 1997 were retrospectively reviewed. A follow-up questionnaire was sent to patients asking about further pneumothorax and the presence of long-term chest problems on the operated side. A statistical uni- and multivariate analysis was performed searching predictors for postoperative complications, recurrence and chronic chest problems. RESULTS: Thirty-six patients underwent extensive pleurectomy through a limited postero-lateral thoracotomy (40%, group A), 54 patients had a limited pleurectomy (60%, group B), 50 by VATS and 4 by axillary thoracotomy. Overall, 11 patients had postoperative complications (12.2%). In group A, 4 patients (11.1%) had complications (2 reoperation, 2 air leak >7 days). In group B, 7 patients (12.9%) had complications (1 reoperation, air leak >7 days, 1 wound infection). Two patients experienced recurrent ipsilateral pneumothorax after surgery, both belonging to group B (overall recurrence rate 2.5%, group B 4.1%). Thirteen patients in both groups (respectively 41.9% in group A and 27% in group B) admitted chest problems on the operated side. From statistical analysis, "indication" resulted a predictor of complications (p=0.03) and "thoracotomy" a predictor of long-term chest problems (p=0.03). CONCLUSIONS: Many theoretical advantages of limited VATS pleurectomy have still to be confirmed and it is reasonable to use it in uncomplicated primary pneumothorax. The superb exposure obtained with thoracotomy and the superiority of extensive pleurectomy in terms of recurrence indicate this approach in case of complicated pneumothorax or when long-term security is of paramount importance.     

Management of recurrent primary spontaneous pneumothorax after thoracoscopic surgery: should observation, drainage, redo thoracoscopy, or thoracotomy be used?

Background

Video-assisted thoracoscopic surgery (VATS) is the popular method for treating primary spontaneous pneumothorax (PSP). Nevertheless, the optimal management of pneumothorax recurrence after VATS remains unclear. This study evaluated the efficacies of various treatment methods.

Methods

Between 1992 and 2008, 53 cases of recurrent ipsilateral pneumothoraces were noted after 978 VATS treatments for PSP. The primary treatments included 19 observations, 14 pleural drainages with and without sclerosis, 19 redo VATS, and one thoracotomy. The demographic data and treatment outcomes were collected through retrospective chart reviews.

Results

The mean interval between VATS and the first recurrence was 12.8 months. Patients who underwent observation had smaller recurrences than those who underwent pleural drainage or redo VATS. The primary failure rate was 5% (1/19) for observation, 50% (7/14) for pleural drainage, 0% (0/19) for redo VATS, and 0% (0/1) for thoracotomy. After a mean follow-up period of 36 months, the repeat recurrence rate was 63.1% (12/19) for observation, 7.1% (1/14) for pleural drainage, 0% (0/19) for redo VATS, and 0% (0/1) for thoracotomy. The mean total hospital stay was 2.5 days for observation, 8.1 days for pleural drainage, 6.6 days for redo VATS, and 15 days for thoracotomy. Finally, redo VATS was performed as the primary or salvage treatment for 34 patients. Neither conversion to thoracotomy nor blood transfusion was required for any patient. Only one patient had a repeat recurrence (2.9%, 1/34).

Conclusions

Redo VATS is a feasible and less invasive alternative to thoracotomy for treating recurrent pneumothorax after VATS. In contrast, both observation and pleural drainage have high treatment failures rates and thus are not recommended.     

Is talc pleurodesis safe for young patients following primary spontaneous pneumothorax?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether talc used for pleurodesis in young patients with a spontaneous pneumothorax has any long-term adverse effects. One hundred and eighty-one papers were identified using the search below. Eight papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of the papers are tabulated. We conclude that talc pleurodesis in young patients with a spontaneous pneumothorax appears to have minimal long-term adverse consequences.     

Strategy of treatment of patients with recurrent spontaneous pneumothorax: is active surgical treatment necessary?

The diagnostic accuracy of computed tomography in treatment of bullous disease as the most frequent cause of recurrent spontaneous pneumothorax was 55.5%, while that of roentgenography was 16%. The recovery of patients with recurrent spontaneous pneumothorax treated by active surgical measures takes place in 85% of cases, while with drainage of the pleural cavity--in 65%.     

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/χ². 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.     

Should thoracoscopic three-stage esophagectomy be performed in the prone or left lateral decubitus position?

A best evidence topic was written according to a structured protocol. The question addressed was whether the thoracoscopic phase of three-stage minimally-invasive esophagectomy is best performed in the prone or left lateral decubitus position. A total of 31 papers were found using the reported searches, of which seven represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. We conclude that there is no convincing evidence that prone thoracoscopic esophagectomy is superior to left lateral decubitus positioning. Four papers retrospectively compared the prone and lateral techniques, and while the authors suggested that the prone position was associated with better surgical ergonomics due to the effects of gravity pooling blood outside the operative view and the reduced need for lung retraction, outcomes were not significantly different. All four studies had significant limitations, such as small patient populations and sequential operating with the possible effect of a learning curve. Two studies compared respiratory and haemodynamic changes associated with prone positioning and suggest that it is physiologically well tolerated and may offer better oxygenation, similar to that seen in the prone positioning of acute respiratory distress patients. The evidence for prone thoracoscopic esophagectomy is currently not mature enough to reach any significant conclusions, and randomized studies are required.     

Is video-assisted thoracic surgery justified at first spontaneous pneumothorax?

OBJECTIVE: The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justified at the onset of a first spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. PATIENTS/METHODS: The study includes 70 patients affected by first spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The first group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). RESULTS: Prolonged air leaks occurred in four patients (11.4%) in the first group and two patients (5.7%) in the second; recurrences occurred in eight patients in the first group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at $2,750.00 per patient for the first group compared with $1,925.00 for the second group. CONCLUSIONS: The use of VATS at first spontaneous pneumothorax is justified in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the first group and economy savings resulting from use of VATS.     

Should a diuretic always be the first choice in patients with essential hypertension? The case for no

A more extensive use of diuretics as first-line drug for the treatment of hypertensive patients has been recommended on the basis of the results of the recent Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial, yet diuretics have numerous drawbacks that may limit their undisputed ability to lower BP. These include the stimulation of the renin-angiotensin-aldosterone system with the attending negative cardiovascular effects that ensue from this activation and several metabolic alterations, namely those in glucose, lipid, and potassium metabolism. Numerous mechanistic as well as interventional trials indicate that these limitations of diuretics can adversely affect the clinical outcome of patients and their compliance to treatment and consequently the cost of therapy. In addition, there are a number of clinical conditions in which the diuretics are admittedly contraindicated as first-line drugs. Thus, the emphasis should be on obtaining optimal BP control rather on the drug used to achieve it.